Hello,
I have a situation that I have not encounterd in past. I know it is contraindicated to put a PICC line in someone who uses crutches due to the pressure on the vessel and vein irritation with increase risk for thrombus. Today I had a consult for a young man who weighs 265 pounds who is a parapalegic. He uses both his upper arms for body transfers , he is a very active man and says he does transfers and uses his arms to hold full body weight as he does his activities. He says already at 12 noon he has done 8 transfers. So.......I know we recommend no heavy lifting and or repetive strenuous activities to the affected arm. This situation sounds like it might place him at an increase risk for DVT. I questioned using the non dominant arm, his left arm, but then I know just using the left side increases the risk of dvt and the pt says he really uses both arms equally when we are talking about strength and where the pressure is applied.
After throwing all this around we opted for peripheral ivs and areas where there will not be stress . He is going to get 14 days of antibiotics for a uti. I told him if the peripherals didnt work out we can re think it, but we felt like the risks out weighed the benefits at this point.
I wanted to throw this out to you all to get your input. Thanks in advance, Gina Ward R.N.
Gina, Being a parapalegic will he end up needing infusion therapy off and on over the years? Would he benifit from an implanted port, Hickman or I have had 2 renal patients that had their PICCs placed in the chest. Food for thought:) Valorie
Valorie Dunn,BSN, RN, CRNI, PLNC
First, I do not think that use of crutches is an automatic contraindication for a PICC. Having been on crutches for almost a year when I was a child, I was taught not to put pressure on the axilary region. The reason for this then and now is to avoid damage to the nerves supplying the arm. When there is a PICC in place, pressure on the axillary region could increase the risk of vein thrombosis. The most important issue is will the patient be provided with correct instructions for using the crutches and will she/he adhere to those instructions. This should determine PICC use with crutches.
For your patient, this is a tough call. I would also be concerned about infiltration/extravasation from a short peripheral catheter with some much arm use. 14 days of ABX but you did not say what the drug was. I would not trust a short peirpheral for infusion of Vancomycin or Nafcillin in this case because both are vesicants. But most other ABX can be compounded where the osmolarity will be less than 600 and the pH is usually not a problem and they are not vesicants. However, many can and do cause phlebitis, which could lead to severe superficial thrombophlebitis. Maybe I have seen too many legal cases! Is he doing his therapy in the home? Has he been taught to completely assess the site before infusion including aspiration for a blood return? If in some other facility, do all nurses know how to properly assess the site including checking for blood return. I am finding that many nurses know about flushing but virtually none are aspirating for a blood return. So they are not doing a complete and comprehensive assessment. For only 14 days if the drug was not a vesicant, I would probably try peripherals. If he becomes a frequent patient needing numerous courses of infusions, I would opt for an implanted port. But given the risks I would try it with other options first. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
If he is otherwise in good health, and depending on the antibiotic involved, he might be a candidate for the Powerwand extended dwell peripheral catheter that was presented at AVA. I haven't personally had any experience with them yet, but he sounds like the type of patient who could benefit from some kind of extended dwell peripheral. Would anyone actually using them care to give some input?
Daniel Juckette RN, CCRN, VA-BC