Recently, our PICC Team had a request for a line to be placed in a patient who had multiple blood clots in his lower extremtities, lungs and right atrium. We were quite hesitant but multiple medical providers felt it was appropriate and did not place the patient at increased risk. Is there a policy or standard out there to address such a a scenario?
The Infusion Nursing Standards of Practice address prevention of catheter-associated venous thrombosis in several evidence-based ways - proper tip location, small size catheter, etc. This document also includes a standard on Catheter Associated Venous Thrombosis, however that is not what you are asking about. There is also a set of guidelines published in Chest. Here is one of the articles but there are others in this same issue of this journal. I am not sure what or if this document would say anything related to this situation, but this is where I would begin.
1. Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. Feb 2012;141(2 Suppl):e419S-494S.
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
Thank you Lynn, very much appreciated.
AND I think one of the associations should have a statement or position paper defining pre-existing conditions that would preclude PICC placement. I can find several generalized guidlines that we all know such as coags; existing DVT; lymphedema, etc. We are always challenged to find clinical statements regarding access in a patient with a freshly placed pacer/defibrillator or in this case pre-exisiting atrial thrombus. It might even be a good mini course presentation at the next conference.
We already have an online CE course on CVADs and pacemakers - a 2 hour course that has been updated within the past year. www.hadawayassociates.com
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 there was ever a need for an expert vascular access consult this is it! The pt. is of course at increased risk of DVT with central line placement, especially in the presence of existing thrombosis. I am assuming central access is required so the next question to me would be what type of central access presents the least amount of risk for additional thrombi. I think a strong argument could be made for small bore right sided IJ! Relativly short and small diameter catheter that will not bang around venous intima as much as a PICC(would be my second choice). Although DVTs certainly occur with IJs they are less frequent than with PICCs. The inserter should be skilled in US and use as small a catheter that will get the job done! Good Luck!
Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness
You will need to provide some form of evidence to support your statement about IJs causing less vein trauma at the catheter tip than a PICC. What is your source of this strong statement? Yes, call me skeptical and doubtful without some form of evidence. 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
The pt. in this scenario presents an interesting clinical case. Multiple existing "clots" and the need for central line placement. As a clinician I would want to give the pt. the greatest benefit with the least amount of harm. Here is how I arrived at my clinical judgment.
1. The rt. sided IJ approach is virtually a straight shot to the cavo-atrial junction.
2. The jugular is likely much larger then the UE veins for PICC placement. (Better vein to catheter ratio)
3. A PICC would take a turn at the axilla, another at the brachiocephalic, and another at the SVC.
4. A PICC would be 40-45cm(guessing) of catheter with possible venous intima contact.
5. A small bore IJ would be 14-15cm of catheter with possible venous intima contact(clotting cascade)
6. In my own clinical practice I have placed hundreds of small bore IJ's w/o incidence of DVT.
7. The associations between PICCs and symptomatic/asymptomatic DVT is well established.
Until there are enough evidence based studies on which catheters have the lowest incidence of DVT on patients with coagulopathies and pre-existing thrombi(which may or may not ever happen!) we need to utilize our clinical judgment. Would love to hear others!
Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness