Forum topic

There are no published recommendations or guidelines from any professional organization about a cut-off point for PICC placement when there is a high INR. Most experts feel that a PICC is the safest catheter to place when there is any type of coagulopathy. So you will not find any evidence to base your practice upon. Also, I have not seen any professional organization published these guidelines for any other catheter. I have seen some articles that provides information about their practice, but there are no studies used for their practice. 

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

If we have a patient who has a very high INR, it is probably an ICU pt who really needs a central line and the PICC is the only safe alternative, as we can hold pressure. I have done one with an INR of 9, and was able to achieve hemostasis by holding pressure. I would have a hemostatic agent at the bedside just in case, but have yet to have to open it up and use it. I have spoken with someone who has inserted a PICC in a pt with INR of 18. If you set a limit, what happens to the patient? In some hospitals, they send the pt to IR, but why?? Even IR wonders, as they do the same thing the nurse would do at the bedside - access carefully, using ultrasound, hold pressure after insertion until hemostasis is achieved. I have been in some hospitals in which I.R. refuses pts with a high INR, but it is for financial reasons. If the pt bleeds, they have to keep them in the I.R. suite and hold pressure until the bleeding stops, which takes up time they could be spending doing profitable procedures. Do what is best for the patient, and don't base your decisions on one number. Remember that some of these patients need their INR to be above normal, and holding their anti-coagulant for a PICC insertion puts the pt at risk.