We insert PICC lines in patient regardless of their PTT, INR, and Platelet count. PICC lines are the safest for these patients. A smaller gauge line in a compressible peripheral vessel is much safer that a larger bore (such as a TLC) inserted directly into a large vessel. We do look at these studies to be aware of them and take precautions if we need to. Such as not double walling the vessel, and staying further away from arteries. We also hold pressure to the site a little longer on these patients. Frequently, these patients don't even develop bruising. I have more concern with clotting issues on patients taking medications that we don't have tests for, such as Lovenox, Plavix and xarelto. At least with high INRs from Coumadin, and low platelet counts I know what I am dealing with.
I have inserted a PICC line on a patient with an INR of 14. The patient was in the ER and we were unable to obtain peripheral access to transfuse with FFP. The line was inserted without difficulty, no increased bleeding and the FFP was then hung. I do have to add that we are using a tapered catheter, so that might help.
Physicians seem concerned with the numbers when they order PICCs and they want to discuss it with me. I am not phased by elevated INRs. We have seen a few patients lately that have come in for GI bleeding from xarelto. Even the hematologist thinks we should not PICC these patients. These patients often are hypovolemic and need multiple lumens for transfusions, fluids and may also need vasopressors which are vesicants. We have not had difficulty with bleeding with PICCs in these patients either. I would not expect a physician to want to insert a CVC in these patients.
As with all the care we provide our patients, we need to weigh the benefit/risk potential for each incident. We need choose the best option for that patient at that moment and document accordingly.
Juline DiSilvestro BSN, RN, CRNI, VA-BC, CPUI
Central Access Team Nurse
Inspira Medical Center- Woodbury,NJ
We insert PICC lines in patient regardless of their PTT, INR, and Platelet count. PICC lines are the safest for these patients. A smaller gauge line in a compressible peripheral vessel is much safer that a larger bore (such as a TLC) inserted directly into a large vessel. We do look at these studies to be aware of them and take precautions if we need to. Such as not double walling the vessel, and staying further away from arteries. We also hold pressure to the site a little longer on these patients. Frequently, these patients don't even develop bruising. I have more concern with clotting issues on patients taking medications that we don't have tests for, such as Lovenox, Plavix and xarelto. At least with high INRs from Coumadin, and low platelet counts I know what I am dealing with.
I have inserted a PICC line on a patient with an INR of 14. The patient was in the ER and we were unable to obtain peripheral access to transfuse with FFP. The line was inserted without difficulty, no increased bleeding and the FFP was then hung. I do have to add that we are using a tapered catheter, so that might help.
Physicians seem concerned with the numbers when they order PICCs and they want to discuss it with me. I am not phased by elevated INRs. We have seen a few patients lately that have come in for GI bleeding from xarelto. Even the hematologist thinks we should not PICC these patients. These patients often are hypovolemic and need multiple lumens for transfusions, fluids and may also need vasopressors which are vesicants. We have not had difficulty with bleeding with PICCs in these patients either. I would not expect a physician to want to insert a CVC in these patients.
As with all the care we provide our patients, we need to weigh the benefit/risk potential for each incident. We need choose the best option for that patient at that moment and document accordingly.
Juline DiSilvestro BSN, RN, CRNI, VA-BC, CPUI
Central Access Team Nurse
Inspira Medical Center- Woodbury,NJ