Our hospital has been doing monitoring on all DVTs that occur from PICCs being placed. Now we do get about 60% of our DVTs related to PICC, from patients whom are not gettting DVT prophylaxis (Heparin SQ or Lovenox SQ) because of medical reasons like GI bleed, Subdural hematomas, etc. However the rest of our DVTs from PICCs are getting Heparin SQ (which is mostly used as our DVT prophylaxis of 5000 unit every 12h) and a few patients may get Lovenox SQ with dosing based on their weight. Here is a few questios:
1) Does your hospital have standardized DVT prophylaxis ie Heparin with the same dose being given to all patient who can have DVT prophylaxis? Again, we we mostly use Heparin 5000u sq every 12 hrs.
2) Is the same dose of Heparin, enough coverage for all types of patients with difference is weight (150lbs vs. 300lbs or greater) and considering mobility issues (a patient getting our of bed to the chair vs. bedbound patient in critical care vented and restrained or just even bedbound)
3) Has anyone heard of difference between Heparin SQ being better than Lovenox SQ or the inverse .....if this can be studied at all?
Any feedback would be welcomed.
Tracy
I don't think you will find evidence to answer all your questions. I have not found any recommendations for DVT prophylaxis for any type of CVAD. However there are strong recommendations for therapeutic anticoagulant dose to treat CVAD DVT and PICCs do have higher rates of DVT than other CVADs. 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
There was a discussion about using aspirin for prevention of upper extremity dvt vs lovenox/heparin for prevention of lower extremity dvt. When I have time I'll search for it.
I just found these references from another project:
The first one is a strong set of evidence based guidelines from thoracic surgeons that recommended NO prophylaxis.
Kahn SR, Lim W, Dunn AS, et al. Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. Feb 2012;141(2 Suppl):e195S-226S.
Here are 2 other studies that came after the release of the guidelines that addressed the issue
Ahn DH, Illum HB, Wang DH, Sharma A, Dowell JE. Upper extremity venous thrombosis in patients with cancer with peripherally inserted central venous catheters: a retrospective analysis of risk factors. J Oncol Pract. Jan 2013;9(1):e8-12.
Akl EA, Ramly EP, Kahale LA, et al. Anticoagulation for people with cancer and central venous catheters. Cochrane Database Syst Rev. 2014;10:CD006468.
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
There is old Heme/Onc literature from the 1980s using 1 mg Coumadin to prophylaxis central lines.
The patients PT/INR does not change but fibrin sheath formation is hindered or prevented.
I have used this successfully with many patients through the years.
When I had a private practice with many PICCs for ATB infusion, we rarely had DVTs.
i have not searched this topic recently so I do not know any recent articles.
Could be a nice Inhouse or multi-center trial since PICCs have earned a poor reputation in this area.
Craig E. Smith, MD, MS, CTropMed, FACP, FIDSA
Deputy Chief, Specialty Care for Inpatient Care
Associate Program Director, GRU Internal Medicine Residency
Charlie Norwood VA Medical Center
Augusta, GA 30904
There were a couple of studies supporting use of warfarin for this purpose and several showing no benefit. So this never developed into recommendations or guidelines by any group. I did a lit search on this isse a few months ago and the guidelines from CHEST on thrombosis in my post below is the most recent guidelines where they are no recommending any type of prophylaxis at this time. 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
PICCs can cause lower-limb blood clots
PUBLISHED: 18 AUGUST 2015
Peripherally inserted central catheters (PICCs), a type of IV typically inserted in a vein in the arm, are frequently used by healthcare professionals to obtain long-term central venous access in hospitalised patients. While there are numerous benefits associated with PICCs, a potential complication is deep vein thrombosis (DVT), or blood clots, in upper limbs.
A new study of more than 70,000 patients in 48 Michigan hospitals indicates that PICC use is associated not only with upper-extremity DVT, but also with lower-extremity DVT. “Prior studies had not assessed whether PICCs are independently associated with an increase in the risk of subsequent lower extremity DVT,” explained lead investigator Dr Vineet Chopra, assistant professor of medicine, University of Michigan School of Medicine, and The Michigan Hospital Medicine Safety Consortium. “Our study confirmed that PICCs are strongly associated with DVT in upper limbs. However, what is novel and noteworthy in this study is that the presence of a PICC was also associated with an increased risk of lower-extremity DVT.”
Researchers used data from 76,242 hospitalised patients from 48 Michigan hospitals to review PICC placement, existing medical conditions, venous thrombosis risk factors, and thrombotic events within 90 days of hospital admission. A total of 3,790 patients received a PICC during hospitalization.
Analysis revealed 876 thromboembolic events, including 208 upper-extremity DVTs, 372 lower-extremity DVTs and 296 pulmonary emboli. After adjusting for other risk factors, researchers found that PICC use was independently associated with a three-fold higher risk for any type of thromboembolic event compared to patients who had not received a PICC. Specifically for upper-extremity DVT, the risk was more than 10 times higher, while for lower-extremity DVT, the risk was nearly 50% higher. There was no increased risk of pulmonary embolism from PICC use.
The investigators also found that infusion of drugs to prevent venous thromboembolism did not reduce the risk of subsequent DVT. “Taken together, these findings suggest that the thrombotic burden associated with peripherally inserted central catheters may not be restricted to the extremity where the device resides or easily attenuated after insertion,” commented Chopra.
PICCs are not appropriate for every patient. Chopra and his co-investigators advise that: “Careful weighing of the risks and benefits of PICC use and consideration of alternative devices in patients at high risk of deep vein thrombosis seem essential. Of note, our data suggest that clinicians should not focus only on the extremity where a peripherally inserted central catheter resides, but the composite risk of venous thromboembolism among patients who receive a peripherally inserted central catheter.”
Short-term central venous catheters are placed in a patient’s neck or chest, while PICCs, are placed into a vein in the arm and threaded to the central vein, enabling them to be used for diverse tasks including the easy administration of drugs like antibiotics or chemotherapy, as well as haemo-dynamic monitoring.
Abstract
Background
Peripherally inserted central catheters are associated with upper-extremity deep vein thrombosis. Whether they also are associated with lower-extremity deep vein thrombosis or pulmonary embolism is unknown. We examined the risk of venous thromboembolism in deep veins of the arm, leg, and chest after peripherally inserted central catheter placement.
Methods
We conducted a multicenter, retrospective cohort study of 76,242 hospitalized medical patients from 48 Michigan hospitals. Peripherally inserted central catheter presence, comorbidities, venous thrombosis risk factors, and thrombotic events within 90 days from hospital admission were ascertained by phone and record review. Cox proportional hazards models were fit to examine the association between peripherally inserted central catheter placement and 90-day hazard of upper- and lower-extremity deep vein thrombosis or pulmonary embolism, adjusting for patient-level characteristics and natural clustering within hospitals.
Results
A total of 3790 patients received a peripherally inserted central catheter during hospitalization. From hospital admission to 90 days, 876 thromboembolic events (208 upper-extremity deep vein thromboses, 372 lower-extremity deep vein thromboses, and 296 pulmonary emboli) were identified. After risk adjustment, peripherally inserted central catheter use was independently associated with all-cause venous thromboembolism (hazard ratio [HR], 3.16; 95% confidence interval [CI], 2.59-3.85), upper-extremity deep vein thrombosis (HR, 10.49; 95% CI, 7.79-14.11), and lower-extremity deep vein thrombosis (HR, 1.48; 95% CI, 1.02-2.15). Peripherally inserted central catheter use was not associated with pulmonary embolism (HR, 1.34; 95% CI, 0.86-2.06). Results were robust to sensitivity analyses incorporating receipt of pharmacologic prophylaxis during hospitalization.
Conclusions
Peripherally inserted central catheter use is associated with upper- and lower-extremity deep vein thrombosis. Weighing the thrombotic risks conferred by peripherally inserted central catheters against clinical benefits seems necessary.
Elsevier Health material
The American Journal of Medicine abstract
Does a PICC increase the risk of thrombosis for a pt who is receiving therapeutic warfarin treatment for PE and lower extremity DVT? Pt needs one more week of antibiotics and they want to send to rehab. Any thoughts, please?
Nancy Rose