There has been some recent concern in my facility with the possibility that patients are at greater risk than originally thought for thrombus r/t PICC dwell time. We have had a couple patients have a PE following the d/c of a PICC line with documented thrombus via ultrasound assessment. One patient died shortly after from a massive PE. Another threw several small PEs' following the d/c of his PICC line, also thrombus +. One of these patients also had an IVC filter in place, which narrows down where the clot may have originated. Is this a blip on our screen or are patients developing silent thrombus as outpatients that are not documented or treated? This is a concern for us based on obtaining informed consent and properly informing patients of risk. Has anyone out there done any studies on the rates of this phenomenon? If so, what were your results? We are considering doing an assessment for 30 days or more of all patients discharged with a PICC line. We would maybe like to call them at thirty days out to assess if there were any complications or c/o. We are not sure how to pursue our concern and we recognize that the results could affect our practice greatly. However, first do no harm. Thank you in advance for any input you all may have.
As with anything I put on this forum, you should always begin with the INS Standards of Practice. In this case, go to Standard #52, Catheter Associated Venous Thrombosis. The vast majority of all types of CVADs have silent vein thromboses. This fact is well documented in the literature and is not limited to PICCs. Start with the list of 13 references for this standard. Removal of any CVAD could cause a PE from these silent thromboses. There are numerous patient-related factors that you increase the risk of thrombosis and you have no way to control for those including diabetes, cancer, acquired and inherited thrombophillia conditions, pregnancy, fluid volume deficits, etc. You should have outcome data on all CVADs in your facility including PICCs. So I would encourage you to collect this data for evaluation, but it should not be limited to a short 30 days. Of course you could collect periodic data such as this multiple times during each year rather than on each CVAD all the time. Multiple data sets would allow you to track and trend any changes. 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
Quarry for Lynn Hadaway, you mention outcome data to the above question. We would like to improve our faciltities data collection, is there a site or information that I can obtain to help improve our data collection for CVAD's?
Quarry for Lynn Hadaway, you mention outcome data to the above question. We would like to improve our faciltities data collection, is there a site or information that I can obtain to help improve our data collection for CVAD's?
I would recommend collecting the insertion data and outcome data for all CVADs inserted at your facility. It is easier if you have an electronic system where this data is input and can then be harvested I would recommend that you work very closely with your Infection Prevention and Control dept as they will have specific requirements for collecting data on CLABSI. Then work with your Quality Management or Performance Improvement dept to learn their recommendations for collecting data on other complications. This varies between facilities due to the differences in resources available to you. So there is no specific website or form that provides information that works for all situations. The INS textbook also has a chapter about QI and that would be a good place to start. 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
Lynn,
I apologize for not having clarified our issue and our current data collection practices. The patients I was referring to in my original note were outpatients. We are an inpatient team and the lines were inserted here. The symptoms began to show up after their discharge. We were then asked to consult and make recommendations. We currently collect data in great detail working very closely with our Infection Control department. Data is collected on various complications, infection rates, etc. Our data is very comprehensive and we do it continuously. The 30 day study I referred to was just to be done on outpatients. We thought that perhaps if we followed patients that were discharged with a PICC line for 30 days that perhaps we could see a small sample of how often this complication is occuring after discharge. Perhaps it is related to increased dwell time? Thank you for any input. :)
You say the patient died of a massive PE after a documented UE-DVT? How big was that thrombus seen in ultrasound evaluation? Was the patient anticoagulated to a therapeutic level? Did the patient have symptoms that caused the evaluation finding the UE-DVT? Check out the latest recommendations from the American College of Chest Physicians. "In upper extremity DVT associated with a central venous catheter: Suggestion is to not remove the catheter if it is functional and there is an ongoing need for the catheter. Anticoagulation should be given as long as the catheter is in place. If the catheter is removed, anticoagulation should continue for 3 months thereafter."
If the patient couldn't be anticoagulated a superior vena cava filters can be placed. I wouldn't place a PICC in a patient at bedside because the patient had an SVC filter. A patient with an SVC filter needs their central line placed under fluoroscopy so that the line tip isn't inadvertantly caught in the filter. You won't see it very often but read your chart carefully. If all it says is a vena cava filter make sure of its placement before you PICC.
Mary Penn RN Vascular Access Team
St Charles MO
The patient you refer to that passed away was an outpatient that had been discharged to a rehab facility with a PICC line in place. He had symptoms of DVT and then was evaluated via ultrasound to have a thrombus. The line was removed and shortly after he had a PE. The patient with the filter indeed had an IVC filter and not an SVC filter. We of course would have had it placed under fluoroscopy as well as removed it that way if the opposite were true. We also always recommend keeping a line and treating the thrombus when the patients are here in our facility and within our control. The patients mentioned were those discharged with PICC lines. The lines were referred to us based on symptoms and it was determined that the lines were no longer needed. I apologize for the original post being unclear. Thank you.