Had a patient today with the following scenario:
Admitted 10/14 to MICU from a nursing home with multiple,multiple problems.
Respiratory failure with MRSA in lungs,renal failure,CHF,GI bleed,diabetes.
Trach'ed a few days ago,on ventilator. Also some sort of undiagnosed
'platelet problem'--normal PLT levels but prolonged bleeding times.
Basically a very very sick guy. Because of the bleeding problems,he can get
no anticoagulation beyond an aspirin down the dobhoff.
6Fr Triple Lumen Power PICC placed 10/16 in right basilic about 2" above
ACF--routine procedure,tip into lower SVC. Asked to look into patient today.
Both of his forearms have +3 edema from ACF to hands. Doppler showed
thrombus in right basilic around the PICC. Right upper arm looks fine-no
swelling and in fact the circumference is 3.5cm LESS then when line placed.
No palpable phlebitic vein. Both forearms are EQUALLY swollen.
The issue is whether to leave the current PICC or place one in the other
arm.
My views are thus: his right upper arm is essentially asymptomatic and the
PICC is not causing the forearm swelling,it's the CHF/ARF;of all his
problems,swollen forearms are pretty minor;this is not acting like a septic
thrombophlebitis;whether the PICC comes out or not,the thrombus is still
there and the risk for PE is still there,PICC or no PICC;there's no
guarantee that a different PICC will not develop a thrombus and in that case
he will have not only a known thrombus but yet another line at risk for
developing more;his left arm veins are barely big enough to safely
accomodate a 5Fr line anyway. My conclusion--the risks for placing another
line are at least equal to if not greater than leaving the current one.
I welcome any guidance,opinions or insights from the group.
Regards
David
