Very tough situation but here is what I thought of:
Aspirin is a pretty good antiplatelet drug, so this may keep the clot
from growing, maybe.
Many risk factors are present to cause a DVT - third spacing (severe
extremity edema) probably leading to systemic fluid volume deficit,
diabetes = hypercoagulability + large 6 Fr PICC
Seems like the best thing you can do is leave the current PICC and
closely monitor the clot. When he becomes more stable, and if the
clot worsens, you may have other options. I would personally want to
monitor this patient and not leave this one to his primary care
nurse(s) alone though.
Eager to read the thoughts of others. Lynn
At 9:31 PM -0500 10/25/06, DAVID LONGSETH wrote:
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
--
Lynn Hadaway, M.Ed., RNC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
http://www.hadawayassociates.com
office 770-358-7861
