Re: PICC with thrombus

[DAVID LONGSETH]

I would think a fem line for this guy would be too risky--between the MRSA 
and the fact that he already developed a clot around one line,that would be 
asking for more troubles. IJ is probably out,too--his clotting/platelet 
issue is such that he has one big bruise from the chin to the neck to the 
clavicles due to the trach placement and the trach collar would be right on 
the insertion site. Subclavian? That's probably the next best alternative 
but they darn well better let IR do it with US guidance--no blind sticks for 
this guy.

From: "Laura Cook RN" <[EMAIL PROTECTED]>
To: "Lynn Hadaway" <[EMAIL PROTECTED]>,        "DAVID LONGSETH" 
<[EMAIL PROTECTED]>, [EMAIL PROTECTED]
Subject: Re: PICC with thrombus
Date: Thu, 26 Oct 2006 12:40:28 -0400
I'm thinking, would it not be better to have a subclavian, IJ or femoral 
placed and remove the PICC?  To at least give the clot some time to resolve 
and maybe the patient some time to stabalize?

>>> "Lynn Hadaway" <[EMAIL PROTECTED]> 10/26/2006 10:43 AM >>>
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



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