Hi David, It sounds like your patient has several reasons to be locally clot prone despite prolonged bleeding times. I'm curious about several things. Did the patient have evidence of previous puncture sites involving the anterior communicator vein or the basilic at the ACF? Did you place the PICC using MST and ultrasound? If you use ultrasound, do you do any kind of vein assessment prior to cannulation (checking vein compressibility or measuring the internal diameter of the vein)? Thrombus formation is associated with trauma to the vessel wall and lining, interruption or alteration of blood flow through the vessel and hypercoaguable states. Physical trauma to the vessel in this case could be caused by previous IV's and infusions, placement of the PICC close to the ACF (you don't mention if he moves his arms), the number of insertion attempts and of course, the procedure itself. Venous stasis caused by lack of arm movement, circulatory factors (CHF, diabetes, renal failure) and ! catheter to vein disproportion (hard to know without an internal vein diameter measurement) may also be factors. All of these would constitute risk factors for PICC placement in the other arm as well. Did the dopplers show the right cephalic and brachial veins to be patent? This is an important consideration since they will have to act as outflow tracts for the affected arm. If the basilic and brachial vein lumens of the left arm above the ACF at the proposed insertion site are less than 3-4mm then they probably are too small for 6 FR PICC placement (2 mm outside diameter). Also, the literature reports a greater incidence of thrombus formation related to left sided PICC placement. Is there any doppler evidence of preexisting thrombus or compromise to the outflow tracts in the left arm? It's not unusual to find occluding SVT's or chronic thrombotic scarring in the veins of patients with chronic illness who have had many PIV's. These affect not only vessel size but! flow. One other thing comes to mind. Depending on the pati! ent's ag e and the anticipated need for future dialysis (diabetes and renal failure), it may be best to avoid PICC placement in the left arm without the blessing of a nephrologist. In our facility all patients with chronic renal failure must have the approval of an attending nephrologist prior to PICC placement. While not ideal in a patient with a trach, replacement of the PICC with a nontunneled or tunneled IJ catheter may be appropriate if the thrombus propagates and/or to preserve access for a future dialysis graft or shunt. (A subclavian site should be avoided if dialysis is a future possibility.) I agree with Lynn. If the catheter remains in place, this patient needs to be closely monitored by a vascular access nurse for symptoms of septic thrombophlebitis or DVT. Serial repeat dopplers would also be a good idea since, like most, this thrombus appears to be clinically silent. If there is an interventional radiologist or vascular surgeon in your facility, I would seek out t! heir recommendations for follow up care and interventions.
Good luck with this complicated patient!! -----Original Message----- From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] Behalf Of DAVID LONGSETH Sent: Wednesday, October 25, 2006 10:32 PM To: [EMAIL PROTECTED] Subject: PICC with thrombus 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
