Thanks for the reply.
PICC placed with US,MST. "One stick,one PICC". I always check both arms and
the left side was clear but too small for the 6Fr. The biggest vein he had
was the right basilic. I don't recall any peripheral being in the way in the
rt ACF but he'd been in the unit for a day or two so it's possible. As for
moving his arms--not a chance. He was intubated when I saw him and now
trach'ed,so he's paralyzed,restrained or both. This is dependent edema,not
venous congestion edema. As for dialysis,I don't think our nephrologists
would ever offer that as a humane option.
One other factor is that I think the ICU residents just need to look at the
big picture. They did the Doppler study because of his swollen forearms,not
because of a swollen upper arm. I'll bet if we looked at every PICC and
other CVAD in the hospital we'd find a few more lines with a clot on them.
The question is whether to do anything about an asymptomatic (in my opinion)
line/vein. I think the residents need to learn that not every problem is a
problem you have to deal with urgently. They want the line replaced,I say
not. I won't be back to PICC'ing for a few days,unfortunately,so I may get
trumped.
Regards
D
From: "King, Kathy" <[EMAIL PROTECTED]>
To: "DAVID LONGSETH" <[EMAIL PROTECTED]>
Subject: RE: PICC with thrombus
Date: Thu, 26 Oct 2006 13:53:32 -0400
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 patient's age 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 future dialysis graft or
shunt. 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
thrombophlebitis, 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 their 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
