I think this is something we need to talk about more in the future: is it alway neccessary to pull the Picc if there is a diagnosed thrombosis? According to our ultrasound techs ALL lines placed into blood vessels will eventually cause to build up fibrin and thrombotic material. The real question is: is it completely occluding the blood vessel, how symptomatic is the thrombosis(how well is the body utilizing collateral circulation) and what is the risk for the clot to dislodge?
We have in some cases left the lines in, just put patient on lovenox and symptoms subsided soon.
Michael Drafz San Diego
Nadine Nakazawa <[EMAIL PROTECTED]> wrote:
Nadine Nakazawa <[EMAIL PROTECTED]> wrote:
I agree with your assessment. He may be at risk with a second PICC. I'd
discuss risks with MD team and with patient and family. Document your
findings and observe daily. No easy answer, but we want to err on the side
of the least harm to the patient. Sounds like you're looking at everything
from all angles.
Save your email description. It makes for a great teaching story. Pose it
to your nurses and ask what they would do. BTW, can I use it in a class??
Nadine Nakazawa
>From: "DAVID LONGSETH" <[EMAIL PROTECTED]>
>To: [EMAIL PROTECTED]
>Subject: PICC with thrombus
>Date: Wed, 25 Oct 2006 21:31:57 -0500
>
>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
>
>
>
Michael Drafz RN, OCN, CRNI
Clinical Lead Vascular Access Service
Sharp Memorial Hospital Metropolitan Campus
San Diego,
California
