I am asking if I gave the correct advice to an attending physician. The patient is elderly, originally admitted for C. diff colitis, was on a ventilator for a few days, and has an active malignancy. He has been on good DVT prophylaxis the entire time. He remains on bowel rest and is receiving TPN through a physician placed right IJ CVC. He has a history of CVA affecting his right side. The CVC has been in place for 8 days. He developed a fever of 102 during the night and had 2 blood cultures drawn, one peripherally and one through his CVC. His WBC is normal. He has had no further fever. The next morning the attending requested a PICC and then removal of the CVC. US examination of all 4 extremities was also ordered and I watched the tech do the study. The patient had a thrombus in the left cephalic vein. Everything else was clear.
I discussed the issues with the attending. I told the physician that the existing thrombus despite heparin, and the malignancy significantly increased the risk of DVT from a PICC. Also, I would need to use the left arm because of the CVA. I suggested that replacing the existing CVC with a new physician placed catheter might be a better choice. Her decision was to leave the CVC and see how things progressed. She then ordered full anticoagulation with a heparin infusion. Blood cultures are not back yet.
My question: did I advise her correctly?
I think you did give the correct advise. I would want to see those preliminary culture results before doing anything. Do you know what method is being used by your lab - cfu count or time to positivity? You do not know yet if the present CVC is causing the elevated temp and fever alone is not an indication to remove a catheter immediately according to CDC, IDSA, etc. The malignancy and PICC insertion would add to risk for thrombus formation in the chosen vein. So I agree with you assessment based on your description above. Let us know what happens. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Thank you Lynn,
I feel better.
I do not know the method our lab uses. But, the peripherally drawn BC preliminary report just came back "yeast". The line drawn BC still shows "no-growth" at 36 hours. Also, the MD ordered a CT angio earlier this afternoon and lo and behold, the patient has had a PE. However he hasn't shown any obvious symptoms of that. In light of the US exam yesterday, could the PE have come from his cephalic vein? So far there has been no change in his therapy. Still no more fever. CVC insertion site looks benign.
Richard Simpson RN, CCRN
Sure the PE could have come from the cephalic vein thrombus. But did they do US of all extremities? He may have more thrombus in his legs and that could be the source. Cultures are sounding like they are not implicating the catheter as the cause. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
No more fever. BC via CVC - no growth after 4 days. Two new BC's done Saturday - no growth. The original US exam did include all 4 extremities. ID doc will see the patient tomorrow. We do use the coated Arrow TLC. That's what the patient has. Looks like the MD made the correct call to leave the CVC.
Thanks all.
Richard Simpson RN, CCRN
But only with your correct advice. This is the level of respect and collarboration that we need everywhere for every patient! Congratulations, Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I would agree with your assessment that this patient is at high risk for a DVT if a PICC is placed, and an IJ CVC is likely the best choice, due, in part, to the size of the IJ compared to peripheral veins. I would also suggest a treated CVC, with a broad spectrum treatment such as ArrowGard Blue plus, as it is effective against gram positive and gram negative bacteria and fungus. These catheters can be left in place up to 30 days per the FDA and Instructions for use, depending, of course on your hospital's policies.
Great job on doing a complete assessment of your patient and suggesting the plan of care to provide the BEST outcomes!
Disclaimer---I am an employee of Teleflex Medical as a Clinical Specialist.
Chris Cavanaugh, RN, BSN, CRNI, VA-BC
I hope that there is an infectious disease consultant on this case
You mentioned blood cultures have come back "yeast" via peripheral and that the patient is getting TPN.
kathy Kokotis
Bard Access Systems
I hope that there is an infectious disease consultant on this case
You mentioned blood cultures have come back "yeast" via peripheral and that the patient is getting TPN.
kathy Kokotis
Bard Access Systems