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Yes, there are several studies that report the risk of catheter related thrombosis associated with PICCs. But the truth is that the patient needs some type of vascular access to deliver the therapy. What are your alternatives? If he is thinking short peripheral catheters, there are numerous studies showing phlebitis and thrombosis when peripheral veins are used for solutions with extremes of pH and osmolarity. What is the comparison of thrombosis rates between PICCs and nontunneled CVCs? The bottom line is that you must provide the device with the least risk to the patient. 

 I would never allow any other professional to put me in this position. They say XX and send me on a wild goose chase to locate the published research to support or refute both sides of the issue. If this physician is so dedicated to evidence, put the responsibility on him or her to produce the evidence to which he or she is referring. Don't do their job for them. Lynn

First off the article in cleveland clinic your first reference - I need to pull as Cleveland Clinic PICC Team did not use micro's or ultrasound in 2002.  In fact they only placed PICC lines on nutritional support patients back than and they did not incorporate micro or ultrasound until 2005.  The majority of PICC line placements were IR driven and those done by RN's were below the antecubital fossa or in the fossa.  IR did not do ICU patients due to risk of transport.  By the way nutritional support has a high rate of thrombosis

I have to look up the other two articles and get back to you as the majority of these publications are based on lower arm PICC line insertins even if they are published in JVIR or ASPEN's journal.  The level of high tech RN's in 2000, 2003 was very low.  There is no new articles since ultrasound is becoming more commonplace

I think thrombosis is blown out of proportion if you want my opinion

I also think since the peripheral veins are more superficial one is apt to see the symptoms versys a subclavian placed line

Lorelle,

  Just my two cents worth, but I agree with Cheryl Kelly and Lynn.  If you are doing a good pre-assessment, you should find out quickly that not all patients need a picc. When we started pre-assessing our patients, we went from doing 150 to 200 picc's per month, to less then 100 per month.  We also became closer with our radiology group since we started doing more port and tunneled line placements.  I think that thrombus in picc's is also more related to placing picc's in patients that are not properly anticoagulated.  For instance, we had a patient that had a tramatic bran injury with a pretty severe bleed.  He could not be anticoagulated for that reason.  We placed a picc in him and it developed a clot. He does not move either.  We pulled that picc and despite our best efforts, the docs asked for another, and you guessed it, we had another clot.  It just was not the smartest thing to do for this patient.  But Lynn is absolutely correct when she told you to ask the doctor for the information he has read on this subject.  She may not have been very expicit in the way she told you to ask, but what I am sure she means is that you will then have the exact documentation the doctor obtained his information from, and then you can properly refute it, or come up with a collaborative plan of action for his patients.  You also need for him to let you know what he prefers in his patients as access, so that you can also provide him with evidence against that if need be.  After all, a PICC is the least invasive central line you can place, but all options must be weighed so that ALL of the disciplines can provide the best access for the patient collaboratively, instead of fighting amoungst yourselves about it.  I do most of the physician teaching around my hospital.  You are correct when you say that doc's are research driven.  Most are, but you cannot always be the one running around like a chicken with your head cut off.  It will drive you crazy.

Heather 

The Allen article doesn't say if they define thrombosis as a total occlusion of the vein or just the finding of a clot in the vein,and the gist of the writing is vein preservation for future dialysis patients. The authors note that the vast majority of theses 'thromboses' are asymptomatic. Two important findings in the article,however,are that there was a huge difference in rates between cephalic (57%) and basilic (10%) but NO difference found based on catheter size.

Another one:

Ong B.,et al (2006) Peripherally inserted central catheters and upper extremity deep vein thrombosis. Australasian Radiology: 50,451-454

Their numbers:7% symptomatic thrombosis in PICC inserted for chemo vs 1% for non-chemo reasons;a higher incidence in the left (63%) versus right;a symptomatic rate of 2.6%.  One important finding of these authors was that of the patients who developped a DVT in the arm,had the PICC replaced and were then anticoagulated (LMWH) only one developped a second DVT and that one was iffy.

My take on it all--PICC placement,like any procedure,has its incumbent complications and that can't be changed. What we do have control over is how we synthesize the available evidence while considering the risks vs benefits,and how we use this to guide our assessment and implementation decisions.  

cheryl, could I get a copy of your assessment tool?

[email protected]

thanks.

Cheryl,

I would also appreciate your assessment tool if possible. Please email if you don't mind(or maybe you could post to the downloads section of this web-site)

[email protected]

Thanks so much

Trish

Good afternoon colleagues,

 I have a critical care physician who is being particularly difficult getting on board with our Early Assessment PICC Program.  More specifically, he states that there is a significant amount of research available to support NOT using PICC’s because of the unknown incidence of risk for upper extremity DVT. 

I have found multiple research articles that conclude that Venous Thrombosis is a significant complication of PICC placement, and that it occurs more frequently than previously recognized.I am looking for some professional help in approaching this physician with some alternate research that promotes the use of PICC lines.

Is there anything out there that says the incidence of DVT is LOW? I believe that if appropriate assessment of risk factors are taken, as well as appropriate management of the PICC line including passive range of motion, the incidence of upper extremity DVT will be low - however this physician is RESEARCH driven and I need some help.  Thank you for your time and consideration.

Out of curiosity...... Kathy - What would you say to this physician?Lynn - What would you say?Thanks! 

Here are some of my sources that say that the incidence of DVT with PICC's is high:

Chemaly, R. F. , de Parres, J. B., Rehmn, S. J. et al. (2002). Venous thrombosis associated with peripherally inserted central catheters: A retrospective analysis of the cleveland clinic experience. Clinical Infectious Diseases, 34, 1179-83. 

Allen, A. W., Mergargell, J. L.. Brown, D. B et al. (2000). Venous thrombosis associated with the placement of peripherally inserted central catheters. JVIR,11, 1309-14.

Gonsalves, C. F., Eschelman, D. J., Sullivan, K. L., DuBois, N, & Bonn, J. (2003). Incidence of central vein stenosis and occlusion following upper extremity PICC and port placement.  Cardiovascular Interventional Radiology, 26, 123-127.

Would you send me a copy of your tool also?  [email protected]  Thanks