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Amy Graham
PICC lines in weakened extremities due to CVA

Patient presented with Small bowell obstruction. Surgeon wanting to attempt conservative treatment.  Requested a PICC line for TPN.  Pt has h/o of CVA that has his right arm impaired, he can move the right arm but there is obviously less strength and use of the right arm.  I placed a PICC in the left arm but the tip of the PICC  flipped back on itself and would not thread SVC.    I removed the PICC line from the left arm.  My work place has no IR department to help with PICC placement. I did not attempt the right arm due to his weakness.  My question is - if this was your patient would you have attempted a PICC in the right arm?

 

lynncrni
 NO, been there, done that!

 NO, been there, done that! Many years ago, one of our early PICC patients had a paralyzed arm and a PICC was placed in that arm. The nurse's thought was that it would save his good arm for him to do activities of daily living more easily. He developed a massive venous thrombosis along a great length of the catheter. This was in the early 1980's so this was long before US. Before I pulled out the left arm PICC, I would have removed the guidewire, allowed some time and got a repeat xray a couple of hours later. It could have spontaneously repositioned itself - worth a try before loosing it. Lynn

Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Saharris
PICC in weak arm

I would have looked at the risk vs. benefit, talked with the surgeon about options for line placement and if a PICC was still indicated I would do a careful vein assessment of weak arm and proceeded if the vessel looked good. I have had many pt's do very well with carefully placed piccs in "weakened" arms, again careful assessment and team collaboration are important.

Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness

lynncrni
 And a comprehensive patient

 And a comprehensive patient assessment would rule out the routine use of a paralyzed arm due to the lack of muscle pump action in that exrtremity and the greatly increased risk of vein thrombosis. A short peripheral catheter placed in a paralyzed arm in the case of bilateral paralysis, and for a short period is very different than a PICC placed in a paralyzed arm for many weeks. Lynn

Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Saharris
Not paralyzed

I read the original post as a weakened arm, not paralyzed. Absolutes are a tricky thing in healthcare, I believe there has been some research showing similer rates of thrombosis for piccs placed in quads vs. general population. At any rate I did not mean to suggest routine use of weakened extremities, but to share anecdotally that there have been multiple risk vs. benefit situations in my practice where this pt. population has completed therapy without complications.

Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness

lynncrni
 Weakened, impaired do not

 Weakened, impaired do not equal paralysis and we don't have the complete answer from the original post. But the muscle pump action is what moves blood back to the heart. Any arm that is impaired and not fully used will have the circulation slowed and the risk of vein thrombosis would be increased. I would like to read the article you mentioned if you can post the reference. Lynn

Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Saharris
Article

The Journal of the Association for Vascular Access
Volume 13, Issue 2 , Pages 82-87, 2008
A Retrospective Review of Peripherally Inserted Central Catheters and Upper Extremity Deep Venous Thrombosis in Persons with Cervical Spinal Cord Injuries
Donna Loupus, APRN, BC, Susan Schuetrumpf, RN, CRNI, Laura F. Vazquez, MPH

Abstract
Introduction
Peripherally Inserted Central Catheters (PICCs) are a proven and cost effective alternative to traditional short term central venous catheters inserted via subclavian or jugular vein routes. It has been theorized that persons with cervical spinal cord injury (SCI) are more prone to upper extremity deep venous thrombosis (DVT) post PICC insertion.

Purpose
This study was conducted to determine if there is a statistically significant increase in the incidence of PICC-related upper extremity thrombosis in persons with quadriplegia as compared to other patient populations.

Methods
A retrospective chart review of 56 PICC insertions, performed on 44 patients, was conducted to identify risk factors associated with symptomatic upper extremity DVTs.

Results
The overall incidence of symptomatic DVTs was 7.1% per PICC line insertion (95% CI 2.8% – 17.0%) and 9.1% per patient (95% CI 3.6% – 21.2%) and the number of DVTs per 1,000 catheter days was 3.14. DVT diagnosis was not significantly associated with any of the patient or PICC-related characteristics examined. The incidence of symptomatic DVTs per PICC line insertion was not significantly different than the lowest incidence of thrombosis reported in the scientific literature among all patients receiving PICCs.

Conclusions
Results from this study do not suggest that persons with cervical spinal cord injuries are at increased risk for developing upper-extremity DVTs related to PICC insertion. Due to the retrospective nature of the present study and small sample size, prospective studies are recommended to further examine DVTs in patients' with spinal cord injuries. Estimates from the present study can be used in planning prospective studies.

Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness

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