We had a patient with PICC that flushes but is without blood return. Patient was dopplered and found to have a non-occlusive DVT in same vein as PICC. Is there a contraindication to using cath-flo on this patient? Pts PICC in place per CXR, patients arm asymptomatic. If cath-flo IS contraindicated, should PICC come out, or be used without blood return??
The criteria for leaving a PICC in place in the presence of a DVT is correctly positioned catheter at the CAJ, absence of infection, a fully functioning catheter with no resistance to flush AND a blood return, and absence of extreme patient complaints of pain. You have not provided enough information to determine if tPA is contraindicated for this particular patient. There are protocols where low dose infusions of tPA have been used for situations like this but you would need to do a complete patient assessment of the risk factors for those contraindications for tPA. 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
I have a very similar question. I work for a PICC placement service, and received a call to replace a PICC. Pt had line placed in hospital, so it is correctly positioned; flushes with no resistance, but unable to obtain blood return. Pt C/O pain in arm with PICC, new onset. MD wants PICC removed, and replaced in other arm, while waiting for US to R/O DVT. Pt has a known history of previous DVT. I asked the nurse not to remove the current PICC until I can obtain a reasonable answer for her. If we remove the current PICC, it is possible that we might not be able to get another line in; I can't put another PICC in the same arm, and I should not use the arm that already had a DVT. My inclination is to have her sent to hospital, but I am sure that at one of the AVA conferences, we had a speaker tell us not to remove a PICC d/t DVT, but to treat through it, to maintain Access. Any insights ot thoughts on this?
These articles discuss management of catheter-related UEDVT:
1. Clinical practice. Deep-vein thrombosis of the upper extremities. Kucher N. N Engl J Med. 2011;364(9):861.
2. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, Nelson ME, Wells PS, Gould MK, Dentali F, Crowther M, Kahn SR, American College of Chest Physicians.
Chest. 2012;141(2 Suppl):e419S.
Basically, the recommendation is to not routinely remove a functioning line I the setting of catheter-related UEDVT. "Routine removal of the catheter is not recommended. In patients who have an ongoing need for the catheter, it is reasonable to administer anticoagulant therapy without catheter removal, provided the line remains functional and well-positioned (as cited in UptoDate).
Of course your line does not give blood return, so perhaps a course of alteplase (as long as it is not contraindicated by conditions not mentioned in your scenario) would give you a functional line that could stay in place during and after anticoagulation.
Keith W. Gilchrist, MSN, RN, PHN, OCN, CRNI, VA-BC
Oncology Nurse Navigator, David Grant Medical Center
Travis AFB, CA
My criteria for line removal in the presence of DVT comes from Keith's #2 reference. The line has to be functioning properly which does include a blood return. Chances are the problem being described is due to a fibrin sheath. This sheath could be just a flap or tail over the catheter tip, a partial shealth or a complete sheath the entire length of the catheter. You have no way to know which is the case at the bedside. This requires a cathetergram to diagnose. The complete fibrin sheath has been documented to cause infiltraiton/extravasation events. The original question was about "contraindications" for tPA. That is based on patient factors that were not included in the original post. This situation is an indication for tPA. 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