I have an oncology patient with a platelet count of 1-2. Her MD has decided that a PICC line will be placed while she is getting an infusion of platelets from a PIV site. Has any one had any experience with this theory? The patient needs long term IV abx therapy.
There isn't a better line for this type of patient! I've seen this approach of infusing platelets during invasive procedures for thrombocytopenics, but I've never seen a study establishing it's benefit or safety. Still, there isn't a better type of VAD for these people, in the absence of other contraindications (ESRD, um...). Just my two cents.
Keith W. Gilchrist, MSN, RN, PHN, OCN, CRNI, VA-BC
Oncology Nurse Navigator, David Grant Medical Center
Travis AFB, CA
We place PICCS in patients quite frequently with very low platelet counts. We like to have them minimum of 40 but if they are lower we infuse platelets while placeing the line. Statseal takes care of the bleeding issue post line placement.
I agree that any patient with any type of bleeding risk is far better with a PICC than any other type of percutaneous CVAD. Fewer nearby critical structures to be damaged and direct pressure can easily be applied to control bleeding if required. This is not true for subclavian or jugular sites. 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
We place PICCs with low platelets but ask the MD to write an order stating that it is "OK to place PICC with platelets of ___". Our cut off is 50, then request the order. We also use StatSeal for those pts to control bleeding.
Linda C. Smith, RN
I placed 1 PICC for a patient with platelet of 2. no bleeding whatsoever.
Do you even realize the risks of doing this? what if the outcome is different and they take you to court because you tought it was going to be fine? What would be your answer to the question Why did you do it knowing guidelines called for better platelet count before placement of a vascular access device. Don't want to be negative, but I believer there is a reason why guidelines exist.
Sorry Santos, but there are no published guidelines or standards from any organization stating the lowest level of platelets or any coag factors when a PICC or other CVAD should not be inserted. It is a matter of weighing the risk vs benefit.If the patient truly needs a CVAD to infuse the prescribed infusion therapy, then a PICC presents the lowest risk because you can put direct pressure on the PICC insertion site. This is not true of a subclavian site. All factors considered in the decisoin to place a PICC in this situation must be documented to support your decision. Don't just think about it and do it. Write down your thoughts and reasons in the medical record. In case of a lawsuit, this documentation will be very important to support what was done and why. We can not avoid all risk in every situation, so it is up to knowledgeable professionals to choose the option with the least risk. 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
Sorry Santos can't agree with you here. Early on in our practice there was a guideline for ruling out PICC placement. Anything under 50,000 plt would not be done at the bedside. But I think time and research has proven that unwarranted. As a matter of fact, it is the safest line to insert. Lawsuit?...well we can have a lawsuit brought against us for anything. Just know what your doing.
Jack
Hi Jack,
Thanks for your response, unfortunately we have to follow hospital policies and where I work there are guidelines on placement of PICC lines. Practice can vary from
place to place, it does not mean it is right or wrong, simply different. If the PICC line is an emergency I would probably take the risk, but if the patient can wait
I don't see the need to expose him/her to bleeding. ACR shows guidelines and recommendations on this if you want to look into this.
Thanks
agree with you.
Make it 4 cents....that's my experience no safer access.
I also agree with Lynn and Jack. I do have a thought to add- Many times this type of patient may "eat" up their platelets shortly after transfusion, so inserting the PICC line during the platelet transfusion is a great option to have. Many times we don't have the option of having peripheral access when inserting a PICC. Benefit/Risk ratio consideration and documentation are always the best practice. We can't just walk away saying- "Not a PICC Candidate". I also wonder if they are transfusing HLA matched platelets for this patient as they may provide a longer period of an increased platelet count and activity for this patient.
Juline DiSilvestro BSN, RN, CRNI, VA-BC, CPUI
Central Access Team Nurse
Inspira Medical Center- Woodbury,NJ
Hi Juline,
How are things going at Inspira?...probably a good idea if you say you only agree with Lynn. The mention of my name will not bode well...LOL
Jack
Not much new at Inspira. Still not permitted to start inserting jugular lines- still frustrated!
Juline DiSilvestro BSN, RN, CRNI, VA-BC, CPUI
Central Access Team Nurse
Inspira Medical Center- Woodbury,NJ
It is probably even more important when you both agree.
Juline DiSilvestro BSN, RN, CRNI, VA-BC, CPUI
Central Access Team Nurse
Inspira Medical Center- Woodbury,NJ
Here are references:
AABB Clinical Practice Guideline 2015 from Annals of Internal Medicine: "The AABB suggests prophylactic platelet transfusion for patients having elective central venous catheter placement for a platelet count of less than 20 x 109 cells/L." (Grade: weak recommendation; low-quality evidence)
Comparison of different platelet transfusion thresholds prior to insertion of central lines in patients with thrombocytopenia. Cochrane Database of Systematic Reviews 2015, Issue 12. Art. No.: CD011771. DOI: 10.1002/14651858.CD011771.pub2.
In my department, we are assuming that the AABB recommendation for central lines means IJ, SC, or femoral. But we use the 20,000 guideline when initiating a conversation with the physician ordering a picc. My most recent experience was oncology patient with platelet count 4000, had single implanted port with poor peripheral access and needed PN, blood products, abx, prn meds. Established piv for platelet transfusion and inserted dual lumen picc. No excessive bleeding before or after insertion.
Patti Dickinson CRNI VA-BC
Lawrence Memorial Hospital
Lawrence, KS