Reviewing our indications and contraindications for PICC insertions and looking for input:
Is history of upper arm venous thrombosis (superficial or deep) an absolute contraindication?
If patient has current upper arm venous thrombosis (superficial or deep), do you place on the opposite arm?
If the patient is on anticoagulants, does that make a difference?
Regarding blood cultures, assuming there is an indication for PICC:
If the patient has blood cultures (BC) still pending, do you wait until you have final results to place PICC?
If the cultures are drawn and the patient is on antibiotics, do you place the PICC before BC are final?
Appreciate any input.
Marcia
Yes, history of SVT or DVT is important when making your assessment. Current SVT or DVT in the veins to be used for insertion and advancement is a contraindication for PICC placement. If DVT develops after PICC is inserted, it should be treated and NOT removed IF tip locatio is correct, there is a blood return and no signs/symptoms of infection.
Anticoagulants do not make a difference, insert it with those on board.
Make sure all blood cultures are obtained before starting ABX and if possible before PICC insertion. But you can not hold treatment until BC results are known. Treatment must begin immediately with the VAD that is the most appropriate for that patient, including a CVAD. Do NOT wait for BC results to place any CVAD. 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
While attending the AVA convention last September Dr. Chopra gave a presentation of MAGIC. Which was developed after a large study about appropriateness of CVAD placement in several clinical situations. The situation refering to PICC placement while blood cultures are resulting stated that a PICC should not be placed for 48 hours while blood cultures are resulting and if blood cultures are positive you should wait until Blood cultures become negative. Of course you wouldn't hold treatment until BC resulted but a PIV can be placed for the first 48 hours of administration. In the situation that no PIV can be found then the decision to place a CVAD might have to be addressed but the best practice is to wait BC to result in 48 hours.
With all due respect to Vineet Chopra, he is not an epidemiologist or infection disease specialist. I would look to this group for a more definitive answer on infection issues. In speaking with a leading epidemiologist, I have learned that the Infectious Disease Society of America is working on an update to their guidelines for diagnosis and managing CRBSI. Please note this is different from CLABSI, which is a surveillance process not a clinical diagnostic process. The new guidelines on sepsis and severe sepsis emphasize the importance of rapid treatment with large volumes of fluids, and medications. A CVAD need for sure. So holding off the insertion of any CVAD waiting for cultures is not appropriate. Any type of VAD can become colonized after insertion, including a short PIVC. So the goal should be to immediately insert the most appropriate VAD based on patient infusion needs. We will have to wait for these new IDSA guidelines to be released and see if they address this issue.
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
The infection disease group we work with are following our hospital policy regarding waiting 48 hours post antibiotics initation when blood cultures are drawn prior to PICC placement. The attached article shows a study that was published in the Journal of Vascular and Interventional Radiology showing the increase in infected PICC's when placed in patients with positive cultures during the first 48-72 hours.
I think we are dealing with 2 different scenarios. Patient is not diagnosed, admitted with fever of unknown origin, maybe other S&S. Needs to be on some type of ABX after cultures obtained. It would be very appropriate to determine the plan of care before inserting any type of CVAD. Once culture results are known and long term ABX is prescribed, then an appropriate CVAD can and should be placed. I would not recommend waiting for cultures to clear. That could take a long time depending on the organism and its location.
If there is a suspicion of CRBSI and a CVAD in place, it is not appropriate to pull the CVAD without knowing it is the cause. If that CVAD is determined to be the cause, it should be removed and there are no standards or guidelines at this point instructing to wait any amount of time before a new CVAD is inserted.
We have very little data on PIV-BSI and there is limited information in a few populations that PIVs inserted before a CVAD is actually the cause of some CLABSIs. Definitely need more data.
As you mentioned, each facility makes their own policies and most of the time, this is dependend upon the physician and not a written policy. The study you mentioned is familiar to me. It is one study, retrospective, nonrandomized, low level of evidence. I am not aware of others with similar outcomes. We will have to wait to see what IDSA recommends in their new set of guidelines. Now each facility must do a literature search, analyze the evidence and make their own decision. 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
Thank you Lynn
I think we are talking different patient groups. I am saying that we need to determine plan of care prior to placement of a PICC which usually takes sometime after blood cultures are done which is why our policy is to wait 48 hours for placement.
I wish I could get all the physician to determine the PICC is the source of infection prior to removing when patient has a temperature spike but they seem to be stuck in the idea of pulling all lines when in this scenario.
Thank you so much for this conversation. The information that the Infectious disease organization is looking for best practice in this area is exciting and I look forward to their recommendation.
Fever alone is not an indication to remove is already addressed by CDC, SHEA, APIC, and INS.
IDSA also has guidelines from 2009 about diagnosing and managing CRBSI. This is what is being updated now.
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