we have a new medical director for our picc team who is opposed to inserting a picc line in any dialysis pt. this population includes any pt s/p renal transplant, has a av shunt, currently on peritoneal dialysis, esrd dx, etc. most of our picc nurses disagree as well as most of the house md staff. any literature out there? i have read esrd as a contraindication in a couple of places. any input welcome
thanks,
jim willman, rn
picc team/interventional radiology
If a patient has renal problems, we have to get an OK from the nephrologist, if there is one, and if not, the attending. They know the patient best and can better look at the patient's needs and future needs. Janet Brown-Wise, RN
There is a great article by Dr. McLennam titled "Vein Preservation: An Algorithmic Approach to Vascular Access Placement in Patients with Compromised Renal Function".
Published in JAVA, Summer 2007 edition, volume 12 number 2
It's important that all vascular access RNs understand this issue and not place PIVs or PICCs in the arms of Chronic Renal failure patients.
Margy Galloway, RN
PICC team Clinical Educator
We also discuss the PICC insertion with the nephrologist. Some of them are absolutly against a PICC and a few want a PICC in the dominant arm. It still requires asking them what they really want.
Gwen
Austin, Texas
We do not place PICCs in renal patients unless there are extenuating circumstances. In the last five years I have placed 2 PICCs in renal patients, both with the blessing of the nephrologist. One was CRF, and the renal doc said that her cardiac condition would kill her long before she was a candidate for dialysis, and the other pt was imminently terminal. One of my teammates placed one in a pt who refused dialysis. We assess the pt's creatinine level, as well as its trends. For ARF pts, we wait to make sure the RF is turning around before placing a PICC. CRF patients are likely to become ESRD, so we preserve their veins also.
Even if the pt has an AV fistula, that fistula is unlikely to effectively work longer than a few years, and the patient will need another. If the pt has had a PICC, there is a distinct possibility of stenosis somewhere in the vessel where the catheter had been. This stenosis could reduce blood return enough to make it unusable for creation of a functioning AV fistula in that vessel. Stenosis in the subclavian (not uncommon) can reduce blood flow proximal to that.
The best access for a renal pt is often a right IJ, as it is the shortest, straightest path to the SVC. If access is needed for long-term therapy, a tunneled right IJ is preferable.
There is much documentation on this, including a couple of excellent articles by Tom Vesely. One was in JAVA, and discussed the role of PICCs with renal patients.
Fistula First is the best way of providing hemodialysis access. We have to take responsibility for preserving veins for fistulas, and we need to educate physicians (even some nephrologists) and nurses about the need for peripheral vessel preservation for these patients. Any nephrologist who is not aware that veins need to be preserved for fistula access also needs education. This is not common, but I have been to some areas in which the nephrologists do not seem to be seeking education, and do not use fistulas or have adequate education about vascular access.
Leigh Ann Bowe-Geddes, RN, CRNI
University of Louisville Hospital
Ditto with Leigh Ann. Renal patients need their access for dialysis. PIV's are even a danger to them.
Heather