This is a follow up to my post from yesterday. Pt presents with forearm swelling over a week. Picc is in basilic vein about 3cm above the A.C. 5FR dual lumen solo power PICC used. PICC had been in place for 11 days. Venous doppler shows Venous thrombosis of the bracihal vein. Pt on heparin therapy and has no complaints with PICC. No tenderness or pain with infusion. M.D. ordered PICC line out. Any thought on this?
I would agree with the order to remove the PICC. If the pt has a blocked Brachial and a Basilic partially blocked by the PICC, this only leaves the Cephalic for blood to leave the arm. Removing the PICC would hopefully allow blood to flow again through the Basilic.
Putting the PICC in the other arm (if possible) may be a better Idea.
Cheryl Kelley RN BSN, VA-BC
In reference to upper extremity and surrounding chest area deep vein thrombosis, in the past I have read differing material on the subject whether another PICC should even be placed in the opposite extremeity even after Heparin therapy was started. I have also read information that once a patient has a history of DVT in either upper extremity or chest area that this would constitute reason enough to contraindicate the placement of a PICC line. If anyone can comment on this subject I would really appreciate having the correct information to finally know exactly what the correct standard of practice is concerning this subject.
Thanks in advance!
Recent research leads to more questions. However, I found this article enlightening:
Sajid, M., Ahmed, N., Desai, M., Baker, D, and Hamilton, G.: "Upper Limb Deep Vein Thrombosis: A Literature Review to Streamline the Protocol for Management", Acta Haematol 2007; 118: 10-18.
On page 13: "There is no consensus regarding the optimum treatment of ULDVT because of difficulty in obtaining an adequate number of patients for an acceptable prospective randomized trial." (my thought: yes, I know, help me out here . . . )
On page 14 of this article there is a flowchart for treatment of catheter related secondary ULDVT. From this flowchart I am determining:
catheter independent: anticoagulate, then remove catheter
catheter dependent with infection/line sepsis: remove catheter, anticoagulate
catheter dependent without infection AND less than 1 week-old thrombus or less than 2cm thrombus: anticoagulation, fibrinolysis OR thrombectomy, preservation of catheter.
catheter dependent without infection AND greater than 1 week old thrombus or greater than 2cm thrombus: anticoagulation, remove catheter
ULDVT = Upper limb deep vein thrombosis.
UEDVT = upper extremity deep vein thrombosis (in other articles)
UEVT = upper extremity venous thrombosis.
in another article, "superficial" was defined as involving the cephalic, basilic, external jugular, or axillary veins and did not extend into the innominate, subclavian, or internal jugular veins. "Deep" was if the thrombus extended into the subclavian vein or was located more centrally. (Chemaly R., et al: Venous Thrombosis Associated with Peripherally Inserted Central Catheters: A retrospective Analysis of the Cleveland Clinic Experience. Clinical Infectious Diseases 2002; 34:1179-83.)
Treatment included anticoagulation therapy with heparin IV then warfarin; warfarin alone; heparin SQ, PICC removal only, and SVC filter. Mechanical devices are also discussed in some articles.
Carole