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Amy Graham
DVT Rate

I have read the previous posts on DVT's with PICC lines and have a few questions.  The number of PICC lines that I place steadly increases, average montlhy in 2007-16, current average in 2008-23.  I had one DVT last year that was symptomatic.  This year I have had 4, overall DVT rate in 2008 is 3.7%.  Is there a rate that I should be below?  Should I expect there to be zero DVT's?  I swithced form the Groshong PICC's to Solo Power PICC's and am considering switching back.  I am reviewing the PICC notes on the placement of the 4 to see if I would do something different in the future.  Thank you.

swensonals
Amy, I do the stats for our
Amy, I do the stats for our vascular access dept, and the rate we use is 5% or less.  One threshold reported by  Interventional Radiologists is 6%, and we felt we could do better.  There are some months we have had 0 DVTs, and some a few where the rate was 8% (when this happened, we did some intensive looking at possible causes/risk factors, to try to find reasons for big jumps in the rate). On the average we run between 2.5 to 3.5%. There are many causes for DVTs occuring:  age, gender, which side the line was placed, manipulation of the line (like repositioning), the patient's predisposition to thrombosis, whether the patient is on any kind of anticoagulants, certain diagnosis (like cancer), size of the vein and the size of the catheter placed in it, and on and on. We track thrombus (nonocclusive/occlusive, peripheral vein, such as basilic, brachial, cephalic) and DVT (deep vein, axillary, subclavian, jugular, innominate, SVC) together, as usually our team identifies patients with symptoms (loss of blood return, increase in upper arm circumference, pain, tightness) during routine care (we do the dressing changes and blood draws from these lines throughout our hospital). It is routine for us to ask for a venous doppler if we suspect the patient is developing a thrombosis. We switched from Groshong PICCs to Power PICCs, without any significant change in our DVT rate. We did a short trial of the Solo PICCs, but had difficulty with the valve not working well enough during blood draws that we went back to the Power PICCs.  As far as getting to zero DVTs, I'm not sure if that is possible, only because there are so many variables.  What I have read indicates that using the smallest size PICC that will accomplish what the patient needs may lower the rate of thrombosis, and again for the least amount of time necessary. Hope this is helpful!
kokotis
Kathy Kokotis Bard Access

Kathy Kokotis

Bard Access Systems

Wow SWen from Alexian Brothers I commend you on your answer.  There is no way to get rid of DVT's.  In fact I believe that 70% of all VAD patients not just PICC patients have asymptomatic DVT's.  So let' s talk symptomatic DVT's that one treats.  The society of interventional radiology has published a benchmark in 2004 in the quality indicator gudelines for vascular access in their journal the JVIR and it is 6%.  Patients have so many factors that the rate will never be zero.  As we use more and more PICC lines in higher risk patients i.e. ICU etc the rate will be higher than we ever saw before.

What is anyone kidding.  We used to only use 3 and 4 F lines before and only did halfway sick patients going home.  No wonder our DVT and infection rates for PICC lines were low.  Think about it???  We now use ultrasound and the patients we get are train wrecks full of multiple issues.  You want a low DVT rate.  How would it even be clinically possible.  Triple lumen PICC lines allowed us to access sicker patients and so did ultrasound as well as catheters that do power injection, CVP.  All of these toys put you into placing PICC lines in patients that are high risk for DVT regardless of the line. 

Thank you SWEN from Alexian for finally spelling it out it is the patient variables that cannot be controlled.  Someone finally spelled it out

Kathy Kokotis

Bard Access Systems

Kathy Kokotis

Bard Access Systems

momdogz
I agree it may not be

I agree it may not be possible to have zero thrombi.  I think most of us that have been discussing this issue try hard to manage the variables that we can.  Our team has excellent relationships with physicians, we discuss patient cases comprehensively as necessary, and then make a collabortive decision.

this is a partial repost from another thread about risks:

   ***** Inflammatory disease process present (data shows increase thrombotic risk - includes crohns, ulcerative colitis), Cancer, Immobility, Pregnancy/puerperium, family history of hypercoagulability, DVT or PE in first degree relatives, multiple venipunctures (associated with higher thrombosis rate of 38% - great case for early vascular assessment!), diabetes and HTN (prior damage to endothelium), high procoag factors (Factor II, VIII, IX and XI).

    It doesn't mean we don't place PICCs in these patients (a large percentage of patients!), but it is very helpful in our assessment, and planning with MDs.  For e.g., if they are not on anticoags and it's not contraindicated, the above scenarios might influence that decision.  This information also supports EXCELLENT discharge planning/case management/pt. teaching.  And, as mentioned above - some of these risk factors are excellent arguments FOR a PICC line (.....and some not).*****

It's not black and white, but one part of a thoughtful preplacement evaluation.  Understanding that thrombi - silent particularly - are likely part of the picture for any patient, can we help prevent clinical complications by having a better understanding? or should we just throw up our hands and disregard?

A couple of years ago I discovered a patient that had an cephalic vein induration/cording from the PICC insertion site (above antecubital) along the entire length of her arm.  Her arm had the 5 cardinal signs of inflammation - dolor, rubor, calor, tumor, and functio laesa (the 5th added by Virchow).  I had the MD do doppler studies, and found she had occlusive thrombus from elbow to neck, starting with at least the brachial and cephalic veins.  I think the basilic was partially occluded, and then extended into the axillary, subclavian, and brachiocephalic.

It was a left sided PICC.  It was in the cephalic vein.  The patient was very thin, and on parenteral nutrition for Crohns.

We could argue whether any of these potential risks were causative, though I believe that until we have more definitive studies we need to err on the side of caution. 

If the PICC RN had been more aware of the risks involved (including patient with inflammatory disease), I doubt she would have placed the PICC where she did, and I believe could have helped to prevent this outcome.  I don't remember her rationale for using the cephalic in the first place, but I do know that she takes all of the above considerations much more seriously now.

NKF takes this situation very seriously as well with their fistula first program - we can't make vascular access decisions about our patients in a vacuum.  Again - early vascular assessment and whenever possible - with a macro view.  What kind of vascular access is the patient going to need in the future?  Will the type of line you're placing and where you're placing it, have a negative outcome for the patient in the future?  Is it still the best possible choice?

Maybe.  Maybe not.  That's why each patient's case is unique.  

Mari Cordes, BS RN 

Nurse Educator IV Therapy
Fletcher Allen Health Care, Burlington VT
Educator, Bard Access Systems 

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

bnosal
Study attached
Study attached
Michael Drafz
Michael Drafz Vascular

Michael Drafz

Vascular Access Specialist

Sharp Memorial Hospital San Diego, CA

 

I agree that we will not see zero thrombosis rates. The variables are so plentyful which can contribute to thrombus formation. We recently readmitted a patient in which I placed a 6 fr. triple lumen PerQCath picc 3 years ago, I almost couldn't believe my eyes that he had zero (symptomatic) complications. He had all the risk factors you can think of (left arm, skinny, small veins, HX cancer, on TPN.

Then we have patients which have a single lumen line for one day and they have close to none of the risk factors and they already have a thrombus.

I believe that most factors are beyond our control.

Following the simple rules like smallest size in largest vein to accomodate perscribed therapy, using ultrasound for placement in the upper arm with good technique for example,will in most cases be all you can do.

One thing I started doing is putting an disposable instant hot pack on the insertion site one I finished placement/dressing.

The other thing is that I tell patients to move their arms regularly, open and close their hands 10 times every hour if able and while awake. I think that this will help improve venous flow, most patients try not to move because they are afraid it is hurting the line.

None of this is scientific though, but our (symptomatic) thrombosis rates have dropped over the last months.

Michael Drafz RN, CRNI, VA-BC

Clinical Lead Vascular Access Service

Sharp Metropolitan Medical Campus

San Diego, CA

 

kokotis
Kathy Kokotis Bard Access

Kathy Kokotis

Bard Access Systems

Michael:

You may be on to something

First off if one reviews the literature on thrombosis the majority believe it or not occur in the first 12-14 days after line insertion.  That is symptomatic thrombosis.

Therefore if one is going to get it they get it rapidly

One can draw some comparison to difficulty on insertion, trauma etc.  The heat and range of motion promotes blood flow and may reduce blood stasis

It is worth study

 Kathy

Kathy Kokotis

Bard Access Systems

kokotis
Kathy Kokotis Bard Access

Kathy Kokotis

Bard Access Systems

Mari

Great discussion and info

There is a great new article from JVAD the AVA Journal this month and it shows left sided placements had the highest thrombosis rates when you look at the results.  75% occurred the left side.  they had zero thrombosis in the cephalic but had so few cephalic insertions it may not be necessarily true.  I think the key is the left sided insertions.  Check out the article in this months JVAD

Kathy

Kathy Kokotis

Bard Access Systems

momdogz
thanks Kathy....I have the

thanks Kathy....I have the journal sitting near my desk, but I've only glanced at the cover.  I'll have to try opening it up now!

 

Mari Cordes, BS RN 

Nurse Educator IV Therapy
Fletcher Allen Health Care, Burlington VT
Educator, Bard Access Systems 

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

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