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RDSimpson
PICCs and Thrombus

I am a PICC nurse in a community hospital without a vascular access team. We have 6 RN's trained and certified to insert PICCs and we are doing about 200 per year. We are using Bard Solo PowerPiccs and Sherlock. For the 1st year and a half we had almost no PICC related thrombus. Now, we have had 5 in the last month and our physicians are expressing concern. Anyone else have a sudden increase like this? What could be the problem? Is the law of averages just catching up to us?

Since we don't have a "team" our data collection is not the greatest, however there seems to be no commonality to these cases.Each line was placed by a different nurse.

3 of 5 were not on DVT prophylaxis, 2 were on Lovenox.

4 were 5 fr. DL, 1 was a 6 fr. TL.

4 of the 5 were in the ICU at one time or another.

4 had dwell times of 2 weeks or more. 1 had dwelled only 3 days.

Thanks for any input.

Julie Shomo
My first question would be

My first question would be "are you are measuring the vein size prior to insertion?'.  If the vein size is too small to safely allow plenty of blood flow around the PICC, the risk of thrombus rises significantly. Dr. Thomas Nifong has presented information at AVA and around the country using research to show how thrombus risk increases as the area for blood flow around the catheter in the vein decreases.  I was shocked at how quickly the thrombus risk increases when you put a catheter in a smaller vein.  Our team is now measuring the vein size before insertion with NO Tourniquest on.  No significant data has shown exactly what percentage of the vein the catheter can safely take, however  50% is considered the highest allowable area the catheter should take within the vein.  Our team is generally using 30% as a standard.  If the vein is a small size such that more than 30% of the vein will be occupied by the catheter, we discuss the risk with the physician and look for another infusion route if possible. We all know there are some train wreck patients that have very few options, so the discussion with the physician allows us to collaborate together to determine the safest therapy route for the patient.

 

Julie Shomo BS, BSN, RN, CRNI

Infusion Solution LLC

Julie Shomo BS, BSN, RN, CRNI

Infusion Solution LLC

RDSimpson
Thank you for your comment.

Thank you for your comment. Yes we do assess vein size pre-insertion without a tourniquet. That doesn't seem to be the issue. We are also using 30%. I had the pleasure of hearing Dr. Nifon at AVA. 

Richard Simpson RN, CCRN

Richard Simpson RN, CCRN

Karen Day
Karen Day's picture
Julie can you give us some

Julie

can you give us some measuring tips.  we too measure the vessel and follow the 30% or 50% rule.  i am assuming that since a 5Fr dual lumen catheter has a diameter of .167cm, then our vessel should range in size from at least .33cm to .50cm to fall within this ratio, preferably more towards the .52cm size?  Am I using the correct formula?

thanks

 

RDSimpson
That sounds correct. We use

That sounds correct. We use Site-Rite 5 and utilize the cm markings on the screen to estimate vessel diameter.

Richard Simpson RN, CCRN

Richard Simpson RN, CCRN

Chris Cavanaugh
There are ultrasound

There are ultrasound machines available now that can give you an accurate measurement, which you can document by photo, instead of just having to "guesstimate"

Chris Cavanaugh, CRNI

Chris Cavanaugh, RN, BSN, CRNI, VA-BC

afruitloop
FYI, it is very difficult to

FYI, it is very difficult to "eyeball" mm or worse yet, tenths of mm, such as the difference between a vessel that measures 3.2 mm and let's say 4.0mm.  Simply placing the catheter into the vessel creates venous stasis.  If the vessel is "border line" simply move up the extremity, where the CVR is better. 

I hesitate when I say this, but I will, LOL.  If your catheter is reverse tapered, remember the 4F PICC is 1.67 from outer wall to outer wall.  So if your catheter tapers to a 7F, you must now do your calculation on the 7F size, which is about 2.3mm from outer wall to outer wall, thus requiring a vessel that measures about 6.9mm.  You can see that taking into consideration the taper increases the need for a larger vessel. 

Thanks.  

Cheryl Kelley RN BSN, VA-BC

kokotis
Kathy Kokotis Bard Access

Kathy Kokotis

Bard Access Systems

If you have access to Journal of Infusion Nursing I suggest you read the article on "predictibility of thrombosis" which was very well done.  there is a tool in the article to assess thrombosis risk.  I would see where your patients fall in relation to the risk factors

Kathy Kokotis

Bard Access Systems

Candee Eisenhar...
Does anyone know the

Does anyone know the timeframe that a vein w/thrombus can be used?  I have generally just avoided any arm with a hx of dvt. period.  After appropriate treatment, is there a time period where you could use that arm? 

Candee Eisenhart RN, CRNI, VA-BC

Chris Cavanaugh
I would imagine it would be

I would imagine it would be different on each patient, depending on how long it takes that patient's body to heal and dissolve the thrombosis.  This is where a good vessel assessment using ultrasound is so important.  Prior to placing the PICC, without a tourniquet, look at the veins all the way up the arm to the axillary.  If they compress easily all the way up, then the vein is OK to use.  If they do not compress easily, the vein is not OK to use.  

Chris Cavanaugh, CRNI

Chris Cavanaugh, RN, BSN, CRNI, VA-BC

fizerjk
It seems most of those were
It seems most of those were patients at the greatest risk for DVT anyway. I don't know of the research to back this up but the larger the catheter the greater the risk of thrombosis.

Jeffery Fizer RN, BSN

Karen Day
Karen Day's picture
Kathy, is the article in the

Kathy,

is the article in the Journal of Infusion Nursing the same as the one I have attached here?

 

kokotis
Kathy Kokotis Bard Access

Kathy Kokotis

Bard Access Systems

Thanks for attaching the predictibility article. It is a nice screening tool.  Your highest rate was the 5 French not the 6 French so it is not size.  It is patient related.  Please relate the patient factors after your review using the article.  From your analsis prophylaxis does not prevent thrombus and that is what the literature states that has been recently published.  I do find that the majority occuring after two weeks to be a surprise as most appear in 14 days.  Were these oncology patient backgrounds?  Kathy

Kathy Kokotis

Bard Access Systems

Hi. was your increase in DVT

Hi. was your increase in DVT related to a change in catheters?  We have seen a trend in DVT in open ended catheters verses  closed end.  Currently, our IV team only places bard 5f dl picc, we are looking into solo piccs so would be interested in your response.

TY for the screening tool, very interesting article.

TY

Andrea

dsnyrn

RDSimpson
Thank you for the article.

Thank you for the article. We have not changed catheters in the last year. We use all Bard Solo 5 and 6 Fr.

We went about a year with virtually no DVT and then had this cluster. I'm beginning to think that this was a situation where the laws of probability just caught up to us. Over the last 1 1/2 years our rate is actually just below 2%. We've had nothing in the last 2 weeks.

I did discover that each of the patients had been in the ICU at one time or another.

None were oncology patients.

 

Richard Simpson RN, CCRN

Richard Simpson RN, CCRN

lynncrni
A 5 Fr is not required for

A 5 Fr is not required for every patient. Certainly a dual lumen is not required for every patient. I have been the expert in cases where nurses only placed dual lumen catheters and patients with many risk for DVT were developing serious life-long problems from the thrombus that developed. I will always testify that the patient should be evaluated for the most appropriate size catheter and number of lumens. For 2 antibiotics only in a stable patient, a dual lumen is never appropriate in my opinion. Studies have shown that larger catheters produce great numbers of DVT. I recently heard Dr. Tom Nifong speak about this. He was also at AVA last year. He is getting his work ready to be published about the size of the catheter in relationship to the size of the vein lumen. Smaller will always be better for the vein. 

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

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

RDSimpson
I agree that 5 fr is not

I agree that 5 fr is not needed for every patient. However, all of our PICC's are beinbg placed in acutely ill hospitalized patients who have need for more than one IV site and frequent lab draws.

Richard Simpson RN, CCRN

Richard Simpson RN, CCRN

afruitloop
In my previous practice with

In my previous practice with 200 PICC's placed per month, in a level 1 trauma center in a large teaching facilty, the division between 4F single and 5F dual was about 50/50.  Just because a patient needs blood draws does not mean he needs a dual lumen.  INS and CDC both recommend the least # of lumens required to deliver the therapy needed.

When assessing the need for which size of PICC, please beware that consideration must also be made as to what type of line.  Nurses who do not have in depth education in the very details of all of the lines on the market, PIV, midine, PICC, antimocrobial CVC, non antimicrobial CVC, tunneled lines, ports, etc are ony using as their chose of line that of which they are familiar with, that being a PICC.

Thanks.

Cheryl Kelley RN BSN, VA-BC

Wendy Erickson RN
We too have had a cluster of
We too have had a cluster of UEDVTs.  I found the Seeley/Santiago/Shott article to be very helpful.  What is recommended for prophylaxis once you determine that the patient is at high risk of DVT?  What is everyone using and at what dosages?  Thanks!

Wendy Erickson RN
Eau Claire WI

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