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Karen Day
Karen Day's picture
PICC's and UE Thromboses

I know we have discussed this before, but I am sure there is some new and more recent data that you could direct me to.  Upper Extremity thrombosis r/t picc lines seem to be the number one concern right now with our physicians and I need to find some studies that provide current treatment regimens, recommendations etc for this.

I am aware of the patients that pose high risk factors for development of thrombosis (obesity, trauma, cancer, pregnancy, bed confined etc) and am also aware that with the technology of MST and the use of ultrasound, we have made great strides in reducing and identifying these, but still need some info to provide to my physicians who are concerned about the placement of picc lines due to this risk.  Recently one physician informed me that it was nothing personal against us or the use of picc lines, it was just that lawyers are tearing them apart when it comes to DVT's.  They need info on treatment measures (should we leave in if partially occlusive and treat with anticoagulants or pull the line).  Our neuro physicians are very reluctant to use picc lines because the majority of their patients are NOT candidates for anticoagulants and they don't want to take the chance on a thrombosis. I also realize that catheter selection can play a part in this, but I am quite positive that this is not the case with us.

One theory I have is that with the development of a dedicated picc team in our facility a little over 3 years ago, we have provided a large amount of education to our nurses regarding the care and maintenance of all central lines, to include picc lines.  With this new knowledge, were these DVT's there before and nurses were just ignorant to the fact to inquire about them or is there truly an increase in this problem?

I have included an article I recently came across and would like some input and thoughts from you.  Any ideas, studies etc. would be greatly appreciated.

 

lynncrni
As your article states in

As your article states in the first sentence of the abstract, there is no consensus on treatment and there are no published guidelines on the management of catheter related thrombosis from any professional organization. So you are left with having a collaborative group of professionals in your facility analyze the data and make the best decision for your patients. You have to arrive at you own decisions about the treatment. 

The only other resource that I can direct you to is a set of guidelines from the American College of Chest Physicians. You can download the entire set by starting here

http://www.chestjournal.org/content/133/6_suppl/71S.short?rss=1&ssource=mfc

I will warn you that the entire set of guidelines is quite long. I downloaded it and it took 2 very large binders to hold it all. They do not really address catheter related thrombosis except in one small section where they do not recommend the use of LMWH or warfarin as a prophylaxis in hospitalized cancer patients with CVCs. There are no other statements that I can find about the treatment of these CVC-related thromboses. 

I think you are correct about education drawing attention to the signs and symptoms and therefore the diagnosis which may have gone undetected previously. The largest majority of all CVCs have silent thromboses. This is true for all CVCs and not just PICCs. In fact the rates of thrombosis for PICCs is about the same as for other CVCs. Ultrasound has made it very easy to diagnose with a noninvasive method. So we are seeing more than ever before. 

From discussions I heard at the last AVA conference, the verbal information was to leave a catheter alone as long as it was properly functioning and not presenting huge clinical problems for the patient. Removal and reinsertion will only cause the same problem in the new site, however this is not published anywhere. I wish there was a clear direction from some professional organization, but no group has taken this on yet. 

 

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

Karen Day
Karen Day's picture
Has anyone ever done or know
Has anyone ever done or know of any published studies regarding the use of pneumatic stockings on the upper extremities to decrease the risk of thrombus (I don't even think there is a product currently on the market that would fit the upper extremities, but maybe people are using diabetic stockings or something like them or even having PT/RN's do increased ROM on the affected extremities).  One of our pulmonologists seems to think that this may prove beneficial - he said that maybe even something like plexi-pulses, but again I don't think there are any designed for the hands or upper extremities.  It sounds like it would make sense since it has helped with the lower extremites.  Any thoughts?
lynncrni
I would strongly advise

I would strongly advise against using any type of pressure device on an extremity with a PICC or midline catheter. Based on my knowledge of anatomy and physiology, I would think that these devices will do more harm than good and there are no studies to support their use for this purpose.

Think about normal venous blood flow. Muscles contract to put pressure on veins. Proximal valves open while distal valves close and blood moves back to the heart. This is known as the muscle pump or venous pump. These pressure devices are intended to assist with this normal process. When there is a catheter inside those veins, these pressure devices will bring the vein wall into greater contact with the catheter. This contact will disrupt the endothelial vein lining. This disruption exposes the basement membrane which then will start the clotting process. Therefore, in my opinion, these pressure devices would increase the presence of thrombosis, and not decrease the risk at all. 

Finally I would urge you to contact the manufacturers of these devices before you do it. I have not checked but I suspect this would be an off-label use, therefore you would bear the entire legal liability for the outcome. Just my opinion. Let use know if you attempt this and the outcome. 

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

nstenhouse
NStenhouseRN The National

NStenhouseRN

The National Comprehensive Cancer Network published extensive guidelines on therapy options for DVT treatment and cancer. They were published in 2007. The guidelines also recommend against removal of catheter in the presence of acute DVT, under certain circumstances. These guidelines can be found on the NCCN website.

NStenhouseRN

Karen Day
Karen Day's picture
we don't plan to attempt

we don't plan to attempt this as there are no products on the market intended for this, i just wanted to pose the question as one of my pulmonologists wanted to know if i knew of any studies or data regarding this.

 

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