Does anyone have any protocol on placing PICCS in patients on argatroban drips? Historically, our docs have placed them in IR. Thoughts?
A PICC would be the best option, safest CVAD, for any patient on any type of anticoagulant. That is the generally accepted consensus among experts. You can more easily manage any bleeding problem at a PICC insertion site than at the subclavian (due to close proximity of clavicle) and jugular (close proximity of large nerves, neck motion, etc) sites. It looks like no one has responded with experience specific to this drug though. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Office Phone 770-358-7861
The argatroban protocol we use is very similar to our heparin protocol with the same type of rate adjustments according to coag labs. We are very careful with the argatroban as it is quite expensive. Generally we are talking about chest pain patients and any ongoing anticoagulation therapy will be quickly bridged to coumadin. Because the therapy is so short term, peripheral iv's are all we have used so far.
I am curious as to why you would send a patient in Critical Care to IR for a line that can be placed at the bedside. Do you send all patients without trying them first? You may want to investigate how your IR department places PICCs. In some facilities, I have seen the Rad tech or IR Nurse be the one to place the line, with the tech working Flouro. Some facilities use a PA or ARNP. Usually the MDs are tied up with more complicated procedures, and send the PICCs to other clinicians. Often the same technique and tools are used that you use at the bedside. Sometimes IR departments have strange "rules" for patients needing a PICC. Does your IR asses what type of line the patient needs, best vessel to place and other assessments prior to placement? Some IRs "only place 5FR DL" in patients, and the vein selection is determined only by how the patient is placed on the table.
My point is this, you have the best tools and best assessment skills to get the line in the patient with the least amount of trauma to the patient. Agratroban is just like any other anticoagulent, so place the smalles line possible, use one stick, don't make a skin nick and hold pressure or use a clotting dressing (like Bioseal) after the line is placed.
Each patient needs to be assessed on an individual basis, rather than making blanket "rules" or protocols. Medicine is not black and white.
Chris Cavanaugh, RN, BSN, CRNI, VA-BC
I work in a cardiac hospital and we regularly place piccs in patients on argatroban as well as heparin. We have no parameters for not inserting the picc at the bedside from a coag point of view. We will use Bioseal at the site in those patients.
D. Cole, RN, CRNI, VA-BC
Darilyn Cole, RN, CRNI, VA-BC
PICC Team Mercy General Hospital Sacramento, CA
thank you all for your comments. We shut off heparin for 1-hr prior. How are you handling the argatroban? is there even a need to stop these infusions for PICC placment?
Cheryl E. Aldo, RN, BS VA-BC