Hi,
The patient is female, middle-aged, with a hx of PICC placement to right brachial in April 2012 at a different facility. May 2012 US shows DVTs in brachial, axilla, subclavian and IJ on same side as the PICC. Patient was started on Coumadin. June 2012 shows DVT in brachial, axilla and subclavian and PICC had been removed. July 6 shows DVT in axilla only. Still on Coumadin. Two days ago US was negative for DVT. Anticoagulation studies WNL at this point -- not sure if that was accidental because she received Coumadin yesterday.
Her right arm is still swollen down to her fingers and painful in the axilla. Her right hand is puffy and pale compared to left and is 1.5cm larger; forearm is 2 cm larger and upper arm 6.5 cm larger.
We decided to get another US and get Vascular Surgery on consult.
Is there anything else I can do for this patient?
Thank you,
Carole
I cannot think of other nursing interventions at this point. I am curious to know what the vascular surgeon diagnosed and prescribed. This sounds like venous valve insufficiency and post thrombotic syndrome. The venous valves may have been damaged and now are not working properly to promote venous return and thus the venous congestion, edema, etc in the forearm. There could be lots that could have prevented this outcome. You did not say the primary diagnosis and other hypercoagulability factors, the size of the PICC in relationship to the size of the vein, the tip location, type of stabilization and whether the PICC remained in the original location or had problems with secondary malposition, any issues with fluid volume deficits, etc. All of these factors could have an impact on catheter associated thrombosis development. Lynn
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
The patient had abdominal surgery for diverticulitis/diverticulosis originally. Then had another surgery to correct the first surgery. Then went to another physician to correct the other two surgeries and now has a colostomy. She states she will have another surgery in September to reverse the colostomy.
The PICC, according to x-rays, appeared to be lower SVC while it was in. I am unable to locate the original documentation regarding single or dual lumen or size of the catheter. I did a sneak peak at her right arm and found the brachial was large, able to be compressed and appeared patent from elbow to axilla. Her basilic is tiny and tortuous, listed on US reports as "normal flow, compressible."
She is going to need better vascular access and I do not want to put a PICC in on her left side, considering this history. I will write again with the doctor's recommendations.
Thank you,
Carole
You didn't mention WHEN the PICC was removed. I know the CHEST guidelines for management of DVT suggest keeping the PICC in place in the presence of DVT if it is working, etc. However, here are several studies that discuss the higher incidence of post-thrombotic syndrome in thrombosed vessels when the catheter remains in place as compared to removal and anticoagulation.
There are also several articles that discuss in patients who are at risk for CRBSI (neutropenic) that catheter removal, in the presence of UEDVT may also be the prudent thing to do. There is a strong relationship between infection and thrombosis. Because of this fact, one must look at individual patient situation for these decisions.
Cheryl Kelley RN BSN, VA-BC
You didn't mention WHEN the PICC was removed. I know the CHEST guidelines for management of DVT suggest keeping the PICC in place in the presence of DVT if it is working, etc. However, here are several studies that discuss the higher incidence of post-thrombotic syndrome in thrombosed vessels when the catheter remains in place as compared to removal and anticoagulation.
There are also several articles that discuss in patients who are at risk for CRBSI (neutropenic) that catheter removal, in the presence of UEDVT may also be the prudent thing to do. There is a strong relationship between infection and thrombosis. Because of this fact, one must look at individual patient situation for these decisions.
By the way, there are new guidelines from ACCP discussing this. The whole document is huge, but there is a quick summary entitled: New ACCP Guidelines – DVT and PE: Highlights and Summary Here is the link: http://professionalsblog.clotconnect.org/2012/02/27/new-accp-guidelines-%E2%80%93-dvt-and-pe-highlights-and-summary/
Cheryl Kelley RN BSN, VA-BC