Is there any evidence-based research regarding criteria for inserting a PICC in the presence of an elevated INR? Our IR want the INR less than 3 to do a PICC, but we as an IV Team have never used it as a contraindication. Just wondered what others are doing. Thanks.
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I am not aware of any research that limits a PICC insertion based on the INR. Because it is peripheral and we can hold pressure, we do not use an INR of 3 as a limiting factor.
Gwen Irwin
Austin, Texas
Our Vascular Access Specialty Team will do PICCs at bedside if the INR is high. We do check to see if the primary service wants to try to reverse the INR first. We also call to see if the team wants to transfuse platelets if the platelet count is <20,000. If the INR is high and the patient really needs central access, a PICC is the only thing I am comfortable doing. If we were to refuse, the physicians may feel compelled to try a short-term CVC, with limited options for holding pressure. We do sometimes have Surgicel at the bedside if the INR is high, but I have never had to use it. I just budget more time to hold pressure, usually planning on an extra 30 minutes.
I can understand why the I.R. suite staff do not want to do PICCs on patients with high INRs. Time is money to them, and time spent holding pressure could be time they are performing higher tech procedures for which they can generate revenue. Most inpatient PICCs generate no revenue at all for the I.R. suite, and very little income for the physician or advanced practitioner inserting the catheter.
Leigh Ann Bowe-Geddes, BS, RN, CRNI
Vascular Access Specialist
University of Louisville Hospital
Our facility does not give much weight to the INR. We are accessing with a 21 gauge needle and using ultrasound. I get a little more concerned when the INR is high AND the patient has no platlets. It is a lot saferto insert a PICC than a blind stick in the chest wall.
Rhonda Wojtas, RN,BSN, VA-BC
Platelet 17K or better.
INR is not required.
Due to the nature of PICC insertion locations, I wouldnt be too concerned with the INR if its high. They are mostly all compressible sites.
A high INR is actually cardioprotective to prevent thrombus development also.
Platelet counts >10000 are preferred but we do go lower if need be.
We use a micropuncture kit and US also.
For CVCs, I have a cutoff point with both INR and platelets where I wont insert a CVC - INR >1.5 platelets <50000 (although I have done CVCs with lower platelet counts as the staff specialists WANTED the line specifically)
Patients are transfused platelets prior to CVC insertion if platelet count below 50K.
Timothy R. Spencer, RN, APN, DipAppSci, BH, ICU Cert, VA-BC™
That CVC guy from Australia :-}
do not see the option of attaching file with the 'reply' option. -- sorry, I attached the file to the original message instead.
Transfusion. 2005 Sep;45(9):1413-25.
Paucity of studies to support that abnormal coagulation test results predict bleeding in the setting of invasive procedures: an evidence-based review.
Segal JB, Dzik WH; Transfusion Medicine/Hemostasis Clinical Trials Network.
Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Baltimore, MD 21205, USA.
Comment in:
BACKGROUND: The literature was systematically reviewed to determine whether a prolonged prothrombin time or elevated international normalized ratio predicts bleeding during invasive diagnostic procedures. STUDY DESIGN AND METHODS: MEDLINE and CENTRAL were searched through August 2004, with no language restriction, and reference lists were reviewed. For inclusion, articles must have reported on bleeding in more than five patients with abnormal test results undergoing diagnostic procedures. RESULTS: One trial and 24 observational studies were included. In 2 studies of bronchoscopy, the bleeding rates were similar among those with normal and abnormal tests, with wide confidence intervals (CIs) around the risk differences. During central vein cannulation (3 studies), bleeding rates among those with abnormal tests was unlikely to exceed 2.3 percent. The largest of 3 studies of arteriography found equivalent bleeding rates in patients with and without abnormal tests (risk difference, 0%; 95% CI, -3% to 2%). In the 3 studies of liver biopsy with plugging, bleeding rates were 0, 4, and 5 percent with the upper bounds of the CI as high as 17 percent. In the largest study of transjugular biopsy, the bleeding rate was 1.5 percent (95% CI, 0.3%-4%) in patients with abnormal tests. The highest bleeding rate in the 3 studies of percutaneous liver biopsy was 5.3 percent (95% CI, 1%-13%), similar to the rate in patients with normal test results. CONCLUSION: There is insufficient evidence to conclude that abnormal test results predict bleeding. Randomized controlled trials should be performed to provide stronger evidence for clinical decision making regarding preprocedure transfusion.
There was an article in JAVA not too long ago, where a team looked at the INRs of the patients and found no significant risk up to an INR of 3.
Personnally, I think the decision needs to be made based on the patients needs. Does the patient REALLY need a central line? If not, then perhaps FFP, Platelets, or Vitamin K can be given or you can wait to place the line. If they REALLY need central access, then a PICC is the safest option, both due to size (if not reverse tapered or taper is completely left out) and location of placement. Holding pressure on a jugular or Subclavian is not recommended. Acute CVC lines are 7-9FR, whereas a non-reverse taper PICC is 4-6FR.
Smaller hole=less risk of bleeding and easier to control.
A high INR may mean extra dressing changes and instructions to the staff to watch the site, but I would not let it limit me from providing access to the patient.
Keep in mind, the IR creates is policies for ALL Procedures, and they often access arteries as well as veins, and in all locations. So in that setting, a limit for access can make more sense.
Chris Cavanaugh, RN, BSN, CRNI, VA-BC
Anna,
I believe as a clinician you have to look at risk vs. benefit. I will assume the patient does require central line access. That being said is it better to have an proficient vascular access nurse with ultrasound experience insert the device or a intensivist who uses anatomical landmarks? Is it dangerous to reverse the patients anti-coagulation or not? Will the patient deteriorate without adequate vascular access? All types of risk vs. benefit questions may come up that are best answered with clinical collaboration.
I do disagree with the opinion regarding reverse taper on this patient population. Personally I take into account the reverse taper during my ultrasound assessment and if the vein is appropriate for the selected device size then I use it. The advantage of the venous tamponade effect of the reverse taper is very important. Unlike non-tapered catheters where the micro-introducer makes the largest hole in the access tract(which will often ooze with elevated INR's) the tapered catheter itself creates the largest hole in the skin tract and this prevents the tract from bleeding and in most cases oozing is eliminated. As someone who learned MST PICC insertion on non-tapered PICCs and then switched to tapered PICC's, I saw first hand the reduction in PICC's being pulled unnecessarily because a nurse unfamiliar with PICC's called a MD and said it would not stop bleeding. Also I am convinced that the reduction in surface blood reduces infection, and allows for a cleaner dressing to remain in place for it's intended duration. In my practice the outcomes for patients receiving PICC's with elevated INR's has been outstanding, and all I use are reverse tapered PICC's.
My disclosures are as follows.
V.P. of Sales and Education for Carolina Vascular Wellness, PLLC
Clinical Educator for Bard Access Systems
Strong Advocate for Vascular Access Nurses to take control of their practice!!
Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness
do not see the option of attaching file with the 'reply' .
-- sorry, I attached the file to the original message .
.
2005 Sep;45(9):1413-.
Paucity of studies to support that abnormal coagulation test results predict bleeding in the setting of invasive procedures: an evidence-based .
Segal JB, Dzik WH; Transfusion Medicine/Hemostasis Clinical Trials .
Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Baltimore, MD 21205, .
Comment in:
.
2005 Sep;45(9):1404-6.
BACKGROUND: The literature was systematically reviewed to determine whether a prolonged prothrombin time or elevated international normalized ratio predicts bleeding during invasive diagnostic .
STUDY DESIGN AND METHODS: MEDLINE and CENTRAL were searched through August 2004, with no language restriction, and reference lists were .
For inclusion, articles must have reported on bleeding in more than five patients with abnormal test results undergoing diagnostic .
RESULTS: One trial and 24 observational studies were .
In 2 studies of bronchoscopy, the bleeding rates were similar among those with normal and abnormal tests, with wide confidence intervals (CIs) around the risk .
During central vein cannulation (3 studies), bleeding rates among those with abnormal tests was unlikely to exceed 2.3 .
The largest of 3 studies of arteriography found equivalent bleeding rates in patients with and without abnormal tests (risk difference, 0%; 95% CI, -3% to 2%). In the 3 studies of liver biopsy with plugging, bleeding rates were 0, 4, and 5 percent with the upper bounds of the CI as high as 17 .
In the largest study of transjugular biopsy, the bleeding rate was 1.5 percent (95% CI, 0.3%-4%) in patients with abnormal .
The highest bleeding rate in the 3 studies of percutaneous liver biopsy was 5.3 percent (95% CI, 1%-13%), similar to the rate in patients with normal test .
CONCLUSION: There is insufficient evidence to conclude that abnormal test results predict .
Randomized controlled trials should be performed to provide stronger evidence for clinical decision making regarding preprocedure .
_______________________
hello
Citation for INR and USG PICC insertions:
Effects of INR levels on bleeding occurrences during the first 24-hours of ultrasound guided PICC line insertions.Daniels LS; Gouvas MO;Journal of the Association for Vascular Access (J ASSOC VASC ACCESS), 2008 Spring; 13(1): 22-5
I have had success with INR >3.5 and Platelets less than 15. HOWEVER, this should be assesed on case by case basis. I have inserted with INR of 6 because a central line was needed and a PICC line is the safer to insert with high bleeding times than a jugular or subclavian access. I had minimal bleeding at PICC insertion site with INR of 6, but did place QR powder at insertion site and applied manual pressure post insertion.(watched the picc insertion site like a hawk).
I have also had platelets infusing WHILE inserting a PICC with Platelets less than 15 with excellent results.
I must say if the patient can wait till INR is lowered or Platelets raised to have PICC insertion, that is my first choice. But, as many situations present themselves the PICC insertion may be the best choice for hign INR and lower platelet counts.
so sorry!
I did not started the post -- sincere apology to every one
I was trying to attach a file with my reply; without success, somehow I attached the pdf file to the original posting.
did not realize my name shown on the original
While I have done PICCs on pt.s with elevated INR >3 before, one must be aware of other departments within the hospital where you work and the protocol they follow. What I mean by that is: IR at the hospital where I work insists the INR be <1.5!!!! If I insert and an issue occurs and it is looked at from a legal aspect, this could open me up to the line of questioning that if IR won't place a PICC when IR >1.5, why would the PICC team. It has to be a universally followed policy within your institution.