Forum topic

I am not aware of any published guidelines for this issue. It is important to remember that we remove asymptomatic CVCs all the time that have silent catheter-related thromboses. In fact the vast majority are clinically silent. So you still need to have the assessment skills and knowledge, and removal skills regardless of whether there is a diagnosed thrombosis or not. Lynn 

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

www.hadawayassociates.com

I posed this same question to a clin. spec. for the company that provides our PICC lines and it got passed around the clin. spec. arena and came back to me like this:

This topic came up today in a discussion with a colleague.  She was told by a younger physician that it is acceptable to use the indwelling thrombosed line for infusion of heparin, and that this is a better treatment than pulling the PICC on the affected side and replacing it with another PICC on the opposite unaffected side, because "the damage is already done".  I have always wondered personally if pulling these lines dislodges the thrombus causing a pulmonary embolism, but maybe it's not significant enough to cause a symptomatic response.  Lynn's point is well taken, since we know there is a large volume of clinically silent catheter-related thromboses. I have never seen symptoms of a PE when I pulled a PICC, with known clot or not, but have certainly wondered about it.  Are there any circumstances under which pulling the line is not clinically indicated?  Anyone else ever heard what this young physician told my colleague?  There was one case I recall where a patient has a large thrombus along the line extending into the SVC and they treated the patient with a slow drip of TPA for a while before removing the line, but I never saw the outcome.  We sure could use some more studies/information in this area!

Halle Utter, RN, BSN

Intravenous Care, INC 

Ditto for us on the info posted thus far.  We used to refuse to pull a line with a known thrombus, and had the MDs do it.  It bothered me that we had such a firm stance and no data, little literature.  Now, our team decided we'll remove the line after discussing with MD (the extent of occlusion, pt. history, etc.), and ask that the physician be in house/available in case of embolus.  We've yet to have an embolic episode occur (that we were aware of).

Plus....most of the residents know very little about PICCs and we do a much better job handling them, so we'd just as soon be the ones removing them (and the MDs agree!).

I've also suggested in some cases that the line be used for lysis, but usually they want them removed immediately. 

Mari Cordes, BS RN 

I am so glad that this subject has been raised again!  The information already posted has been very valuable.  The question I would like to pose to the experts on the forum is......once a patient has a documented history of DVT in the upper extremitiy or chest area whether it was due to a PICC line or another type of CVC is there a standard in regards to the placement of a new PICC line or another type of a CVC in this type of patient at any point?  If there are no contraindications to placing a new PICC or CVC does anyone know if there are standards or guidelines to follow in regards to how soon this may take place and if the catheter should be placed in the opposite side if not contraindicated for some other reason.....and if the opposite can not be used.....how soon can a PICC or CVC be placed on the side of thrombosis once it is has been resolved with antiocoag therapy?  Is there any information in regards to this same question with patients who have a history of SVC Syndrome? 

Thanks in advance to anyone who can help me to find the correct standard of practice once and for all!  

Our facility participated in a pilot trial studying the outcomes of leaving a CVAD insitu in the presence of a thrombosis. The published study conclusion: "Treatment of UEDVTs secondary to central catheters in cancer patients with standard dalteparin/warfarin can allow the central line to remain in situ with little risk of line failure or recurrence/extension of the DVT."

KOVACS, M. J. ; KAHN, S. R. ; RODGER, M. et al. Journal of Thrombosis & Haemostasis. 5(8):1650-1653, August 2007.

Regards,

Daphne Broadhurst
Ottawa ON

I am looking for any information on what the standard is for most facilities with regard to the PICC nurse pulling a line associated with thrombus formation....I did see the one entry form Mari Cordis, stating that the nursing staff pull the lines....we also asked the physicians to pull the lines associated with documented clot formation, but as Mari stated, we are rethinking this...does anyone have any literature or have any experience with this?  What is the general consensus of most PICC teams...I look forward to obtaining any advice or information.  I am doing a lit search on the incidence in pulmonary embolism with thrombus due to picc line placement but have not had much success.  Once again, any information would be helpful.