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coffeemania
DVT developed after PICC removal.

5Fr DL BARD PICC was inserted on November 2nd for Home Health ABX for UTI. Treatment was done on November 19. PICC was removed by Home Infusing Nurse. Next day the arm started swelling and painful, getting worse over the weekend. Patient went to see primary MD and doppler US was done. Extensive DVT was confirmed from basilic, part of cephalic, axillary, subclavian, and jugular veins. Patient stated that the arm was perfectly fine before PICC removal. Anybody has any idea about this situation? Thank you in advance.

lynncrni
My guess would be trauma on

My guess would be trauma on insertion that just did not present signs and symptoms until after it was removed. Why did he have a double lumen when only antibiotics was prescribed? This could easily have been infused through a single lumen 4 Fr. Smaller catheter = less risk of thrombosis. Lynn

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

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

momdogz
Thrombus was already developing

before the PICC was removed.  I'm wondering why a 5 Fr catheter was used; a 4 Fr. for abx would have been better.  What vein was used?  What were the patient's co-morbidities?  Any inflammatory disease, cancer, pregnancy?

I'm not sure why a sub-clinical thrombus would manifest clinically the day after removal, unless some of the thrombus was attached to the PICC and dislodged a bit upon PICC removal, causing more inflammation and activating further thrombus formation.

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

Chris Cavanaugh
Asymptomatic DVTs common

There are 3 reasons, according to Virchow, for thrombosis to occur.  One is stasis.  What was the vein measurement the catheter was placed in?  What was the catheter measurement at the point of insertion?  Some reverse taper catheters can get as large as 2 FR sizes at the hub.  Was the catheter taking up more tha 30% of the vein? 40%? 50%?

The next is vessel injury.  What size introducer was used to place the catheter? 5FR? 5.5? 6FR? Not just what the introducer says, but the actual size, as some are larger than stated to accomodate a reverse tapered catheter.  What needle size was used?  Was the line placed on the first attempt or multiple attempts?  Did the needle backwall during placement?

The third is hypercoagulablity.  The fact that the patient had an infection starts an inflamatory process, which can contribute to hypercoagualbility.  So can pregnancy, diabetes, cancer, COPD, Lupus, and other disease states that we may not be aware of, such as Factor deficiencies.

The more of these factors a patient has, the higher the risk for DVT.  Some medications can also contribute to hypercoagulablity and thrombosis, what was he receiving via the PICC.

There have been studies showing PICC thrombosis can be asymptomatic in 30-60% of patients, perhaps, and very likely, that his thrombosis was there yet asymptomatic while the PICC was inplace, and continued to progress after it was removed, until it produced symptoms.  PICCs are not the complication-free device that we used to think they were.

I hope this gives you some food for thought as you investigate this problem.

Chris Cavanaugh, RN, BSN, CRNI, VA-BC

amaguila2009
Just an observation

What baffles me is that several of the cases that I've seen have the thrombosis at the subclavian and axillary veins but not at proximal to the insertion site. There is so much we need to know as far as this issue is concerned.

lynncrni
That tells me that the venous

That tells me that the venous endothelium was disrupted at those mid-catheter locations. It could be related to curvatures in the vein and the catheter itself coming into contact with the tunica intima. Or it could be related to insertion technique with the tip damaging this segment of vein as it is inserted. I can see many reasons why it happens in the segments of catheter between the insertion site and tip location. Lynn

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

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Peter Marino
Clinical manisfastation of thrombus formation

It is my understanding that thrombus formation can become clinically significant up to 72 hours post injury. I can't find my reference this minute but there is a very nice video of real time thrombus formation here; http://content.nejm.org/cgi/content/full/359/9/938

http://content.nejm.org/cgi/content/full/359/9/938/DC1

Peter Marino R.N. BSN CRNI VA-BC Hospital based staff R.N. with no affiliation to any product or health care company.

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