I recently placed a dual lumen PICC in a 22 year old septic patient whose health began deteriorating in the next few hours. Could I have placed a second PICC in the other arm and could it be a triple lumen? Is there concern about having overcrowding of lines in the SVC? This patient required multiple medications and the staff had placed three PIV's which were all being utilized along with the dual lumen PICC.
Susan
Karen Ratz,RN St. Lukes Hospital, Cedar Rapids,IA
We will do this on pt. in the ICU that need more access than just the one PICC. Recently, I placed a triple lumen PICC, one is each arm on a severely septic pt. We had no problems with thrombis.
Karen Ratz,RN, VA-BC Unity Point St. Lukes Hospital, Cedar Rapids,IA
Just wondering why the patient did not receive a subclavian triple lumen? It seems to me that due to many factors, the triple lumen PICC is being inserted in place of the subclavian triple or quad lumens now. Personally, I would hope that if I am severly septic, that I have a subclavian catheter, capable of the fluid resuscitation that I may require. Remember, the larger the catheter, naturally the less blood flow in the vessel. I have made it a point to learn about venous stasis and how the insertion of ANY catheter changes the dynamics of blood flow in the vessel, whether a small pereipheral in the forearm or a large quad lumen in the IJ. This alteration in blood flow dynamics creates venous stasis. I will add, that this is not only true for large PICCs that have reverse taper, but also for large bore central lines, dialysis catheters, etc.
That is great that you have not seen an increase in thrombus, but I am curious to hear if you used your ultrasound to scan the vessel containing the PICC post-insertion or did you get a doppler after the insertion?. In my experience, which covers several years, I did look at vessels that contained these large lumen reverse tapered PICC's and did find evidence of vessel injury, and partial and complete thrombus. I also scanned veins that contained smaller PICC's, and also saw some injury and problem, but it was not nearly as prevalent as in the first category. I will also add, that in many of these patients, there was NO edema in the extremity, which is usually the most common reason that a physican will order a formal doppler study. So if edema does not exist, is the vessel containly the PICC being assessed for thrombus? Probably not, unless the PICC team is dong this routinely on schedule intervals.
The early goal of the team that I participated on was "put a PICC in every one that we can." We wanted our PICC numbers high. That is the main reason we brought the triple lumen into my facility, to capture those ICU patient's who had subclavians, etc. But only after a few months of triple lumen PICC insertion did we see the negative effects of our actions. It was at this time, that we decided that the subclavian would be used in the patient who needed a subclavian, and the PICC would be used in the patient who needed a PICC. By putting aside the fact that yes, we wanted higher PICC numbers and the physicians no longer wanted to place subclavians, we were doing an injustice to the patient.
Sorry to be so long winded here, but my point is that thrombosis with PICC's is silent in possibly HALF of the patients who recieve PICC's. I am not just talking about reverse taper PICC's either. Therefore one must deduct that just because we do not see edema we cannot summarize that the patient does not have thrombus. Unfortunately the thrombosis does not just stay in the peripheral veins, as it can advance to the axillary and subclavian which opens a whole other can of worms!
Please dont' take this in a confrontational manner, it is not intended that way. I am a nurse who practices a little differently and encourages a patient and vessel assessment pre-insertion AND a vessel assessment post-insertion. I am just relating my experienice and unfortunatley, I am in the minority!
Thanks,
Cheryl Kelley RN BSN, VA-BC