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cathie
PICCs and Clots

Our IV /PICC team is interested in performing a research project on PICCs and Clots...beyond our own observations, experiences and education we are looking for information on frequency, dx,

resolution techniques, and other data or observations that take place in your environment... are there suggestions to reduce the frequency...preventative measures you take...any literature you could point us toward ...our goal is to reduce this risk...a goal each patient deserves

Thanks for any input

afruitloop
I have a great interest in

I have a great interest in thrombosis related to PICC's.  I have this tiny little "nagging" somewhere in the back of my head that if we (PICC Nures) do not develop a better understanding of thrombosis--how, why, when and how to decrease it's occurance, we may PICC oursleves right out of a job!  (That probably is a little harsh, but you get the point!)  

 I would be happy to talk with you on this very interesting topic off the list serve so as not to "ramble."  I have created several educational materials on thrombus and PICC's and have net worked with physicians in the field of thrombus.  Please email me.

Good luck!  You and your team should be commented on the effort you are putting forth to combat this very serious problem.

Cheryl Kelley

Cheryl Kelley RN BSN, VA-BC

cathie
thanks Cheryl...please call
thanks Cheryl...please call 614-566-9604 and leave me your e-mail address so I can contact you
kokotis
Kathy Kokotis Bard Access

Kathy Kokotis

Bard Access Systems

I am not sure we will PICC ourselves out of a job but here is what I have discovered in the literature regarding thrombosis that is not preventable in the majority of cases.

Catheter tip position is important - lower onethird of SVC

Right side is better than left

Basilic is better than right

Upper arm MST/US is mandatory

Antibiotics are a low rate - TPN and chemo is high

Past history of chemo or cancer leads to increased rate

Multiple VAD's in past or this admit not good - do not do multiple lines

Bedrest, vomiting, dehydration, vasoconstrictors, history smoking, birth control pills, infection, oncology past history, renal failure or renal issues  increase rate and risk

SIR says acceptable rate is 6%

Renal patients are totally forbidden as well as oncology for a PICC line unless you are prepared to deal with the thrombosis

Since the PICC is a more superficial vessel vs. subclavian or jugular you will see the results of any thrombosis earlier.  No one talks about that part. The depth is way different to observe swelling, red, painful etc.  When was the last time you say a chest or jugular get red, painful or swollen.  How far down are those veins.  How much tissue does the symptomology have to go thru to be observed. You see these at total occlusion of the vessel.

Due to triad of Virchow thrombosis occurs most of it being unsymptomatic

The only solution is not to place any VAD including periphal IV's

I think personally each patient that gets a symptomatic thrombosis should be carefully evaluated for risk factors as they are not always preventable.  If a patient is high risk I suggest a jugular line which has the lowest risk.  See list given for high risk above.

Thrombois is a fact and I think we need to learn to recognize it and treat it versus the idea that we can 100% of the time prevent it unless you want to stop placing all VAD's.  The majority of thrombosis is not recognized and un-symptomatic.  Think on that one.

 

Kathy Kokotis

Bard Access Systems

estevens102206
Kathy you forgot to mention

Kathy you forgot to mention "using the smallest catheter possible that will work for the patient".  To me this means not using a 7 French PICC that tapers to a 5 French PICC.  

Eric

Eric

momdogz
We're still in the process

We're still in the process of writing these guidelines, but here's what we have so far that relates to thrombus, understanding that each patient is evaluated on a case/case basis:

PICC placement:  pt. assessment, vein assesment, and vein choice

    a.  Document vein name, diamter, depth, number of attempts per nurse in patient medical record

    b.  Use rule of 33% as a best practice until data available to support change in practice.

    c.  Recommended order of vein choice, using U/S and MST

        R basilic, L basilic, medial or lateral right brachial, medial or lateral L brachial, right cephalic, left cephalic.  Avoid basilic if possible if pt. underarm crutchwalking.  Proximity of artieries and nerves seen in U/S eval may eliminate any vein as cannulation choice.

Rationale (abbrev.) Triad of Virchow; Standards of Practice re: smallest size possible; data re: complications from cephalic vein placements; different anatomical concerns re: all the possible veins; data re: antecubital PICCs

We also consider the following d/t higher risk of thrombosis:

    Inflammatory disease process present (data shows increase thrombotic risk - includes crohns, ulcerative colitis), Cancer, Immobility, Pregnancy/puerperium, family history of hypercoagulability, DVT or PE in first degree relatives, multiple venipunctures (associated with higher thrombosis rate of 38% - great case for early vascular assessment!), diabetes and HTN (prior damage to endothelium), high procoag factors (Factor II, VIII, IX and XI).

    It doesn't mean we don't place PICCs in these patients, but it is very helpful in our assessment, and planning with MDs.  For e.g., if they are not on anticoags and it's not contraindicated, the above scenarios might influence that decision.  This information also supports EXCELLENT discharge planning/case management/pt. teaching.  And, as mentioned above - some of these risk factors are excellent arguments FOR a PICC line (.....and some not).

Re: Thrombosis studies   

    We also would like to do a comprehensive study on PICCs and thrombus (placed only in UE with U/S and MST), and look at catheter size as well.  These types of studies will require financial backing, because each patient will need to have baseline and followup doppler studies.  Will need to go through the IRB process.

   

Mari Cordes, BS RN 

Nurse Educator IV Therapy
Fletcher Allen Health Care

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

dmitch
Diane Mitchell RN BSN MA,

Diane Mitchell RN BSN MA, Manager IVT & Infusion Center, SSM St. Mary's Health Center, St. Louis

 

Please expound on the "SIR says acceptable rate is 6%".  Does this mean a 6% occlusion rate is acceptable for all types of catheters grouped together? Specifically, if I'm tracking PICC occlusion rates, is 6% acceptable? 

Thanks.

Diane Mitchell RN

afruitloop
  Dianne, In your comment
 

Dianne,

In your comment it sounded like you were addressing occlusions of catheters where the SIR is relating to occlusions of vessels.  Sorry if I have misunderstood you.

 

I think that as a whole, we need to be aware of the rate of thrombus with PICC’s in our hospitals.  When determining our individual rate of clot, one must decide how the data will be collected. To be accurate, all patient’s who have PICC’s should be included in the data gathering, not just the patients who have symptoms of thrombus (edema,etc.)  By only comparing the patient who has symptoms, we are then only discovering the number of patient’s who are symptomatic.  

 

A recent presentation at AVA by a doctor from the U of Utah (I think) was significant for the presence of silent thrombus.  I am not sure of previous studies on silent thrombus, maybe Lynn would know.  This physician obtained a Doppler study on every patient who got a PICC at established intervals, and the result was that 66% of the patient’s with a PICC, had a clot in the extremity that contained the PICC.  All were silent without obvious evidence of the presence of the clot.  Of the 66% with clots, 80% had an axillary or subclavian clot.

 

We owe it to our patient to track this rate and to gather the data in an accurate manner by assessing all PICC patients.  PICC nurses are overworked and are pulled in every direction. It is not as time consuming as one would think.  If the hospital has an IV team, then when the PICC dressing is changed, they can take a quick look at the vein that contains the PICC.  It can be done with the same ultrasound that was used to insert the PICC.  The vessel should be assessed for blood flow in it and around the PICC.  Nurses should not document thrombus, but they certainly can document blood flow and the condition of the vein.  IF an abnormality is discovered, then the physician should be notified and a formal Doppler preformed.

 

I have a great interest in this area, and would like to see our high-tech teams use these ultrasounds not only for PICC insertion, but for PICC assessment after insertion.

 
    

Cheryl Kelley RN BSN, VA-BC

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