Forum topic

6 posts / 0 new
Last post
Gina Ward
Recent info at AVA from Dr Thomas P. Nifong, MD; need help with resource on treatment of thrombosis related to PICC lines

 

I was excited to hear the lecture on Reducing the risk of cather related thrombosis at the recent AVA confernce.

Dr Nifong had made a specific reference on treatment of the thrombosis which started with identifying as a DVT or not;     If thrombosis is below the axilla , it is not  a DVT and recommends conservative management along with catheter removal.   He warn of a possible recurrence or  extension and risk of PE with catheter removal.   I was so excited to see that specific recommendation.  I promptly went and pulled up a copy of the article he references for that statement;  American College of Chest Physicians Evidence Based clinical Practice Guideline Chest 2008 Supplement.

 

I can not find anywhere where it mentions that; Management of a catheter related superficial venous thrombosis  It makes much mention of SVT but not related to catherter provoked, only spontaneous SVT which woudl be different.

 

  I did find where it mentions treatment of DVT and anticoagulation  for  DVT related to a central line in the upper extremity , ( it includes the brachial vein; is that just the small portion above the axilla where it joins to the subclavian? since we are saying it must be above axilla to be considered a DVT)

 

For an UEDVT; he also recommends to NOT remove the catheter if it is still functioning and needed.  This also I could not find anywhere.

 

Can anyone help me with this info.   I would like to discuss this recommended plan of care with my physicians. 

 

thank you in advance, Gina Ward R.N.

lynncrni
 I am very confused by the

 I am very confused by the anatomy description here. First of all, the basilic vein begins as a superficial vein in the forearm and ACF. Aboce the ACF, very close to the common PICC insertion site, it becomes a deep vein. Otherwise, you would not require US to make the venipuncture. So the basilic is a deep vein where most PICCs reside, so then why is it not considered a DVT? Does not make sense to me. The basilic vein joins the axillary vein near the lateral edge of the chest. Yes if Jack LeDonne sees this he will argue with me, but I am taking this directly from Grants Atlas of Anatomy and Grey's Anatomy. The brachial vein is also a deep vein of the upper extremity but the cephalic vein is a superficial vein all the way from its beginning slightly above the thumb to the infraclavicular area where it joins the axillary vein. I have not read that Chest article for a long time, but I have also never heard anyone else make this recommendation for removal vs allowing it to remain in place. 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

Gina Ward
Just spoke with the physician

Just spoke with the physician who is my resource person.  I was discussing my recent findings.  He also says and agrees that the brachial and basilic vein in the upper arm are

deep veins and says if there is a thrombus they should be treated as a DVT.  The only time he opts for keeping a catheter in is if it is the only lifeline a pt has for HPN or chemotherapy.  All other lines should be removed and a new line placed or a peripheral started.

 

He also says he just recieved some new information that has been presented to the physicians on this subject and he will see if he can get  it to me.  He is a Critical Care Pulmonalogist at our facility.

 

He says there is a  new article out from Chest as well .     So, hopefully I will get some very new data and see what it has to say. 

 

Thanks,  Gina

Gina Ward R.N., VA-BC

afruitloop
Here is the CHEST 2012

Here is the CHEST 2012 guidelines summary. 

As far as leaving in place or removing, individual patient issues should be accessed.  For example, take the oncological patient.....with a documented relationship between infection and thrombosis, BSI in this neutropenic population, the risks of leaving the cathteter in place versus remobal must be considered.  Neutropenic events have shown higher rates of the occurrence of CR-thrombosis....... I guess  my point.....one size does not fit all.  The CHEST 2012 guidelines are not specific about removal or leaving in the presence of thrombosis in the cancer patient.

 

http://professionalsblog.clotconnect.org/2012/02/27/new-accp-guidelines-%E2%80%93-dvt-and-pe-highlights-and-summary/

New ACCP Guidelines – DVT and PE: Highlights and Summary

Stephan Moll, MD writes…  This month the American College of Chest Physicians (ACCP) published its new (2012) guidelines regarding anticoagulation and management of various thrombotic disorders, replacing the 2008 edition. The details of the new guidelines can be found here. A summary of the most important management issues regarding DVT and PE is listed below. The guidelines provide differentiated recommendations that are graded by

a)    their strength (either Grade 1 or 2; “grade 1” = strong recommendation; “grade 2” = weak recommendation) and

b)   the quality of data supporting the recommendations (Grade A, B, or C; “A” = high quality evidence (=solid, plenty, convincing supportive data); “B” = moderate quality evidence (=limited supportive data); “C” = low- or very-low quality evidence (=expert opinion or barely any supportive data).

When applying these guidelines to the management of an individual patient, these grades, obviously, need to be considered, as well as patient-individual factors, to avoid a rigid, black-and-white approach to a patient’s management. The key recommendations regarding DVT and PE are:

1.    Distal leg DVT

a)    Severe symptoms: Treat with anticoagulants. Length of treatment: 3 months (no matter whether DVT was associated with a transient risk factor (surgery, hospitalization, estrogen therapy, etc.) or was unprovoked (= idiopathic).

b)   No, mild or moderate symptoms (and no risk factors for clot extension – see below):

    • No anticoagulation needed.

    • Physician to obtain several (‘serial”) Doppler ultrasound leg examinations over the next 2 weeks to make sure the DVT has not extended (which it does in about 15 % of patients).

    • If DVT has extended: treat with anticoagulants for 3 months.

If extension of clot has not occurred within the first 2 weeks, it is unlikely to occur subsequently. Risk factors for extension: positive D-dimer, DVT that is extensive or close to the proximal veins, no reversible provoking factor for DVT present, active cancer, previous history of blood clots, and inpatient status.

2.    Proximal leg DVT

  • Should be treated with anticoagulants.

  • Suggestion is to not use thrombolytics or clot removal interventions (thrombectomy) routinely.

  • Treat as an outpatient, if feasible.

  • In the acute setting, i.e. the first few days: use once daily Dalteparin (Fragmin) or Tinzaparin (Innohep) or Fondaparinux (Arixtra) or twice daily Enoxaparin (Lovenox).

  • Preferred treatment beyond the first few days: warfarin, rather than Dabigatran (PradaxaÒ) or Rivaroxaban (XareltoÒ).

  • Length of treatment with blood thinners:


    • DVT triggered by surgery: 3 months, rather than 6 or 12 months.

    • DVT due to a mild risk factor (i.e. non-surgical risk factors such as estrogen therapy, long-distance travel, non-surgical hospital stay, etc): 3 months, rather than 6 or 12 months or long-term.

    • Unprovoked (idiopathic) DVT: long-term, if risk for bleeding not very high. Re-evaluation every so often (once per year?) to determine whether long-term treatment is still the right thing to do.

3.  Incidentally discovered (asymptomatic) DVT or PE

DVT (of the leg, arm, pelvis or abdominal/splanchnic) or PE that was asymptomatic and was discovered incidentally, for example because CT scans were done for other reasons:

a)    Leg, pelvic or IVC DVT: Treat with blood thinners. Length: same as discussed in proximal and distal DVT section (discussed above).

b)    Abdominal DVT (portal, splenic, mesenteric or hepatic vein thrombosis): Do not treat with blood thinners.

c)     PE: The CT should be reviewed with a good radiologist to determine whether the reported PE is really a PE. If there is uncertainty, then additional studies should be done (such as D-dimer, Doppler ultrasound of the legs, VQ scan, etc). If the conclusion is that the patient does, indeed, have a PE: Treat with anticoagulants. Length: same as discussed in the PE section below.

4.  Pulmonary Embolism

  • Should be treated with anticoagulants.

  • Suggestion is to not use thrombolytics routinely. However, if the PE is massive (i.e. combination of low blood pressure below 90 mm Hg systolic, heart rate above 100/min, poor perfusion of inner organs, low blood oxygen level, abnormal serum cardiac enzymes, abnormal right heart function on echo or CT) and the patient is at low risk for bleeding, tPA for 2 hours into a peripheral vein can be considered.

  • If the patient with PE is doing relatively well, outpatient treatment with discharge home from the emergency room is appropriate when feasible. “Doing relatively well” means clinically stable and with no impaired pre-existing heart and lung dysfunction.

  • In the acute setting, i.e. the first few days: use once daily Dalteparin (Fragmin) or Tinzaparin (Innohep) or Fondaparinux (Arixtra) or twice daily Enoxaparin (Lovenox).

  • Preferred treatment beyond the first few days: warfarin, rather than Dabigatran (PradaxaÒ) or Rivaroxaban (XareltoÒ).

  • Length of treatment with blood thinners (same treatment decision principles as in DVT):


    • PE triggered by surgery: 3 months, rather than 6 or 12 months.

    • PE due to a mild risk factor (i.e. non-surgical risk factors such as estrogen therapy, long-distance travel, non-surgical hospital stay, etc): 3 months, rather than 6 or 12 months or long-term.

    • Unprovoked (idiopathic) PE: long-term, if risk for bleeding not very high. Re-evaluation every so often (once per year?) to determine whether long-term treatment is still the right thing to do.

5.    Cancer associated DVT or PE

  • Treat for at least 3 months and preferably long-term, unless bleeding risk very high.

  • Low molecular weight heparin is the preferred treatment, rather than warfarin.

6.    Arm DVT

  • If DVT that involves the axillary or more proximal veins, anticoagulation therapy alone is suggested, rather than thrombolytic therapy. Length of anticoagulation: at least 3 months.

  • In upper extremity DVT not associated with a central venous catheter: 3 months of anticoagulation is recommended.

  • In upper extremity DVT associated with a central venous catheter:


    • Suggestion is to not remove the catheter if it is functional and there is an ongoing need for the catheter.  Anticoagulation should be given as long as the catheter is in place.

    • If the catheter is removed, anticoagulation should continue for 3 months thereafter.

 7.    Superficial thrombophlebitis

  • In patients with superficial thrombophlebitis of the leg of at least 5 cm in length, the suggestion is to give prophylactic dose of fondaparinux (preferred) or LMWH for 45 days, rather than no anticoagulation.

8.  Vena cava filter (=IVC filter)

  • Should only be placed in the patient with an acute DVT who cannot tolerate blood thinners because of active bleeding or a high risk for bleeding.

  • “We do not consider that a permanent IVC filter, of itself, is an indication for extended anticoagulation”.

9.    Compression stockings

  • Wear for at least 2 years (to prevent or minimize the occurrence of postthrombotic syndrome.

  • If at 2 years the patient has bothersome symptoms of postthrombotic syndrome (swelling, pain), continue to wear stockings for symptoms relief.

 

Cheryl Kelley RN BSN, VA-BC

mary-ivt
Thanks Cheryl for the

Thanks Cheryl for the information. 

I want to toss out an interesting case for discussion.  I placed a 4 fr single lumen PICC for a pt with a return of his lung infection on 10/1.  S/P outpt bronchoscopy a few days prior to admission identifying same infection.  Pt came to hospital increased SOB and hemoptysis.  Normal coags,  high WBC and PLT, that has been coming down with treatment. He had a right basilic single lumen PICC for a couple of weeks of antibiotics in early July this year and it was removed.  Uneventful insertion at that time.  I examined all of his veins of his right arm .  All looked in good condition with no noticeable obscuring any where in the basilic vein.  Clean stick, smooth insertion.  Today 10/4 order received to remove PICC and reinsert in left arm due to blood clot in basilic vein.  Vascular lab primary report by US tech indicates superficial basilic clot, full study not available yet.  Pt's assessment negative except for a slight amount of puffiness just above elbow.  No other evidence of vascular compromise, no swelling to lower arm, pain, numbness, tingling.  I do take measurement at site of insertion for what it is worth (it is our policy), no change.  Measurement taken at area of puffiness and wrist for further monitoring.  Both arms compare and except for puffy area look the same, noteable for very slight hand wrist edema bilaterally, pt can't get L hand ring off, very slight indentation from R wrist watch, otherwise you might not notice.  Pt can't be anticoagulated d/t ongoing hemoptysis, as a side, just after I finished PICC I assisted him to bathroom as his major concern was all the laxatives given him earlier AM.  While there, severe coughing attack, significant hemoptysis with frank blood and clots, severe SOB, decreasing sats even with increasing O2, rapid response called, transfer to unit and final intubation.  His right wrist stuck for blood gases at least once.  Pt now back on regular nursing floor recovered from whatever happened.

Personal thoughts are clot likely related to very high inflammatory state r/t longstanding lung infection likely mild sepsis on admission?  Recommended conservative treatment as his PLT still high and really think he his high risk to clot his left arm.  Recommended arm elevation, warm tap water bag and very gentle range of motion to lower arm to increase venous return and careful monitoring of measurements taken along with s/s.  Pulmonologist okay with that for now.  Pt was also in agreement with conservative treatment. 

Any thoughts?

Thanks to all

Mary Penn RN    

Gina Ward
  thank you for posting that

 

thank you for posting that information.

 

So.....the dilema still is what is the definition of an upper extremity DVT;    Under section 6 ; Arm DVT;  it makes mention to DVT that involves the axillary or more proximal veins.

 

It also makes mention of leaving catheter in.  This goes along wtih Dr. Nifong presention.  Only thing is;  it ( the article)  just doesnt make mention of treatment for what they (chest magazine) would call a Superficial Venous Thrombosis in the upper arm, like brachial, cephalic or basilic.    

 

Thanks again,   it really helps alot .   Say, how would someone know when these standards were updated or released?

 

Gina Ward R.N.

Gina Ward R.N., VA-BC

Log in or register to post comments