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rivka livni
Safe use of PICC for Chemo

I am having a disagreement with our ONC CNS about the safe use of PICC for Chemotherapy.

She insists that if there is no blood return, chemo should not be given no matter what.

I say if CXR positively confirms tip placement it is absolutlely safe to give chemo even if there is no blood return, and the reason why the PICC is not giving blood return should be investigated and treated.

We had a Chemo patient with a three months old PICC admitted Friday evening (PICC TEAM is off on the weekend) there was no blood return, I called from home, told them the do a CXR which confirmed PICC tip is still at Cavo-Atrial juction, so I told them to go ahead use the PICC for chemo and I will deal with the partial withdraw occlusion when I return on Monday. (which I succesfuly did with one dose of Cathflo).

The CNS was besides herself on Monday that I allowed this.

My point to her was, you could get blood return even if the tip is malpostioned in Contra-Lateral Subclavia or Brachio-Cephalic, in IJ or even in Azygus and that blood return only confirms that the tip is in a VEIN, it does not mean it is always safe, or that the tip is in the SVC. (I have seen good blood return from malpostioned tip)

Am I missing something? shouldn't the critiria be tip in SVC? If it's documented that tip is in SVC is it not safe enought to give Chemo?

Your thoughts?

Robbin George
Why are the chemo nurses not
Why are the chemo nurses not competent to instill TPA and clear the problem before starting the therapy?

Robbin George RN VA-BC

mary ann ferrannini
You are correct in your
You are correct in your thinking that a blood return does confirm the tip location of a PICC nor does a blood return confirm that all is OK with a peripheral catheter either. So ...if the CNS line of thinking was that...... she is incorrect. You actually would want both assessmrnt parameters. You need to get a CXR to confirm the original course of the catheter and tip location and anytime there is a significant change in the amount externally visible,or patient has s/sx of a malposition,or it has been awhile since the last CXR (no current recommendation for frequency of CXR that I am aware of ),or if patient has been vomiting or had excessive coughing. As far as the blood return goes it cannot assess a fibrin sleeve or a hole or fracture in the catheter,so really a blood return is optimal,especially with chemotherapy. I would not have given any chemo without knowing where the anatomical location of the PICC was,it demonstrated a good blood return,and it was free of all local or systemic complications. Even then you must still monitor it during the infusion. I would have given the Cath-flo. We trained many of the Rns where I work and certified them to administer Tpa .
lynncrni
I have to agree with your

I have to agree with your CNS on this one. Tip location alone is not going to provide any information about the fluid pathway. The biggest problem is a complete fibrin sheath that is well document to cause retrograde flow between the catheter's outside wall and this sheath. There are several reports in the oncology literature about serious extravasation injuries caused by this. The ONS Chemo Guidelines are extremely clear about this, and even include what you should tell a patient about holding their chemo until a dye study can be done to actually document the fluid pathway. The other problems include a partial fibrin sheath and a fibrin tail or flap. These would not cause the extravasation injury however the only thing known by the bedside nurse is that there is no blood return. A dye study is mandatory before the catheter is used. A chest xray alone will not reveal these fibrin problems or catheter damage as mentioned by Mary Ann.  

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

www.hadawayassociates.com

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

rivka livni
A question for Lynn and a

A question for Lynn and a note for Mary Ann.

Are there really reports of extravasation injuries with complete fibrin sheath/sleeve of a PICC?

I can see it happening with with Ports, Dialysis catheters, and may be even with a CVC, those are all shorter catheters with a large FR and I could see a fibrin sheath/sleeve  making it all the way up the catheter to the point where it enters the vein, but not on a PICC with an additional 15 or so cm into a smaller arm vein. By the time that fibrin sheath made it into the arm there would be symptoms of arm swelling, or something.

I think we should NOT think of PICC as we do about all other central venous catheters.

Just b/c something happened to a Dialysis cathter does not mean it can happen to a PICC.

To Mary Ann: Using only power PICC we have NEVER seen a fractured catheter. I know a lot of places still use the Groshong and I do not quite understand why, there are much better catheters out there.

lynncrni
You are correct that the

You are correct that the reports of complete fibrin sheath and extravasation injury that I can quickly recall are with implanted ports. But I would not take that to mean that it can not happen with a PICC. Look at the pathology - as soon as any catheter enters the bloodstream it is bombarded with protein. Within 5 minutes, the amount of protein attached to the catheter is equal to the amount of circulating protein. Within 24 hours, the catheter is covered with a fibrin layer at least 1 mm thick. It then progresses over time with smooth muscle cells and collagen moving into the area to form a capsule around the catheter. This process occurs with all catheters regardless of insertion site. There is no studies that have shown it happens differently with different types of catheters.

Cancer patients are going to be hypercogulable. So their chances of having a thrombus on top of this fibrin is greater.

Here are a couple of reports of fibrin sheath and PICCs:

Fibrin sheath entrapment of peripherally inserted central catheters.    J.F. Cardella, M.L. Likens, P.S. Fox    Journal of Vascular and Interventional Radiology    Peripherally inserted central catheters (PICCs), Long-term hyperalimentation, Fibrin sheath formation, surface properties of the PICC    3-9-98.    Vol. 5, No. 3,  May/June 1994    439-442    1182    Case Report

 

FIBRIN SLEEVE FORMATION AFTER LONG TERM BRACHIAL CATHETERIZATION WITH AN IMPLANTABLE PORT DEVICE    H. Starkhammar, M. Bengtsson, O. Morales    EUROPEAN JOURNAL Of SURGERY    catheterization, central venous, peripheral, catheters, indwelling, drug therapy, infusion, intravenous, phlebography, thrombosis    10/22/98    Vol. 158, September 1992    481-484    1609    Clinical Study

 

Endothelial thrombus formation: An unusual complication related to peripherally inserted central catheters    S. Jepsen    Nutrition in Clinical Practice    PICC, diabetes mellitus, multiple drug allergies, cephalic vein, thrombus, cut down    7-14-96    Vol. 10, June 1995    120-122    0152    Case Report 

 

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

www.hadawayassociates.com

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

mary ann ferrannini
 Rivka, We do have the a
 Rivka, We do have the a Power PICC as well and often use the SOLO BARD in our oncology population. Just want to let you in on a little story. We had a patient come in with a new port for outpatient chemotherapy. The port was accessed but no blood return.IV nurse was called and reaccessed. This very experienced nurse knew she was in the portal chamber and felt the distinctive cliick of the back wall. A CXR was done and all seemed OK except port was on the left and tip was butted up against the wall of the upper SVC at a sharp angle. We were told to use "SVC wall very thick". Our IV nurse refused and our outpatient nurse also refused and we requested a dye study. Guess who made a smart decision? Yes......the IV nurses. The port catheter was malpositioned and  needed to be removed. We placed a right arm PICC two days later and had a very grateful Patient. I told our manager that was some really awesome nursing care!!!! Always pays to be careful and follow your gut even though treatment may be postponed or delayed.
ann zonderman
Ann Zonderman, BSN, JD,

Ann Zonderman, BSN, JD, CRNI, LHRM

One more story to support checking placement - Follow your instinct.

Case was of a child with a long term line. The nurses thought something was not right and document " line difficult to flush."  Got an order for a dye study... good so far...

However, next nurse used the line - BEFORE the dye study was done... (there had been sufficient time to have the study)  Well the sad story.... turns out the line was imbedded in the lower SVC and erroded the vessel.  The child died... cardiac tamponade.... 

 ALL NURSES SHOULD BE PATIENT ADVOCATES!!

Ann Zonderman, BSN, JD, CRNI

rivka livni
For all those who responded

For all those who responded thanks. You should read the previous notes written.

I know there are problems, serious dangerous problems and situations with no blood returns but good CXR tip location on PORTS, DIALYSIS CATHETERS, SHORT CVC, and  TUNNELED CATHETERS.

It is my opinion that we should not lump all Cental Venous Access Devices together. Some problems are unique to some catheters.

Since PICCs are so "flimsy" so to speak, meaning they are not stiff, they cannot penetrate through the vessel wall, and since they are of small diameter I don't think they could end up with a "sleeve" of fibrin that could cause a retrograde flow of chemo all the way into the soft tissue of the arm as could happen with short stiffer catheters that can develop that problem and the chemo could retrograde into the port of vessel entry.

Since the new generation of Power PICC came to market, there are no need to worry of catheter fracture.

However, you could have many cases when you get blood return from a PICC and the tip of the catheter WILL NOT be in the SVC, chemo infusion should not be safe then.

But if there is NO BLOOD RETURN and you can easily flush the PICC and the CXR shows PICC in optimal position, I am saying the PICC is safe to infuse the chemo until you have time to declot it for partial withdraw occlusion.

I don't think we should treat PICC like PORTS or TUNNELED CATHETERS.

And by the way I am talking adults only, I have no idea what is the practice for pediatric patients.

mary ann ferrannini
I understand what you
I understand what you are saying but I would still not give any chemotherapy until I did complete assessment ,and this may include administering Tpa depending upon where the assessment lead me. You are also assuming the Tpa will work. Lets say they gave the chemotherapy and the next day 2 doses of Tpa failed to give you a blood return...then what? Yes I agree each VAD could have its unique set of complications,but a lot of them are similar. Most of the holes or breaks that I have seen have been in silicone catheters,especially after the incorrect administration of Tpa. This is a question I always ask and search for now.
lynncrni
For all situations like

For all situations like this, I would approach it from a patient safety point of view. All decisions would be made based on the safest possible method of patient care until it was proven through science that those methods were not necessary. For instance, rather than saying I must have proof that a fibrin sheath on a PICC can lead to an air emboli before I will put the standard practices into use, I would put those standard practices into use and then wait for them to be shown to be not necessary. Again, it is a matter of the science of safety, which is just beginning to develop. But I will always make the error on the side of safety first.  

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

www.hadawayassociates.com

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

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