We have a patient with a MSSA bacteremia. Placed a PICC and she now has clot formation in SVC. ID wants her on 4-6 weeks Vanco. They have suggested a Midline. We won't do that. She is anticoagulated. I asked IR if an implanted VAD to IVC might be considered. IR MD suggested possibility of SVC PICC again with a venogram leaving tip above area of clot as long as she remains on coumadin. ID MD now suggesting we place Midline for course of Daptomycin instead of Vanco. This is a drug I am hearing about for the first time. i have all the literature about it but no experience with it. ID thinks this drug would be appropriate for midline. We have never sent anyone home with a midline for an extended course of abx. Quite frankly, I don't think any home care agency would take her on with a midline for long term abx, anyway.
HELP!!!
The pH of this drug is not listed in my 2008 edition of Intravenous Medications. Last August at a conference, I did have a conversation with a local rep about this information for his drug. I just searched my email and found some additional communication from him but he never supplied the answers to my questions about the pH and osmolarity of daptomycin. This would be the required information before you can determine if it is acceptable for peripheral infusion through a midline catheter. You may have to contact the medical affairs dept of the drug manufacturer to get this information.
Has the first PICC already been removed? If not, what about a catheter-directed thrombolysis procedure in IR to solve the problem with the current PICC? Has this been considered?
Lynn Hadaway, M.Ed., RN, BC, CRNI
www.hadawayassociates.com
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Has anyone studied the efficacy of a TPA drip to resolve the svc clot through maybe a picc in the other side.
Rupert reports a case study of an SVC thrombosis completely lysed with an Alteplase infusion via subclavian v., with concurrent peripheral Hep drip:
The interventional radiologist inserted a 6-F sheath into the right subclavian vein to start an infusion of 50 mg of t-PA. Based on the location of the thrombosis, he also inserted a venous sheath into each arm. The total volume of fluid was 300 mL (50 mg of t-PA in 50 mL of normal saline, placed in 250-mL bags of normal saline); it was divided into two 150-mL infusions, one per arm, and was infused at a rate of 3 mL/hr. In addition, after receiving a 3,000-unit heparin bolus, D. C. received a heparin drip of 1,000 units/hr heparin 25,000 units in 250 mL of normal saline) through a peripheral iv in his left wrist. He also received fluids for hydration and cefazolin (Ancef) 1 g iv every eight hours to prevent infection...Venography [post intervention] revealed complete resolution of the thrombi in the superior vena cava and left subclavian vein, with a small nonoccluding thrombus remaining in the right subclavian vein.
Rupert RA. Superior Vena Cava Syndrome. AJN. 2007; 10(10): 72C-G. (Case report of rapid-onset SVC syndrome treated with Alteplase infusion and Heparin.)
Regards,
Daphne Broadhurst
Desjardins Healthgroup
Ottawa ON
Daphne Broadhurst
Desjardins Pharmacy
Ottawa, Canada
Maureen Lawler CRNI
Clinical Leader Venous Access Team
Salem Hospital
North Shore Medical Center
Salem, Ma 01970
Kathy Kokotis
Bard Access Systems
Maureen Lawler great call on your part for IR. Midline would have just caused another clot as patient is obviously compromised to begin with. IR had to resort to jugualr and a chronic line. Great call
kathy
Kathy Kokotis
Bard Access Systems