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maureen lawler
scratching our heads??

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.


The pH of this drug is not

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

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

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257


Office Phone 770-358-7861

mary ann ferrannini
This also happened to me and
This also happened to me and I could not initially find information on the Daptomycin. We were desperate for a line on this pt where we could only use his left arm. We attempted a PICC but it coiled. The MD called and asked me to make it into a midline. I told her I needed to check the ph and etc. my understanding is that it is made with a buffering agent with a ph of 5.4. I called her back and told her I would make it a midline and IVT would monitor it It was a 5 fr Groshong. Five weeks later it is still in and working great with no venous irritation or any s/sx of thrombosis.  In this case the MD refused to send the pt to IR B/C L SC was occluded. I also will not let the nurses use it for blood draws to maximize its dwell time. This would not be my first choice but sometimes you have to consider all thingds and make the best decision for the pt at that time. I would have bet it would have lasted two weeks...I am glad to say I was wrong...saw it today and re-dressed...not a fan of midlines but this pt really is benefiting from having this in place
Has anyone studied the

Has anyone studied the efficacy of a TPA drip to resolve the svc clot through maybe a picc in the other side.

Daphne Broadhurst
Rupert reports a case study

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.)


Daphne Broadhurst
Desjardins Healthgroup
Ottawa ON

Daphne Broadhurst
Desjardins Pharmacy
Ottawa, Canada

maureen lawler
Thanks to those that
Thanks to those that responded.  Patient went to IR.  Unable to thread in left arm due to non occlusive thrombus mid subclavian. TPA was used to bolus clot and cath would still not pass. right arm was attempted and wire could not pass subclavian stenosis.  Minimal angioplasty attempted with baloon and at this point the patient refused further attempts in this arm..  A temporary right IJ was then placed which will be converted to a tunnelled cath prior to patient disch home for long temr abx.

Maureen Lawler CRNI

Clinical Leader Venous Access Team

Salem Hospital

North Shore Medical Center

Salem, Ma 01970

Kathy Kokotis Bard Access

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 Kokotis

Bard Access Systems

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