The patient is 87 years old, male. PICC inserted right side 12.1.11 -- notes reveal no difficulty with insertion. Ultrasound reveals a thrombosis has developed along the basilic, axilla and subclavian veins on the PICC side on 12.21.11. No mention of SVC thrombosis but the report did not say it was clear, either. The PICC has a brisk blood return and flushes with 20ml saline without resistance in either lumen. Order received for bedside PICC insertion on the opposite side (left). Docs do not want to attempt subclavian as patient recently developed pneumothorax and has chest tubes on the right. He is intubated and on a ventilator. They do not want to attempt IJ due to large crepitus along chest and neck area (it didn't seem that big to me but didn't see him prior to yesterday). I felt the patient should go to IR for placement and was told FOUR times last night by the Attending to do it at the bedside. Assessment of left brachial shows a tiny vein that I felt was too small for the dual-lumen. The left basilic was large enough just above the antecubital, then became very small, then larger again right at the axilla, in fact his underarm hair was at the point where I felt a PICC could be inserted based on size. Noted was a double-ring inside the vein -- beginnings of clotting? I also noted he had quite a number of smaller veins up the left arm which I found unusual compared to "normal" anatomy. I did not feel comfortable inserting into this basilic and in fact my gut clenched at the thought of it.
1. What would you do for this patient for vascular access?
2. Does anyone insert that high up on the arm?
3. How would you discontinue the current PICC? Was on coumadin with INR 5.0, down to 2.3 last evening.
Thank you for your insight and expertise.
I would leave the current PICC exactly where it is, continue to infuse through it and discuss possible anticoagulation with the prescribers with the goal of preventing that thrombosis from getting bigger. Putting in another catheter of any kind will only cause thrombus in those other veins and offers too much risk for this patient. Leave well enough alone and treat what you have. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I agree
Is there and specfic numbers
Yes ! Tried to tell the physician this but he kept talking over me.
Does anyone put PICCs up this high -- pretty much in the axilla?
Thank you.
That would mean insertion into "wet" skin where the number and types of organisms are the max. This is your practice, so simply say NO to this physician, refuse to remove the current PICC and put in a new one. You can not be forced by this doc to do something that is against your best judgment. If you want more support before you say no, contact risk management and get their take on the situation. but I would say NO. I have done it before and it did not kill me! Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
1. What would you do for this patient for vascular access? Leave Current PICC line in place.
2. Does anyone insert that high up on the arm? Our PICC Team rule of practice is 2 inches below axilla...Placing a PICC in axilla hair is not good practice for infection control. Follow that gut clenching feeling it is not leading you astray.
3. How would you discontinue the current PICC? No I would not discontinue current PICC. What I would do is tell the MD your assessment findings as the vascular access expert followed by a resounding NO to removing current PICC. I would document my assessment findings and also document my reasons for leaving the current PICC line in place for further reference.
Carole I hope this situation works out best for you and the patient.
With Regards,
Lois Long Rajcan, MSN, RN,CRNI
IV/PICC Team Leader
The Chester County Hospital, West Chester PA
The patient was sent to IR for PICC placement ordered by the Attending the next morning, placed on the left side. The right side PICC was discontinued by IR at the same time. Unfortunately the patient passed away yesterday.
Thank you for your comments.
I agree with what everyone is saying but disagree completly with HOW you are saying it. Oct. 2008 CHEST journal clearly outlines what to do in the case of UE DVT. I find it much more effective to give physicians who are not up to date on current best practice (such as the doc in this scenario), a clinical reference for why we disagree. I have found that this approach takes away the confrontation and allows the doc an "out". If in the face of clinical guidelines as to why this PICC should not have been removed (incidence of new thrombosis in other arm or site is 86%), then I step it up a bit and ask what clinical piece I am missing as to why the doc is going against the guidelines. It has never escalated beyond that. The goal is not to see who is right...the goal is what is best for the patient
Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness
I do agree with Stephen on his point, however I have worked with some very stubborn physicians who would not accept any type of information from a nurse. They would just demand the nurse do what they wanted. If your collaborative, educational methods do not work, then the nurse is left with simply saying NO to what the physician is demanding that they do. Obviously there are still some physicians out there who will never accept the collaborative practice idea, but hopefully their numbers are decreasing. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I think the best solution for all is to request the physician to do a doppler and the "good" arm as well. We have been doing this at our institution since we completed a study on PICCs and thrombosis. Because we found that if we replaced the picc on the opposite side the patient would often develop a thrombosis in the new PICC as well. So our practice became when thrombosis was suspected in one arm, both arms would get dopplers before we would even place a new picc. Sometimes we would find that the other arm would have thrombosis as well. The comments about the 2008 Guidelines. I brought those back from a conference last year all gun ho that we could change the MD's practice. Well it never happened. We have a Infection Disease physician as our Medical Director and we took them to her, and we could not convince her that this was the way to go, how would we get any one else. I haven't given up but for now we do what the doc's want.
Bonnie Clemence, MSN, RN, CRNI
IV Therapy Department
Pinnacle Health System
Harrisburg, PA
Stephen, I am unable to locate the article you referenced in your post by looking at the Table of Contents from CHEST 2008. Do you have an author or title?
Thank you,
Carole
What Stephen is referring to is a very large set of guidelines published in CHEST in 2008. Here is one article from that set that I quickly found in my database.
1. Warkentin TE, Greinacher A, Koster A, Lincoff AM. Treatment and prevention of heparin-induced thrombocytopenia: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. Jun 2008;133(6 Suppl):340S-380S.
Find this one and you should be able to locate the entire journal issue. I downloaded and printed the entire set and it consumes 2 large binders. So it is very large.
Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861