[barbie71]

Hi,
We started a new picc program at our hospital. I need to know what the criteria is regarding pt.s on Plavix, coumadin, asa, with elevated pt,inr, or ptt. We don t like to do picc's on pt's with >1.7 inr. Are there any guidelines we can go by? Any info is appreciated. Help! Thanks.

[PICC ACE]

Guidelines,no. Clinical judgement,thorough assessment and evaluation of risk vs benefit,yes.
I've done PICC's for patients with platelets of 10,INR of over 7,shortly after 600mg of Plavix,on TPA,etc. Where did you get the INR of 1.7 from? Radiology? They have their "guidelines" because they are going into noncompressible areas,a much different situation than PICC placement. If they hit an artery inside the chest or abdomen on an anticoagulated patient,that's a potential emergency. If your PICC site oozes a little more than usual,open a few more fluffs and hold pressure longer.
A skilled nurse using ultrasound and MST for PICC placement is a lot safer than the alternatives (i.e. the average floor nurses and phlebotomists and their multiple sticks on the patient or an MD using 'landmarks' for a central line).
Think of the relative risk/benefit issues. Imagine a patient with a mechanical valve,needs a PICC,INR 3.2. No CV surgeon is going to agree to risk letting the INR go under 1.7 just for the 45 minutes it'll take for a PICC to be placed.
Good luck with your new program.

[CritterLover]

Originally Posted by PICC ACE

Guidelines,no. Clinical judgement,thorough assessment and evaluation of risk vs benefit,yes.
I've done PICC's for patients with platelets of 10,INR of over 7,shortly after 600mg of Plavix,on TPA,etc. Where did you get the INR of 1.7 from? Radiology? They have their "guidelines" because they are going into noncompressible areas,a much different situation than PICC placement. If they hit an artery inside the chest or abdomen on an anticoagulated patient,that's a potential emergency. If your PICC site oozes a little more than usual,open a few more fluffs and hold pressure longer.
A skilled nurse using ultrasound and MST for PICC placement is a lot safer than the alternatives (i.e. the average floor nurses and phlebotomists and their multiple sticks on the patient or an MD using 'landmarks' for a central line).
Think of the relative risk/benefit issues. Imagine a patient with a mechanical valve,needs a PICC,INR 3.2. No CV surgeon is going to agree to risk letting the INR go under 1.7 just for the 45 minutes it'll take for a PICC to be placed.
Good luck with your new program.

Agree 100%

Clinical judgement/critical thinking is the key.

One of my "sister" hospitals wants to decline anyone with abnormal coags/platelets.

Absurd.

A PICC will (almost) always be the safest type of central line to place.

I, too, have placed PICCs in pts with DIC, on heparin drips, on integrilin drips, etc, without any known complication.

However, I did once decline a patient that had an INR >10, hct <20.0, that was a Jehovah's Wittness (declined blood products). He was on coumadin for an AVR. A collegue placed his PICC (on my day off) when his INR got to therapeutic (still elevated, but within range for his valve replacement).

It isn't always black/white.

When in doubt, I consult with two specialties: IR, to get their opinion, and the ordering MD, so that I can chart that he/she agrees that the benefits outweigh the risks. I make sure, too, that the consenting party (patient or family) is aware of the additional risks, and that the physician believes that the benefits outweigh the risks.

Seriously. If the INR was 10, would you rather have a nurse placing a US-guided picc, or a resident doing an IJ (blind stick????)

[bobnurse]

PICC's are indicated for the patient with a bleeding risk. Much safer than a physician trying to place a cvc.