As a Registered Nurse placing PICCs at bedside, how high is too high for an INR? At what point do you refer the patient to the radiologist?
I have been placing PICCs for over 3 years now. We are doing 1500 - 2000/year bedside placement. We NEVER refuse to place a PICC based on abnormal labs. It is much SAFER to place a PICC in the arm, than a MD to place a line in the neck or chest. You can control the bleeding, if there is any, with a pressure dressing and/or surgicel. The highest INR I have seen is 9.0. Had no compications with placement and very little ooze from the site.
we have been recently trying to find out this type of info, too.
our research has shown that there really arn't any national standards for lab cut offs. we are currently using 20 as a cut off for platlet count, inr >4.5, and ptt out of thearpeutic range for pe treatment. however, it has been reconmended to us that we try to "push" these limits and see what kind of results we get.
as coronapeng stated, a picc is the safest type of central line to place. it would be insane to decline to place a picc based off too high of a bleeding risk only to have someone try an ij placement.
what has come to my mind recently is to go ahead and place piccs if the bleeding risk is increased, but only with additional conseling to the pt/family and discussion with the mds involved with the case. i recently had an md cancel picc he had ordered on a patient because her inr was 3.5, well within our limits, but out of his comfort zone. i even tried to gently persuade him that we could do it, but he wouldn't budge.
we will decline to place a picc in the home if the coags are too high or platelets too low. better to be in a hospital if gentle pressure won't stop the bleeding!
You can also suggest giving FFP if it would make the MD more comfortable. As I said before we don't have ANY cutoffs for labs. Not even platelets. we have placed one where the platelets were 15. I only place lines in a hospital, so i can't speak to home placement, but that would be one place I might be hesitant to place lines under certain circumstances. I always keep surgicel on hand just in case!
As stated above, a PICC is the safest line to place, even if labs are whacked. We have placed PICCs numerous times while the surgeon was waiting for the INR to drop. (Thanks anyway!)
If you need IV access, you're going to have to get it someway, and a PICC is the way to go.
I've inserted a PICC when the pt's INR was 5 and it wasn't a problem.
No we do not have a cut-off value. Piccs are very safe to place as opposed to lines placed infraclavicular or suprclavicular b/c they are compressable. We assess carefully and try to cause minimal trauma and access with one attempt. We can also time it to meet the needs of the pt (ie stop meds...give FFP) If the pt needs it we do it We are often as good if not better than the radiologist. The pt may need more frequent monitoring post insertion as well and I tell the nurse what I think is needed and IVT will go back the next day to check on the site
My facility does not place PICC lines if INR is less than 1.5 and/or platelets less than 50. This is kind of high but the leader has set these standards. I know of no written standards for the lab values.
On our IV/Picc team we do not have a cutoff,it depends more on the pt's anatomy and can we place it with one stick,the bleeding can be controlled at the insertion siteand sometimes the INR can not be reversed,doing so would put the pt at risk.It really is a judgement call on the nurses part after careful assessment of the pt's whole clinical picture.