picc line & blood clots
- 1Aug 16, '05 by sweetyjenHi! I am a new nurse working in Med-Surg. I had a patient today that had a picc in her arm...I noticed slight swelling when I did my morning assessment. Pt said it has been like that.She left the floor for a while and when she came back it was much worse. I called the Dr and he ordered an US of her arm. Results came back...blood clots in her arm. So I dc'd the picc. Started her on Lovenox. What is this caused from?? She had a double lumen, iv fluids infusing at 30/hr and tpn @80. She has had this picc line for about a week or so with fluids infusing constantly. Except she mentioned today that they did unhook her so she could put her own shirt on...but that shouldn't have anything to do with it, should it? I am just trying to think of why this would have happened since I don't have any experience with this. I just pray that I did not somehow do this to her!!!! Her arm is about 4 times the size of her other arm. Very scary to me. I will go back to work in the am and find out more of why and what is going to happen now I guess. But I'm just curious if anyone has any answers for me!! Thanks so much for your help...
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- 0Aug 18, '05 by SandhyaQuote from jmgrn65Can't you just avoid the blood clot complication by certain meds???/OR any other way??? :uhoh21: Just curious to know as a student nurse!It is a complication of picc lines you did nothing wrong. You did everything right because you assessed her and called the doc.
- 0Aug 18, '05 by Gail-AnneThere's those that believe low-dose Coumadin is helpful in preventing thrombus, esc in prone to clot people (e.g. people with intestinal issues), others who think it doesn't do much. Many variables as to who is likely to get a thrombus, which vein was used, size of vein. size of catheter, platelets and usual clotting time....the phase of the moon!!! OK, I'm getting carried away there!
Heat to the arm helps, esc if phlebitis starting, elevation etc.,hopefully that prevents a thrombus.
We don't usually remove PICC and reinsert unless thrombus is causing lots of swelling/ painfull/etc. Often, you remove the PICC and leave the thrombus anyway. The person who did this is likely to thrombous a new site as well. We get them on Heparin to prevent thrombus from growing, while the body works on absorbing the clot that's there. Truth be told, PICCs and other CVCs have a lot more thrombuses than we realize, it's just that we only catch the ones that are felt or are troublesome.
So, take a deep breath, you sound like you did everything right.
(p.s. I insert PICCs for a living)
- 0Oct 8, '08 by MotdogFirstly you did everything right so don't worry. Thrombosis due to picc lines are the bain of my life. It is well known that thrombosis can be a problem with picc lines and around 11% of all picc lines will get a thrombosis. Cancer patients (upper GI and colorectal with liver mets) are particularly prone. My thrombosis rate last year was 7.5% I've now purchased an ultra sound machine to place piccs in upper arm therefore hoping to reduce the incident of thrombosis even further time will tell!!
Its good to know there are nurses out there that are actually taking the time to assess patients picc lines on the ward!
- 0Oct 8, '08 by GailAnneMotdog, it's great that you have an ultrasound, with use of Basilic (and then Brachial at times) veins away from the ACF, you should see a drop in the rate of thromous. We rarely have a known thrombous, is your rate of 7.5% actually backed-up by doppler? Often when someone has a doppler for a firm/sore area along vein, it's not actually a thrombous (yet!) and can be settled with warmth, reasonable movement, elevation etc. Just wondering.
- 0Oct 8, '08 by iluvivtThrombosis related to a Central Venous Catheter is a potential complication and can happen with any type of CVC. Do you remember the Triad of Virchow from nursing school. The pathophsiology of vessel thrombosis is like a three legged stool.......1 leg is stasis....leg 2 is vessel wall injury and leg three is hypercoagulability. Some examples are stasis can occur if there is any stagnant blood flow as in mediastinal disease,vessel wall injury can occur the catheter irritating the vessel wall or aggregation of platlets on the catheter surface and hypercoagulability can occur when cancerous tumors release procoagulants.
Every time you assess any CVC you should be checking for the s/sx of venous thrombosis as well as the other potential complications. Look for pt complaints of chest pain or aching.earache.jawache,axillary ache or heaviness,edema of the neck,face, arm,hands,and supraclavicular area. Pt may also complain of head feeling full and there may be a pronounced venous pattern on the chest and upper arm. The baseline PICC arm circumference will also be increased. You did good...call MD and notify them of your assessment....request a Color Doppler or Venogram. There are different types of clots and there is no consensus on how to proceed. Sometimes depending on the type and nature of the clot as well as its location it is OK to leave the line in and treat...sometimes they will treat for 48 hours and then remove and sometimes it will require immediate removal.
The single most important thing that determines a patients risk for thrombosis related to a CVC is where that catheter tip is. Optimally, the tip should be in the Superior Vena Cava and the farther you get away from the low SVC the risk increases, So if the tip is in the high SVC as opposed to the low SVC the pt will have a higher risk. You stated TPN was being administered...did you check your tip location...I sure hope it was not in the Subclavian Vein. It is crucial to administer TPN in the distal SVC due to its high osmolality and Dextrose concentration. This alone can greatly increase the patients risk. Always find out where your catheter tip is...look at the CXR report and make sure on the PICC or any CVC for that matter,that the catheter has not migrated out,so that is no longer in the SVC.
- 0Oct 10, '08 by MotdogYes all 7.5% were diagnosed with doppler as definate thrombosis not just mechanical phlebitis. The higher rate is most likely to be due to the patients cancer status. All the lines were in the lower svc on chest Xray. Hopefully by now using the ultra sound and placing higher up the arm thrombosis rate will hopefully come down.