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Anticoagulant Preventing CVC Insert?

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I apologize for the grammatically incorrect title I was just trying to find something that would fit in the subject line. I have been a nurse for years but have only been in an ICU for a few months. We commonly have emergent or semi-emergent CVC insertions on my floor. Many times already I have seen it being done because it was necessary even if the patient has recently gotten anticoagulants (I'm mostly thinking of subcut heparin and lovenox here) as long as PT/INR, PTT, etc aren't unusual. But recently I was told a patient can not have one placed because subcut anticoagulant within 12 hours. The patient had no bleeding and coag studies were not concerning values. The patient was very acutely ill and needed pressors (only had peripheral IVs). There is no policy for this at my facility its supposed to be by physician decision.

Does your facility have a policy on this? What do you see most commonly practiced? Thanks

MunoRN, RN

Specializes in Critical Care. Has 10 years experience.

I've never had a doc hesitate about putting in a central line just because they were on VTE prophylaxis heparin. They prefer the IJ to a subclavian if the INR is elevated and might like some FFP to be hanging while they're placing the line if it's critically high, but they've never just not placed one.

Mully

Specializes in SICU.

Subcutaneous heparin is low-dose heparin (5000 U subq). This usually doesn't even alter the INR at all. Patients get these shots right before surgery to prevent DVT post-operatively. You know... surgery. Where we cut people open and whatnot. We also perform spinals/epidurals without consideration of a patient's current subcutaneous heparin status. And if a patient were to bleed from a spinal/epidural, they could very quickly become paraplegic.

What I'm trying to say is, that doc wanted a cop out. Next time politely ask the doctor to reference his research article so you can further educate your peers.

juan de la cruz, MSN, RN, NP

Specializes in APRN, Adult Critical Care, General Cardiology. Has 27 years experience.

There are two regimens for SQ anticoagulation depending on the indication:

(1) SQ Unfractionated Heparin every 8 hours or SQ Low Molecular Weight Heparin (i.e., Enoxaparin) daily or every 12 hours for VTE prophylaxis.

(2) SQ Low Molecular Weight Heparin (i.e., Enoxaparin) given every 12 hours at a dose used for full anticoagulation in DVT, PE and other thromboembolic states used in place of Unfractionated Heparin infusion.

Do you know which regimen the patient was on since you didn't specify it?

I routinely place CVC's in the ICU as an ACNP. As already said, the patient being on VTE prophylaxis with either UFH or LMWH is not a contraindication for CVC placement. However, I would be extra cautious in patients who have been receiving full anticoagulation with SQ LMWH but I would NOT necessarily hold the procedure from being performed if the indication outweighs the risk (i.e., the patient needing pressors). Some providers hold the Heparin infusion for an hour prior to CVC placement but unfortunately, you can not do the same on a patient who got their 12-hr LMWH dose.

The standard now is to place CVC's with ultrasound guidance and this has immensely made a difference in the ease and accuracy of placement. Studies have shown that the incidence of multiple pokes have been virtually eliminated when the clinician visualizes the target vein with ultrasound while poking with a needle. I would certainly make sure that an experienced provider places the CVC in this situation (i.e., not an intern who is doing the procedure for the first time).

The other consideration is the type of CVC the patient needs. Triple Lumens are not that big (Fr 7-8) and hemodialysis catheters are big hoses (Fr 13) so the risk of bleeding with the latter is higher. In a situation when a patient will require a hemodialysis catheter, I would evaluate whether waiting until after the 12-hr LMWH effect is done is feasible.

There are two regimens for SQ anticoagulation depending on the indication:

(1) SQ Unfractionated Heparin every 8 hours or SQ Low Molecular Weight Heparin (i.e., Enoxaparin) daily or every 12 hours for VTE prophylaxis.

(2) SQ Low Molecular Weight Heparin (i.e., Enoxaparin) given every 12 hours at a dose used for full anticoagulation in DVT, PE and other thromboembolic states used in place of Unfractionated Heparin infusion.

Do you know which regimen the patient was on since you didn't specify it?

I routinely place CVC's in the ICU as an ACNP. As already said, the patient being on VTE prophylaxis with either UFH or LMWH is not a contraindication for CVC placement. However, I would be extra cautious in patients who have been receiving full anticoagulation with SQ LMWH but I would NOT necessarily hold the procedure from being performed if the indication outweighs the risk (i.e., the patient needing pressors). Some providers hold the Heparin infusion for an hour prior to CVC placement but unfortunately, you can not do the same on a patient who got their 12-hr LMWH dose.

The standard now is to place CVC's with ultrasound guidance and this has immensely made a difference in the ease and accuracy of placement. Studies have shown that the incidence of multiple pokes have been virtually eliminated when the clinician visualizes the target vein with ultrasound while poking with a needle. I would certainly make sure that an experienced provider places the CVC in this situation (i.e., not an intern who is doing the procedure for the first time).

The other consideration is the type of CVC the patient needs. Triple Lumens are not that big (Fr 7-8) and hemodialysis catheters are big hoses (Fr 13) so the risk of bleeding with the latter is higher. In a situation when a patient will require a hemodialysis catheter, I would evaluate whether waiting until after the 12-hr LMWH effect is done is feasible.

Juan, with that being said what do you prefer in situations with Acute/symptomatic DVTs/PEs for anticoagulation? Heparin drip or full dose Lovenox? Besides issues such as renal impairment I can't see a reason why a provider would opt for a heparin drip over Lovenox. In situations when anti-coagulation would nor be tolerated in DVTs I guess just go right for the IVC filter.

Sorry, off topic.

To the OP when CVC benefits outweigh the risk the providers go for it or just give a couple units of FFP beforehand if the INR is off. We see this a lot in our high liver failure population.

juan de la cruz, MSN, RN, NP

Specializes in APRN, Adult Critical Care, General Cardiology. Has 27 years experience.

Juan, with that being said what do you prefer in situations with Acute/symptomatic DVTs/PEs for anticoagulation? Heparin drip or full dose Lovenox? Besides issues such as renal impairment I can't see a reason why a provider would opt for a heparin drip over Lovenox. In situations when anti-coagulation would nor be tolerated in DVTs I guess just go right for the IVC filter.

Actually, studies that compared UFH with LMWH in VTE showed less incidence of complications of bleeding, improved mortality, and less recurrence of thromboembolic events with LMWH than UFH drip. The LMWH's have better bioavailability and dosing is simpler (i.e., Enoxaparin is 1 mg/kg every 12 hours). UFH infusion requires frequent monitoring as you know as a nurse at the bedside.

There is also a way to check therapeutic levels of LMWH using a lab test called anti-Xa activity though in most cases it's not required. Patients can be discharged on LMWH SQ injections with the appropriate teaching and resources to make sure injections are done correctly. However, LMWH is renally cleared so you would have higher drug levels in patients with kidney failure, hence, they are not ideal for these patients.

The same advantages of LMWH, however, makes it less ideal in unstable patients especially those in the ICU. Our patients may sometimes need surgery, invasive bedside procedures, or develop complications (i.e., bleeding) that would necessitate immediate discontinuation of anticoagulation. UFH delivered as a drip is ideal in these patients since UFH's half life is short (1-2 hours). Some clinicians prefer the ability to monitor aPTT and set a therapuetic goal range. In that regard, you see UFH drip used more often than LMWH for thromboembolic disease in the ICU.

UFH - Unfractionated Heparin

LMWH - Low Molecular Weight Heparin (i.e., Enoxaparin, Dalteparin)

Review Article on UFH vs LMWH: Fixed dose subcutaneous low molecular weight heparins versus adjusted dose unfractionated heparin for venous thromboembolism. - PubMed - NCBI

Actually, studies that compared UFH with LMWH in VTE showed less incidence of complications of bleeding, improved mortality, and less recurrence of thromboembolic events with LMWH than UFH drip. The LMWH's have better bioavailability and dosing is simpler (i.e., Enoxaparin is 1 mg/kg every 12 hours). UFH infusion requires frequent monitoring as you know as a nurse at the bedside.

There is also a way to check therapeutic levels of LMWH using a lab test called anti-Xa activity though in most cases it's not required. Patients can be discharged on LMWH SQ injections with the appropriate teaching and resources to make sure injections are done correctly. However, LMWH is renally cleared so you would have higher drug levels in patients with kidney failure, hence, they are not ideal for these patients.

The same advantages of LMWH, however, makes it less ideal in unstable patients especially those in the ICU. Our patients may sometimes need surgery, invasive bedside procedures, or develop complications (i.e., bleeding) that would necessitate immediate discontinuation of anticoagulation. UFH delivered as a drip is ideal in these patients since UFH's half life is short (1-2 hours). Some clinicians prefer the ability to monitor aPTT and set a therapuetic goal range. In that regard, you see UFH drip used more often than LMWH for thromboembolic disease in the ICU.

UFH - Unfractionated Heparin

LMWH - Low Molecular Weight Heparin (i.e., Enoxaparin, Dalteparin)

Review Article on UFH vs LMWH: Fixed dose subcutaneous low molecular weight heparins versus adjusted dose unfractionated heparin for venous thromboembolism. - PubMed - NCBI

Thanks Juan exactly what I was looking for. I guess I overlooked the fact that heparin can easily be discontinued when emergent procedures are needed ASAP and that it is easier to reverse.

IVRUS, BSN, RN

Specializes in Vascular Access. Has 32 years experience.

Also remember that a PICC is one type of central line which is placed in a "compressable" area. Therefore, if bleeding should occur, pressure may be held to the site till hemostasis resumed. Not so much when central lines are placed in the chest.

Here.I.Stand, BSN, RN

Specializes in SICU, trauma, neuro. Has 16 years experience.

Throwing in some agreement with the PPs. If a pt needs pressors, he needs pressors. He's not perfusing his vital organs.

If push came to shove, we can give some FFP, or K Centra if they came in with a very high INR (we see that fairly often in people on coumadin at home). Or put it in the IJ and hold pressure longer.

What else do the suggest -- give pressors through a PIV?? I would not do that unless it's an immediate life-or-death thing and the MD is actively working on the CVC.

iluvivt, BSN, RN

Specializes in Infusion Nursing, Home Health Infusion. Has 32 years experience.

Perhaps you could have worked around your lack of policy. Do you have a policy stating that vesicants should optimally be delivered through a central line? I agree that the benefit outweighs the risk in this particular scenario and you can minimize the risk with good technique and medical intervention. Perhaps he or she was not all that confident in their skills or maybe they just had had a recent bad experience and it left a bad taste in their mouth. A little encouragement and suggestions can go a long way such as taking the US unit to the bedside and locating the IJ,that vessel is huge compared to the ones I routinely and successfully access for PICCs and I have guided many a physician in the use of the US. I am not sure of what services you have available but we routinely place PICCS on an urgent basis for vasopressors and other drips. As IVRUS already stated, it is a good option since you can compress the site and seal the puncture off with stat seal.

traumanightsRN, NP

Has 13 years experience.

In an emergency you can absolutely give pressors through a PIV. Neo can be given through a peripheral regardless of the concentration. If you need something stronger you can give Levo through a PIV but you need a low concentration such as 4mg/250mL until the central line is put in. I would not give a levo concentration higher than 4mg/250mL in PIV unless there was Regitine in the hospital and the PIV was at least a 20ga and in a big vein such as the AC.

Regarding not placing a central line d/t VTE prophylaxis, that's just laziness on the provider's part. A patient is not at risk for bleeding from sub-q VTE prophylaxis; sub-q heparin, lovenox, or fondaparinox do not increase a person's INR because they are extremely low dose. Never have I ever seen a line not placed because of this, and every single patient on my unit is on VTE prophylaxis! Even patients on heparin drips get central lines if it's emergent. If a patient needs a central line (emergent) they will get one regardless of their coags; if needed they can get FFP to help with clotting.

Thanks to everyone for the feedback. The patient was just on full dose lovenox for a confirmed dvt and had gotten the lovenox a few hours prior. We did wind up giving pressors through a piv for few hours until a different resident arrived and had no issue with putting the central line in (which went just fine). I must have checked that arm every 5 minutes and that is not an exaggeration. It was an 18g in the ac and thankfully nothing adverse occurred. And the resident who put the central line in told the other resident that waiting was wrong so hopefully no more future problems.

IVRUS, BSN, RN

Specializes in Vascular Access. Has 32 years experience.

Crazy, crazy drug books that are telling nurses to use a big catheter and in an area of flexion.... This is a super bad idea! First of all, the IV catheter should be the smallest to accommodate the ordered therapy and NOT in an area of flexion!

Nurseboy1

Specializes in MICU, SICU, CICU. Has 12 years experience.

Working with cardiac patients, I routinely place central lines on patients that have received loading doses of plavix, aspirin, brilenta, or are on infusions of heparin, integrilin or aggrastat. I even place them on patients who have received thrombolytics for STEMI prior to cath. For me site selection is key, IJ or Femoral, somewhere I can compress the vein if necessary. I avoid subclavian veins in these patients.

Edited by Nurseboy1
spelling

traumanightsRN, NP

Has 13 years experience.

Crazy, crazy drug books that are telling nurses to use a big catheter and in an area of flexion.... This is a super bad idea! First of all, the IV catheter should be the smallest to accommodate the ordered therapy and NOT in an area of flexion!

Incorrect. You do not give a peripheral vasopressor in a small IV and yes you do give it through a big vein regardless of where that vein is, whether it's in the AC or an EJ. That's why central lines are put in....they are in big veins. I have seen what happens when you give levo through a 22ga PIV in a forearm vein that extravasated. Patient had to get a skin graft from the damage. Also, unless a central line is put in as a PICC or as a subclavian line, they are put in points of flexion, i.e. IJ (neck) and femoral (groin). To prevent a patient from bending the arm you just put a freedom splint on their arm. Safety first.

IVRUS, BSN, RN

Specializes in Vascular Access. Has 32 years experience.

Incorrect. You do not give a peripheral vasopressor in a small IV and yes you do give it through a big vein regardless of where that vein is, whether it's in the AC or an EJ. That's why central lines are put in....they are in big veins. I have seen what happens when you give levo through a 22ga PIV in a forearm vein that extravasated. Patient had to get a skin graft from the damage. Also, unless a central line is put in as a PICC or as a subclavian line, they are put in points of flexion, i.e. IJ (neck) and femoral (groin). To prevent a patient from bending the arm you just put a freedom splint on their arm. Safety first.

Totally diagree.... Vasopressors should go centrally, we agree on that.. But If given into the peripheral vasculature, then why are you choosing a large bore IV catheter??? That makes NO SENSE! The goal is to prevent damage to the tunica imtima, so one should choose the largest blood vessel possible in the arm, to allow for hemodilution and adequate blood flow around the IV catheter. And by NOT placing the IV catheter into an area of flexion, you diminish the damage to the smooth tunica intima. This damage due to the larger size starts the process of phlebitis/infiltration/extravasation.

PICC should be put in with US thus they are NOT in an area of flexion. Safety should be a consideration, yes, but knowledge about the IV catheters as well as the medication that will be infusing into it HAS TO BE your major consideration. So, in an emergency, and with a vesicant, place a short term peripheral, of the smallest size possible to adequately administer the ordered drug, then get a central line in asap.

traumanightsRN, NP

Has 13 years experience.

We're just going to have to agree to disagree lol.

Mully

Specializes in SICU.

Totally diagree.... Vasopressors should go centrally, we agree on that.. But If given into the peripheral vasculature, then why are you choosing a large bore IV catheter??? That makes NO SENSE! The goal is to prevent damage to the tunica imtima, so one should choose the largest blood vessel possible in the arm, to allow for hemodilution and adequate blood flow around the IV catheter. And by NOT placing the IV catheter into an area of flexion, you diminish the damage to the smooth tunica intima. This damage due to the larger size starts the process of phlebitis/infiltration/extravasation.

PICC should be put in with US thus they are NOT in an area of flexion. Safety should be a consideration, yes, but knowledge about the IV catheters as well as the medication that will be infusing into it HAS TO BE your major consideration. So, in an emergency, and with a vesicant, place a short term peripheral, of the smallest size possible to adequately administer the ordered drug, then get a central line in asap.

Where have you gotten this information about small IV sizes being better for pressor administration? Do you have any research or manufacturer's guidelines? You seem pretty adamant.