Maintaining Patent Venous Access in Hypercoagulable State

[bgxyrnf, MSN, RN]

I have been working with a patient who has a disorder of hypercoagulation, who has limited available vessels, who has lost multiple PICCs and midlines, as well as PIVs, due to clots (thromboses as well as clotted catheters) and yet who has a critical need for IV access to permit daily medication over several weeks.

I am wondering if anybody has had any successful experiences with such a case.

[Susie2310]

Is the patient on anticoagulants?

[Wuzzie]

We have a patient who has this problem. She has a port. Instead of Heparin her oncologist has ordered Alteplase for instillation after her port is used. I am not saying this is right but in this particular patient it works.

[KatieMI, BSN, MSN, RN]

For PIV: NS 20- 50 cc/h round the clock and no irritating solutions pretty much solves the problem.

Believe me or not, for such patient 22g in small peripheral vein with KVO NS is better than PICC.

For inherently irritating things like potassium, get order for "diluted" solution (20 meq in 250 cc instead of 100).

Avoid PICCs and midlines (they stay in veins which are by anatomy predisposed to thrombosis).

If PICC is there, flush it q2h round the clock. Yes, it is more work and against policy, but it works.

Appropriate anticoagulation if no contraindications (attention: for known hypercoagulable conditions, typical protocols like Lovenox 1 mg/kg do not always work. If available, get hematology consult).

SCDs can be applied on shoulders as well, including ones with PICC line in. Yes, you never did it before and it is against policy, but if you have to save that PICC, it works just fine.

Absolutely avoid anything that constantly presses against the shoulder with PICC/midline in it. All those fancy/schmancy sleeves, nets, coverings, etc., etc. Ditto tight sleeves.

Med check (for example, patient on coumadin has to have his daily multivitamin checked for vit K. It is extremely common pitfall).

If long- term access is needed, nontunneled ports are preferred (specialists' opinion, do not know if an evidence for this exists)

And please keep them hydrated!

[IVRUS, BSN, RN]

For PIV: NS 20- 50 cc/h round the clock and no irritating solutions pretty much solves the problem.

Believe me or not, for such patient 22g in small peripheral vein with KVO NS is better than PICC.

For inherently irritating things like potassium, get order for "diluted" solution (20 meq in 250 cc instead of 100).

Avoid PICCs and midlines (they stay in veins which are by anatomy predisposed to thrombosis).

If PICC is there, flush it q2h round the clock. Yes, it is more work and against policy, but it works.

Appropriate anticoagulation if no contraindications (attention: for known hypercoagulable conditions, typical protocols like Lovenox 1 mg/kg do not always work. If available, get hematology consult).

SCDs can be applied on shoulders as well, including ones with PICC line in. Yes, you never did it before and it is against policy, but if you have to save that PICC, it works just fine.

Absolutely avoid anything that constantly presses against the shoulder with PICC/midline in it. All those fancy/schmancy sleeves, nets, coverings, etc., etc. Ditto tight sleeves.

Med check (for example, patient on coumadin has to have his daily multivitamin checked for vit K. It is extremely common pitfall).

If long- term access is needed, nontunneled ports are preferred (specialists' opinion, do not know if an evidence for this exists)

And please keep them hydrated!

I definitely agree with avoiding PICC's as out of the four Central Lines, a PICC has the highest thrombosis rate. But I absolutely do NOT recommend and would discourage anyone from putting a sequential compression device on the arm with an indwelling PICC. This will greatly increase the damage to the vessel walls and the thrombotic process will ensure even faster. Hydration is important too, but studies have disproved the effectiveness of oral anti-coagulant in the prevention of catheter occlusions. I too have seen alteplase used as a "locking" solution, but it is an off-label use. In addition, flushing an IV catheter q 2 hrs is also not appropriate as all of that manipulation greatly will contribute to bacterial introduction. Heparin flush can decrease fibrin build-up, but so does flushing with the right solution, at the right time, and using the right method per the type of needleless connector one is using.

[AnnieOaklyRN, BSN, RN, EMT-P]

Hello,

In my hospital if we have a patient who is frequently having issues with occluding lines we will start flushing with Heparin Flush after use, which has totally eliminated the problem in most patients. You do have to remember to draw back when you access their lines so you are not putting all that Heparin in them, although it is a really small amount it can add up. You may want to try that if it is within your hospital policies.

Annie

[IVRUS, BSN, RN]

Hello,

In my hospital if we have a patient who is frequently having issues with occluding lines we will start flushing with Heparin Flush after use, which has totally eliminated the problem in most patients. You do have to remember to draw back when you access their lines so you are not putting all that Heparin in them, although it is a really small amount it can add up. You may want to try that if it is within your hospital policies.

Annie

Annie, What concentration of Heparin are you using, where you would have to draw it off so it does not go systemically? Standards dictate that if heparin flush is used, one should always use the lowest concentration (10 units per ml) Are you saying that you guys are using 5000 units per ml or greater? Whew... Now, I can see that in Dialysis Catheters, but..

[KatieMI, BSN, MSN, RN]

I definitely agree with avoiding PICC's as out of the four Central Lines, a PICC has the highest thrombosis rate. But I absolutely do NOT recommend and would discourage anyone from putting a sequential compression device on the arm with an indwelling PICC. This will greatly increase the damage to the vessel walls and the thrombotic process will ensure even faster. Hydration is important too, but studies have disproved the effectiveness of oral anti-coagulant in the prevention of catheter occlusions. I too have seen alteplase used as a "locking" solution, but it is an off-label use. In addition, flushing an IV catheter q 2 hrs is also not appropriate as all of that manipulation greatly will contribute to bacterial introduction. Heparin flush can decrease fibrin build-up, but so does flushing with the right solution, at the right time, and using the right method per the type of needleless connector one is using.

There are data that adjusted dose coumadin works at least for cancer patients:

https://www.google.com/url?sa=t&source=web&rct=j&url=https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1538-7836.2012.04817.x&ved=2ahUKEwi04oj1jdnaAhWFz4MKHd4pAioQFjAFegQIABAB&usg=AOvVaw0EBpKL16DKEMI8JFYzOPsQ

Regarding upper limb SCDs, it appears that the idea is being considered but there is no data yet:

Evidence-Based Compression

(excellent article, BTW)

and, finally, why not to use proper technique when flushing line so to prevent bacterial introduction? Heparin can cause HIT, after all (although it is not a frequent complication).

[MunoRN, RN]

I definitely agree with avoiding PICC's as out of the four Central Lines, a PICC has the highest thrombosis rate. But I absolutely do NOT recommend and would discourage anyone from putting a sequential compression device on the arm with an indwelling PICC. This will greatly increase the damage to the vessel walls and the thrombotic process will ensure even faster. Hydration is important too, but studies have disproved the effectiveness of oral anti-coagulant in the prevention of catheter occlusions. I too have seen alteplase used as a "locking" solution, but it is an off-label use. In addition, flushing an IV catheter q 2 hrs is also not appropriate as all of that manipulation greatly will contribute to bacterial introduction. Heparin flush can decrease fibrin build-up, but so does flushing with the right solution, at the right time, and using the right method per the type of needleless connector one is using.

At typically around 50 mmHg SCDs compress the vein less than muscle contractions do with common movements and ADLs, so if SCDs should be avoided in a PICC extremity due compression of the vein then the patient's arm should also be immobilized, which would only increase the risk of thrombus.

[IVRUS, BSN, RN]

At typically around 50 mmHg SCDs compress the vein less than muscle contractions do with common movements and ADLs, so if SCDs should be avoided in a PICC extremity due compression of the vein then the patient's arm should also be immobilized, which would only increase the risk of thrombus.

Totally disagree, as you knew I would Muno. Having a mechanical device squeeze the arm is inappropriate, just like putting a BP cuff or a tourniquet on an arm with a PICC in place is inappropriate. One does not need to IMMOBILIZE the said extremity, but rather not having a outside force compressing the IV catheter against the walls of the blood vessel is the objective. The reflux of blood into the IV catheter from this activity is also problematic as it greatly increases occlusions.

[IVRUS, BSN, RN]

There are data that adjusted dose coumadin works at least for cancer patients:

https://www.google.com/url?sa=t&source=web&rct=j&url=https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1538-7836.2012.04817.x&ved=2ahUKEwi04oj1jdnaAhWFz4MKHd4pAioQFjAFegQIABAB&usg=AOvVaw0EBpKL16DKEMI8JFYzOPsQ

Regarding upper limb SCDs, it appears that the idea is being considered but there is no data yet:

Evidence-Based Compression

(excellent article, BTW)

and, finally, why not to use proper technique when flushing line so to prevent bacterial introduction? Heparin can cause HIT, after all (although it is not a frequent complication).

Agreed that proper flushing of the IV catheter is very important, and HIT, not being concentration dependent is a concern with heparin flush, but currently it is the only approved locking agent we have with FDA approval.

[MunoRN, RN]

Totally disagree, as you knew I would Muno. Having a mechanical device squeeze the arm is inappropriate, just like putting a BP cuff or a tourniquet on an arm with a PICC in place is inappropriate. One does not need to IMMOBILIZE the said extremity, but rather not having a outside force compressing the IV catheter against the walls of the blood vessel is the objective. The reflux of blood into the IV catheter from this activity is also problematic as it greatly increases occlusions.

Venous flow in the limbs occurs primarily through "an outside force" compressing the vein, ie muscle contractions. The purpose of SCDs is to mimic the vein compression that occurs as a result of muscle contractions. Peak compressive forces in muscle contractions that occur with typical activities far exceeds the compressive forces on the vein that SCDs provide.

So if the mechanism that must be avoided is compression of the vein then use of arm in ways that produce vein compression must be avoided, whether it's activity or SCDs. Maybe you could clarify what you see the functional difference being between compression by SCD and compression by muscle contraction.