PICC Line access

[Djadia]

There recently was a patient on our Med/Surg unit who had a dual lumen Power PICC placed during surgery for TPN & Lipids Infusion. 48 hrs later, his arm was edematous, red & warm. An ultrasound was done on his right arm which yielded the presence of a clot in the Basilic, axillary, & subclavian vein. The anesthesiologist (who inserted the PICC) was notified. He stated that we could continue to use the PICC seeing as though the clot wasn't in the PICC Line. Was his statement correct. Is it recommended to use line especially if it is being used for an infusion of TPN/Lipids?

[Anna Flaxis, BSN, RN]

The anesthesiologist is correct, assuming that the catheter tip is in the SVC at the cavoatrial junction and there is no fibrin sheath; then the infusion will still be delivered to the right atrium.

Whether to DC the line and insert a new one will depend on factors such as facility policy and the clinician's medical decision making.

[Djadia]

Thanks for the reply. Sometimes it's nice to get someone elses opinion.

[iluvivt, BSN, RN]

Many patients actually get a thrombus related to CVC placement that we never really know about since most are clinically silent. It is when they do have some s/sx that a Doppler is done and it is confirmed and then the clinical course of action must be decided. The CVC can be left in or taken out and the patient can be anticoagulated or not depending upon a lot of factors. I will not go into the kind of clots that can be formed.

Of consideration, in this case is that the thrombus extends to the axillary and then to the Subclavian vein. So this is a thrombus in a large central vein and not just in an upper arm vein. We often leave the PICCs if it is just an upper arm extremity thrombosis and the patient is not all that symptomatic and is not in any discomfort. If the thrombus is in a central vein we almost always take it out and anticoagulate unless contraindicated for some clinical reason.

Yes it is true the tip of that PICC was in the cavoatrial junction and that is where the TPN is being infused but that totally ignores the thrombus. Was any tx initiated or plans made to DC the PICC and obtain another PICC or CVC? Depending upon the pt's s/sx it may be feasible to use it for a short amt of time until another access can be obtained,

[Anna Flaxis, BSN, RN]

Yes it is true the tip of that PICC was in the cavoatrial junction and that is where the TPN is being infused but that totally ignores the thrombus. Was any tx initiated or plans made to DC the PICC and obtain another PICC or CVC? Depending upon the pt's s/sx it may be feasible to use it for a short amt of time until another access can be obtained,

Not to appear argumentative, but we don't know that the thrombus was totally ignored.

The OP's question was whether or not the line could continue to be used.

My assumption, perhaps incorrect, was that there would be a delay in getting the line pulled and replaced, and that the nurse was instructed that it could still be used in the meantime.

OP, could you come back and elaborate?

[iluvivt, BSN, RN]

Yes..we do need to know more and I was extending my answer. I had a similar issue last week, We decided to leave a PICC in overnight that had an UAEDVT, It was just a very small thrombus in the brachial vein BUT it was causing her some slight discomfort. This pt was also on TPN ans multiple abxs. We could also have placed for a PIV with some D5 or D10 and we have also done that many times as well. These are usually situations that occur late on the pm shift or during the night.