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Incidence and Quality Implications of Deep Venous Thrombosis after Peripherally Inserted Central Catheters
Shawn T. Greathouse, M.D., Jarom N. Gilstrap, M.D., Ramon Garza, III, M.D., Kimberly Reinart, RN, Holly Tavianini, RN, BSN, MSHSA, CNRN, Vera Deacon, RN, CRNI, Robert X. Murphy, Jr., M.D..
Lehigh Valley Health Network, Allentwon, PA, USA.
PURPOSE: Since the Surgeon General’s 2008 “Call to Action to Prevent Deep Vein Thrombosis (DVT) and Pulmonary Embolism,” venous thromboembolism has been targeted by payers and policymakers as a patient safety issue and a potentially preventable condition. Peripherally inserted central catheters (PICCs) are becoming more frequently utilized, yet are known to be associated with upper extremity thrombosis. Plastic, hand, and vascular surgeons are often consulted for acute thrombosis or post-phlebitic syndrome which translates to incremental financial burden on the health care system. The purpose of this study was to examine our experience with PICCs and their associated indications and complications.
METHODS: We conducted a retrospective review of all catheters placed between 2006 and 2011 by the nurse-run PICC team in our health network. All patients with ultrasound-proven DVT were identified and assessed for age, co-morbidities, admitting diagnosis, history of prior thrombus, thrombotic risk factors, type and size of catheter, location of thrombus, presence of symptoms, and dose and type of prophylaxis.
RESULTS: A total of 21,641 nurse-placed PICCs were identified during the study period. Long-term intravenous antibiotic infusion was the most common indication for catheter placement. In 28 patients (9.6%) who later developed a DVT, a catheter was placed without clear indication. The overall thrombus rate was 2.3% (n = 497) and, of these, 58.8% (n = 292) were DVTs. The most frequently cited co-morbidity was hypertension. Histories of cancer and tobacco use were the two predominant thrombotic risk factors identified within this population. DVT was most commonly associated with an admitting diagnosis of sepsis (n=39, 13.4%) followed by cancer (n=33, 11.3%). The median number of days after placement to thrombus formation was 8. A pulmonary embolus was diagnosed in 3 of the patients during the study period. Patients already fully anticoagulated with coumadin or intravenous unfractionated heparin did not receive any additional prophylaxis. In our network, the type of prophylaxis utilized has evolved with changes made to the formulary, and this was demonstrated in our data-set. Our current recommendation for prophylaxis has been once daily subcutaneous injection with low molecular weight heparin. In 29 (19.5%) of the patients in this series who received prophylaxis, inadequate or inconsistent DVT prophylaxis was utilized.
CONCLUSION: Although PICC placement is a common procedure in our network, it is not without the risk of patient morbidity and the potential for mortality. The rate of DVT in our series after PICC placement was 1.3%. Adherence to clear indications for PICC placement, identification of DVT risk factors, and utilization of appropriate anticoagulation prophylaxis are essential in providing appropriate care and limiting poor outcomes.
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