PRACTICE SUPPORT DOCUMENT GUIDELINES
TITLE
HOME PARENTERAL THERAPY PROGRAM – PREVENTION AND TREATMENT OF UPPER
EXTREMITY CATHETER-RELATED THROMBOSIS
DOCUMENT #
INITIAL APPROVAL DATE
(Assigned by Department or Division)
October 28, 2013
APPROVAL LEVEL
INITIAL EFFECTIVE DATE
Senior Leadership Team, Edmonton Zone
October 28, 2013
SPONSOR
REVISION EFFECTIVE DATE
Home Parenteral Therapy Program, Edmonton Zone
Month DD, YYYY
CATEGORY
NEXT REVIEW
Health Care and Services
October 28, 2016
OBJECTIVE
This clinical guideline identifies strategies to reduce the occurrence of upper extremity catheterrelated thrombosis (UECRT) of the deep veins (i.e., brachial, axillary and subclavian) in patients
receiving home parenteral therapy (HPT), and for all patients who require central venous
catheters (CVCs)*.
(*Includes tunneled catheters, implanted vascular access devices (IVADs), and peripherally inserted central catheters
(PICCs) which are inserted for outpatient / home intravenous (IV) therapy.)
APPLICABILITY
This clinical guideline applies to all Covenant Health and Alberta Health Services employees,
members of the medical and midwifery staffs, students, volunteers, and other persons acting on
behalf of Covenant Health and/or Alberta Health Services (including contracted service
providers as necessary) within the Edmonton Zone. This clinical guideline does not limit any
legal rights to which you may otherwise be entitled.
POINTS OF EMPHASIS
•
•
Patients who have an indwelling CVC are at increased risk of developing catheter-related
thrombosis in the deep veins of their arm and chest. UECRT has been assoiciated with
several complications, adding to patient morbidity and potentially increasing patent mortality.
The incidence of symptomatic UECRT varies from 0.3% - 28.3%, with many studies
reporting 0 – 3.1%. The incidence of UECRT assessed by venography is reported to vary
between 27% - 66%, with most (75%) being asymptomatic.47, 65, 39, 92 The incidence of
pulmonary emboli in patients with clinically overt UECRT ranges from 15-25%, with an
autopsy proven rate of 50%. 45, 49, 71
The attributable increase in cost and duration of hospitalization in patients with PICC-associated
deep vein thrombosis (DVT) has been found to be an additional $ 15,973 (US) and 4.6 days. 90
•
•
As a new patient safety strategy, Accreditation Canada has created a Required
Organizational Practice (ROP) for the prevention of thrombosis and prophylaxis of hospital
patients who have specific risk factors for thrombosis. The America College of Chest
Physicians Evidence-Based Practice (ACCP) Guidelines 8th Edition (2008) and 9th Edition
(2012) recommends strategies for prophylaxis, diagnosis and treatment of thrombosis. The
ACCP Guidelines, along with other annotated literature have been used to create the
Edmonton Zone document which summarizes recommendations for prophylaxis, diagnosis,
and treatment of UERCT and pulmonary embolism.
Recommendations related to early patient assessment for appropriate venous access
device, ongoing patient monitoring for complications, catheter characteristics and catheter
placement techniques have also been gathered from both medical and nursing literature,
and are included in this document.
GUIDELINE
1.
Complications of Upper Extremity Catheter-Related Thrombosis
UECRT increases morbidity and the risk of mortality, and has been associated with
severe complications 5, 9, 10, 17, 25, 27, 44, 45, 49, 68.
Complications of UECRT
•
•
•
•
•
2.
Pulmonary embolism
Brachial plexopathy
Chronic venous insufficiency
Loss of vascular access/catheter replacement
Septic thrombophlebitis
•
•
•
•
•
Thoracic duct obstruction
Post thrombotic syndrome
Recurrent deep vein thrombosis
Venous gangrene
Superior vena cava syndrome
Risk Factors for Upper Extremity Catheter-Related Thrombosis
The risk of DVT increases with the number of risk factors present.10, 58, 60, 64, 68, 90, 92, 95
Abnormalities
of Blood Flow
Injury to Vessel Wall
•
•
•
•
•
•
•
•
Venipuncture
Catheter advancement
Catheter tip rubbing on
vessel wall
Infusates that cause osmotic
shifts in
endothelial cell fluid
Diseases that damage
endothelial cells
•
•
•
Presence of catheter in the vein
slows blood flow
Stenosis caused by previous
catheterization
Immobility
Hematologic Abnormalities
•
•
Fluid volume deficits that
increases blood viscosity
Hypercoagulable states, e.g.
cancer, pregnancy
Genetic or acquired clotting
abnormalities
2.1.
CVC Associated Risk Factors
The type and gauge of CVC, number of catheter lumens, insertion technique, difficulties
with insertion, site of insertion, position of the CVC tip, as well as duration of CVC dwell
time will either increase or decrease the risk of UECRT. 36, 43, 44, 49, 90, 92, 96
Increased Risk of UECRT
•
Multiple lumens
•
Tip proximal to distal superior
vena cava (SVC) / right atrial
junction
Other mal-positioned CVC tips
•
References
Decreased Risk of UECRT
8, 25, 47, 49, 60
•
One lumen
8, 17, 19, 23, 24, 31, 32, 33, 34, 37, 37, 40, 41
•
Tip located immediately proximal
to right atrium at level of SVC /
right atrial junction
•
•
•
Single insertion attempt
Non-traumatic insertion
Few peripheral IV catheters prior
to CVC insertion
•
Right-sided entry
47, 49, 64, 67. 88,89, 90, 92, 96
•
•
•
Multiple insertion attempts
Vascular trauma
Multiple peripheral IV catheters
prior to CVC insertion
•
Left-sided entry (catheter rubs
against proximal SVC as it is
advanced past brachiocephalic
vein, causing vessel wall trauma)
•
•
Large gauge CVC
Catheter takes up > 33% of vein
volume
18, 49, 60, 67, 90, 92, 95
•
•
Small gauge CVC
Catheter takes up < 33% of vein
volume
•
Chemical phlebitis secondary to
more thrombogenic CVC
material:
- polyethylene, e.g. Cook
pressure monitoring set
25, 47, 49, 60, 62, 67
•
CVC material less thrombogenic:
- silicone, e.g. Bard, Groshong,
Cook
- polyurethane, e.g. Arrow, Bard
- antithrombotic materials,
e.g. Chloragard®
•
Chemical phlebitis secondary to
irritant and/or vesicant
medications or infusion
solutions:
- total parenteral nutrition
- antibiotics, e.g. Vancomycin,
Piperacillin -Tazobactam,
Cloxacillin
- hyper- or hypo-tonic electrolyte
solutions
- chemotherapeutic agents
9, 41, 92
•
Non-irritant medications or
infusion solutions:
- normal saline
- isotonic solutions
•
CVC infection
7,10, 82, 92
•
•
Sterile insertion technique
Timely removal of CVC to
prevent infection
•
Insertion of CVC by palpation
and landmark technique
47, 50, 65, 66, 67
•
Ultrasound-guided insertion of
CVC
3, 18, 41, 49
3, 18, 25, 41, 43, 49, 89, 92
2.2.
Patient-Associated Risk Factors
Inherited and acquired risk factors for thrombosis combined with risks associated with the
CVC play an important role in the development of UECRT. 36, 43, 44, 49
Inherited 8, 9, 3, 48, 68, 95
Acquired
•
•
•
Presence of CVC / pacemaker 3, 5, 9, 68
Malignancy (4.3-fold increase in risk) 3, 5, 8, 9, 33, 36, 41, 60, 62,
65, 66, 68, 89
, e.g. especially malignant processes involving
right lung, lymph nodes, or other mediastinal structures
where catheter thrombosis may occur due to central vein
compression & thrombosis 92
Previous venous thrombosis &/or thromboembolism 3, 8,9,
20, 33, 36, 41, 60, 62, 66, 68
•
Hypercoagulable states, 3, 41, 68
e.g. pregnancy and puerperium (10-fold increase in risk);
41
; hormone therapy (2-4 fold increase in risk)8, 41,
especially if patient on oral contraceptives or ovulation
induction agents & has a concomitant prothrombin
mutation or factor V Leiden deficiency 92; dehydration 41
Sepsis 3, 5, 41, 33
Bed rest 3, 8, 41, 33
Inflammatory bowel disease 33, 68
Congestive heart failure 41, 68
Chronic obstructive pulmonary disease (COPD) and
(5, 33, 68)
respiratory disease
Recent surgery / trauma (6-22 fold increase in risk) 5, 8,
•
•
•
Advanced age 5, 8,33, 41, 62, 68
41
Renal failure / Nephrotic syndrome
BMI ≥35 (8-fold increase in risk if undergoing surgery) 5,
•
•
•
•
•
•
•
•
•
•
•
•
•
•
20, 9, 68
13, 8, 9, 41, 68
Diabetes 5
33, 41
, e.g. connective tissue
Autoimmune disorders
disorders, rheumatologic disease
41
Myeloproliferative disorders
8, 41
Essential thrombocythemia
Polycythemia vera 8, 41
Antiphospholipid syndrome 8, 41(50% of people with
systemic lupus erythematous have antiphospholipid
antibodies])
Paroxysmal nocturnal hemoglobinuria 8, 41
•
•
•
•
•
•
•
Factor V Leiden deficiency: 3 to 8-fold increase
in risk among heterozygous carriers and 50 to
80-fold increase in risk in homozygote
(Caucasians only)
Prothrombin G20210A mutation (Factor II
mutation): 3-fold increase in risk (Caucasians
only)
Deficiency of natural coagulation inhibitors (10fold increase in risk in heterozygote), e.g. antithrombin deficiency, Protein C deficiency, Protein
S deficiency
Elevated clotting factors (2-3 fold increase in risk
for those > 90th percentile)
Antibody-positive heparin-induced
92
thrombocytopenia (HIT)
Hyperhomocysteinemia (2-fold increase in risk)
Dysfibrinogenemia
3.
Risk Reduction Strategies
Risks associated with inherited and acquired factors may be unavoidable. However, risks
related to a CVC can be reduced by preventive actions taken by the healthcare team prior
to and during insertion of the CVC. 6, 7, 8, 9, 36, 44, 46, 47, 52, 53
3.1.
CVC Insertion
a)
Prior to CVC insertion
•
•
•
•
•
b)
Identify patients at risk for thrombosis. Consult an anticoagulation
specialist if thromboprophylaxis is being considered to avoid UECRT.
Choose the most appropriate CVC type for each individual, i.e., use a
tunneled internal jugular vein catheter for patients at high risk for
thrombosis or any patient who may require an arterial/venous fistula in
the future
Choose the fewest lumens required for goals of therapy to be
accomplished.
Choose the smallest gauge to maintain adequate blood flow around the
catheter.
Consider an alternative device/insertion site if the required catheter will
occupy more than 50% of the vein diameter. (Note: This may not be
possible in infants and young children.)
Consider ultrasonography if there is a prior history of UECRT and there is
still a concern regarding clot resolution/vein patency.
During CVC insertion
•
•
•
•
•
Insert CVC into a vein on the right side of the body, in order to reduce
vessel trauma to the proximal SVC unless contraindicated by clinical
condition or physiology.
Use ultrasound guidance to visualize vein health and patency, and to
reduce trauma from blind catheter insertion attempts.
Place CVC tip at the level of the distal SVC / right atrial junction where it
floats freely within the vein lumen, lies parallel to the vessel wall, and
reduces catheter malfunction.
For PICC insertions: use a micro-introducer technique, and place the
PICC in a large vein above the antecubital fossa (i.e., basilic vein >
cephalic vein).
Most PICC products have a reverse taper at the insertion hub. Do not
insert the reverse taper into the vein, as it may occlude the vein. 97
3.2.
DVT Prophylaxis
Routine DVT prophylaxis is not recommended for patients with CVCs. However,
patients with certain clinical conditions and/or acquired/inherited DVT risk factors
should be considered for DVT prophylaxis if they have a CVC inserted. Consult an
anticoagulation specialist if a thrombophilic work-up and/or thromboprophylaxis is
being considered.
Cancer Patients at High Risk for DVT 55, 88
Medical / Surgical Patients at High Risk for DVT 5
•
•
Congestive heart failure or severe respiratory disease
Prolonged immobility and who have one
or more additional risk factors:
- active cancer
- previous DVT/PE
- sepsis
- acute neurologic disease
- inflammatory bowel disease
•
•
•
•
•
•
•
Abdominal/pelvic surgery for malignancies
Previous history of venous thromboembolism
Bed rest for 4 days
Advanced stage disease
60 years or older
An acute medical illness
Solid tumors
Acquired / Inherited Thrombophilia
Refer to Section 2.3. of this document.
Note:
(i)
Follow prophylaxis as outlined in the 2008 and 2012 ACCP Guidelines: Prevention of DVT in
non-surgical patients 4.2.1 - 4.4. 5, 88
(ii)
For cancer patients and patients with cancer surgery-specific information follow Venous
Thromboembolic Disease: Clinical Practice Guidelines in Oncology from the National
Comprehensive Cancer Network Guidelines (2008) 55 and the 9th edition of Antithrombotic
Therapy and Prevention of Thrombosis from the American College of Chest Physicians
Evidence-Based Clinical Practice Guidelines. 88
a)
Informed Consent for DVT Prophylaxis
•
•
•
For patients with a CVC who require DVT prophylaxis in the
home/outpatient setting, an informed consent must be obtained and
documented, as per Alberta Health Services/Covenant Health consent
policy.
This consent should include information regarding the risk of heparininduced thrombocytopenia (HIT) and its typical sequelae (e.g. new
thrombosis, skin lesions).
Patients with a CVC and receiving DVT prophylaxis while in the
home/outpatient setting should be advised to seek medical attention if
any complications occur.
3.3.
Monitoring for Complications
All patients with a CVC must be monitored for signs and symptoms of UECRT
and other CVC-related complications. Many cases are asymptomatic, therefore,
a high index of suspicion is required. Ongoing monitoring of the patient by the
responsible physician and HPT team members, including Home Care is important
for early identification of thrombosis, prevention of pulmonary embolus, and
initiation of treatment.
•
•
•
Attending physician should assess and monitor for overt signs and symptoms
of UECRT at each patient encounter.
HPT and/or Home Care nursing staff must inform the responsible physician if
symptoms of thrombosis and/or pulmonary embolus are suspected.
When a CVC is inserted by a radiologist, another physician or a nurse, it is
important to keep outcome data. This is well outlined in the Quality
Improvement Guidelines for Central Venous Access 83 of the Society of
Interventional Radiology (SIR) Standards of Practice Committee. These
guidelines include suggested information for data collection, including
indications for a CVC, success rate(s) of CVC placement, as well as
complication rates and suggested thresholds for central venous access.
Complications are also stratified by outcome. See Appendix A for
recommended documentation of outcome data for the Edmonton Zone HPT
Program.
Signs and Symptoms of UECRT 44, 46, 17, 92
•
•
•
•
•
•
•
•
•
•
•
•
Persistent pain / tenderness along catheter course, arm, shoulder, neck, jaw or ear
Erythema, induration &/or increased warmth along catheter course
Palpable, tender venous cord
Functional impairment, e.g. difficulty swallowing or turning head on CVC side or mobilizing arm and/or shoulder
Feeling of ‘fullness in fingers’ or ring(s) too tight
Edema of hand, arm, neck and/or shoulder compared to other arm
Bluish discoloration or blanching of arm
Visible collateral circulation or engorged vessels of arm, chest or neck on catheter side
Fever
Suppurative thrombophlebitis associated with severe local and systemic symptoms where patient may be toxic
with bacteremia/fungemia
Inability to draw blood from catheter and/or CVC occlusion
Paradoxical systemic arterial embolization, e.g. cardiac septal defects, patent foramen ovale
Note: In children, signs may be more subtle, e.g. occlusion of CVC.
Constans et al 92, 93 developed a clinical prediction score for diagnosis of UECRT in a
cohort of 140 patients and two separate validation cohorts with a total of 317 patients.
Four key parameters were found to contribute to the clinical score. One point was
attributed to each of these parameters and a risk score was generated.
CLINICAL PREDICTION SCORE FOR UECRT 92, 93
•
•
•
•
Parameters
Score
Venous material *
Localized pain in upper extremity
Unilateral pitting edema of upper extremity
Another diagnosis at least as plausible
1
1
1
Probability of UECRT by
Score Rating
-1 to 0 (low probability)
1
(intermediate probability)
2 or 3 (high probability)
-1
* includes a CVC or access device in a
subclavian or jugular vein, or a pacemaker
Note:
The clinical prediction score can be used as a guide to better evaluate a patient with suspected
UECRT and to help to decide whether or not further investigations are needed.
Low probability does not exclude a diagnosis of UECRT & does not mean that an ultrasound
should not be performed.
Signs and Symptoms of Pulmonary Embolus
•
Sudden onset chest pain and shortness of breath *
•
Sharp pleuritic chest pain with deep inspiration *Cough +/- bloody sputum production *
•
•
Elevated heart rate and decreased oxygen saturation *
Hypotension or cardiac arrest, especially if a large clot blocks outflow of blood from the right side of the heart
(saddle embolus)
Chest pain that lingers hours to days after the initial PE
In children, signs and symptoms may be more subtle, e.g. occlusion of CVC
•
•
*
Often precede cardio-respiratory collapse.
4.
Diagnosis of Upper Extremity Catheter Related Thrombosis and/or Pulmonary
Embolism
4.1.
Suspected UECRT 5, 12, 17, 44, 88
a) Combined modality ultrasound (compression with either Doppler or colour
Doppler) to rule out UECRT. In children, these tests are often insensitive,
but can start with ultrasonography if child is stable. 91
b) If Venous Duplex Doppler study is negative, and there is still a clinical
suspicion of UECRT, consider serial ultrasounds, traditional venography,
CT venography or Magnetic Resonance Angiography/Venography.
c) If there is a high suspicion of thrombosis, begin treatment with low molecular
weight heparin (LMWH) or unfractionated heparin (UFH) as per the 2008 and
2012 ACCP Guidelines 5, 88, as soon as possible while waiting for the outcome
of diagnostic tests. Start therapy with Vitamin K antagonist (Warfarin) on Day 1.
d) In the pediatric age group, LMWH may be the agent of choice given the
challenges of using Warfarin in this age group. However, predictability of
anticoagulation effect is reduced compared to adults 88. Consultation with an
anticoagulation specialist is recommended in this situation.
4.2.
Suspected Pulmonary Embolism 5, 14, 17, 88
Of the 600,000 patients who develop a DVT, 50,000-200,000 will die of a PE every
year in the United States of America.
a) Computerized Tomography (CT) of the chest with angiography or magnetic
resonance imaging (MRI), e.g. magnetic resonance venography (MRV), for
patients considered at high risk for a PE or if there is a high clinical suspicion
of PE. The sensitivity and specificity of these tests in children has not yet
been determined.
b) Begin anticoagulation therapy prior to and while awaiting results of
investigations, including children with a high suspicion for PE and/or who are
unstable. For children, consultation with an anticoagulation specialist is
recommended.
c) High Sensitivity D-Dimer Assay
•
Intermediate risk for PE: begin anticoagulation therapy if test results will
be delayed for 4 hours.
•
Low risk for PE: do not treat unless results of testing are not expected
within 24 hours. If the test is normal, then the likelihood of PE is very low.
Note: D-Dimer assay is not specific for blood clots in the lungs and can be
positive for a number of reasons, including pregnancy, trauma or surgery
within last 4 weeks, and/or acute infection. There is no data to support the use
of D-dimer testing in the pediatric age group.
d) Consider admission to hospital of all patients with high clinical suspicion for
PE.
5.
Management of Confirmed Upper Extremity Catheter Related Thrombosis and/or
Pulmonary Embolism
5.1.
Management of Confirmed UECRT
a) Patients with an UECRT that involves the axillary or more proximal veins are
at increased risk of death from thromboembolic complications. Anticoagulation
must be started as soon as possible and according to the 2012 ACCP
Guidelines 88, 92:
•
Early anticoagulation prevents clot propagation, facilitates maintenance of
venous collaterals, prevents PE, and prevents long-term sequelae of
chronic venous insufficiency 29, 17.
b) Patients with UECRT of distal veins, i.e., basilic or cephalic, are not at
increased risk of death from thromboembolic complications, unless there is
proximal propagation of the thrombus. In this situation:
•
Consider anticoagulation therapy if patient is symptomatic and there are
no contraindications to anticoagulation.
•
If anticoagulation therapy is not initiated, the patient should be followed
clinically. If symptoms develop or do not resolve, repeat Venous Doppler
(in 2-3 days for children) to ensure that there is no clot propagation.
•
If there is evidence of proximal extension of the clot, anticoagulation
therapy should be initiated.
c) Start treatment doses of low molecular weight heparin (LMWH), or
fondaparinux over unfractionated heparin (UFH) as per 2012 ACCP
Guidelines 88, as soon as possible and continue for 5 days or until INR is
greater than 2.0 for 24 hours. Start therapy with Vitamin K antagonist
(Warfarin) on Day 1 and treat for a minimum of three months, or for as
long as the CVC remains in place, whichever is longer.
d) Consultation with an anticoagulation specialist is recommended. For children
16 years of age and under, consult the Edmonton Zone KIDCLOT Pediatric
Thrombosis Team.
e) Monitor Warfarin doses and INR, or refer patient to an anticoagulation clinic.
f)
g)
h)
If necessary, leave CVC in place. The 2012 ACCP Guidelines 88 recommend
that, in most cases, the CVC may remain in situ, if it is still required.
•
Recent studies have identified that CVC removal and replacement puts
the patient at risk for developing a second UECRT.
If CVC is no longer necessary and UECRT is present:
•
In adults, CVC may be removed after anticoagulation has been initiated.
•
In the pediatric age group, maintain anticoagulation for 3-5 days before
removing the CVC. 88
The patient/guardian must be informed about the risk of embolization
during or immediately following CVC removal, including signs and
symptoms of pulmonary embolism, and to seek immediate medical
attention if this should occur.
Admission to hospital may or may not be required, depending on clinical
condition.
i)
5.2.
5.3.
In all patients with clinically confirmed UECRT, obtain and document informed
consent from patients who receive heparin anticoagulation therapy in the
outpatient setting, including:
•
risk of heparin-induced thrombocytopenia (HIT) and its typical sequelae
(e.g. new thrombosis, skin lesions). HIT is extremely rare in children
(<0.01%);
•
need to seek medical advice if any complications occur.
Management of Complicated Confirmed UECRT
a)
Patients with a confirmed UERCT and the following complications should be
admitted to hospital for further evaluation and consultation with an
anticoagulation specialist and/or vascular surgery:
•
failure of therapy
•
severe symptoms of UECRT with evidence of clot progression
•
occlusive thrombus of chest vessels, e.g. subclavian vein or superior
vena cava, with or without superior vena cava syndrome.
b)
In addition to anticoagulation therapy, these patients may require catheter
extraction, surgical thrombectomy, transluminal angioplasty, or a staged
approach of lysis followed by a vascular interventional or surgical procedure
88
.
Management of Pulmonary Embolism
In 90% of cases, death following a PE occurs within one hour. Therefore,
management is aimed at preventing a repeat PE and not treatment of the initial
embolus. In adults, the risk of PE with upper extremity DVT ranges from 8% 50%. 10, 49 There is little data available in the pediatric age group.
a) Referral of patient to an anticoagulation specialist is recommended.
b)
Begin short-term treatment with LMWH, or fondaparinux over UFH. Initiate a
Vitamin K antagonist (Warfarin) together with LMWH, fondaparinux or UFH on
the first treatment day. There is little safety and efficacy data available for use
of fondaparinux in children.
c)
All patients should undergo rapid risk stratification, including the need for
thrombolytic therapy. For patients with evidence of hemodynamic
compromise, the 2008 and 2012 ACCP Guidelines 5, 88 recommend
thrombolytic therapy, unless there are major contraindications owing to
bleeding risk. Thrombolysis in these patients should not be delayed because
irreversible cardiogenic shock may ensue.
d)
The decision to use thrombolytic therapy is dependent on clinical assessment
of PE severity, prognosis, and risk of bleeding.
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Recommended Data Collection for PICC Outcome Studies - 1
Date
Patient
Name
dd/mm/yy
Last, First
Age
Gender
Inpatient
Home Parenteral
Therapy
M/F
Immunosuppression
Y/N
Outpatient
APPENDIX A
TPN
Anticoagulation
Heparin
Coumadin
Reason(s) for PICC
ASA
LMWH
Blood Work
Other
Hgb
WBC
Platelets
Other
Rx of Infection: Y/N
If yes, type of Infection:
Recent Surgery
Creatinine
/GFR
Other
Y/N
If yes, indicate type of surgery:
If yes, indicate type of
immune suppression:
Activity Level
Bedridden
Moderate
Independent
Previous
PICC
Y/N
Date:
Side:
Comorbidities
Atrial
Fibrillation
Collagen
Vascular
Disease
(e.g., RA, SLE)
CHF
Diabetes
Inflammatory
Bowel
Disease
Malignancy
Obesity
Previous
DVT
Sepsis
Other
Recommended Data Collection for PICC Outcome Studies - 2 Positive Blood
Cultures at Time of
PICC Insertion
Site of PICC
Insertion
Y/N
R/L
Arm
If yes, Indicate
organism(s) isolated:
Vein Used to
Insert PICC
Length of PICC
After Insertion
Brachial
Internal:
Basilic
External:
PICC Type
(e.g., Groshong, Power PICC,
other)
PICC Lot No.
Gauge of PICC
Cephalic
Pending
Vein Size
Small
(0 – 34 mm)
Normal
(35 – 44 mm)
Process of Venipuncture for PICC
Insertion
(Normal or Difficult)
Large
(> 45 mm)
Venipuncture
N/D
Advancement
N/D
Comments:
Need for Patient Sedation
Prior to or During PICC
Insertion
Y/N
Healthcare Professional
Inserting PICC &
Date of Insertion
Name:
If yes, indicate type of sedation: Department:
Date:
PICC-Related Complications
PICC Interventions
e.g., pneumothorax, hematoma,
phlebitis, arterial injury, thrombosis,
plugged PICC, procedure-induced
sepsis, other
Y/N
If yes, indicate type of complication:
Declotted
Repaired
Removed &
Replaced
Date of PICC
Removal
No. of Days
PICC
Remained In
Situ
Comments