1. Is the line needed? If not remove. I think the optimum time for removing the line is “as soon as it is not needed”.
2. If it is needed what are the risks of moving it?
3. Once the need for the line is ascertained, what are the risks of anticoagulation? If very high then I would probably leave the line alone if the patient was asymptomatic with a view to removing the line when possible.
With regards to the second question I would theorise that we would end up reducing our larger bore veins which would be useful for PICC lines if we went for midlines instead of peripheral cannulae, without a massive improvement in infections. Should we not be asking whether we should be using midlines instead of CVP lines for patients who don’t need multi lumen CVCs, or who aren’t receiving really unpleasant drugs? This would be especially relevant following the discussions about peripheral Norad.
With regards to the NEJM article- the debate about GI prophylaxis- ulcers or C diff? continues. I am none the wiser but will continue to prescribe some form of GI protection until someone tells me not to, or until I get buried in a pile of c. diff provoked effluent.
There is no strong evidence base for such decisions.
Most CVC catheters will develop some clot or fibrin sleeves around the vein entry site which are non occlusive and can be seen with ultrasound but don’t warrant anticoagulation.
Patients with acute venous occlusion ( as opposed to chronic blockage with collateral formation) who are symptomatic with upper or lower limb swelling/pain/redness, or facial swelling/neck tenderness should have imaging to demonstrate presence and extent of clot and should be fully anti coagulated unless this is contraindicated. This is to prevent clot extension centrally and peripherally and prevent PE which is described in this scenario. Further it helps reduce unpleasant late sequelae of DVT. Most cases will settle but if the limb is very swollen, painful and viability is questioned urgent discussion with vascular surgery or interventional radiology will guide benefits of directed thrombolysis (mechanical clot removal not used at Leeds when I last asked the question). The choice and duration of anticoagulation typically follows trust guidance for DVT and PE, i.e. therapeutic dose LMWH then oral drug for 6 months.
CVC removal whilst intuitive probably does little to restore early limb vein patency and should be considered in overall clinical picture. If easy and safe, then remove and resite but this may not always be right choice.
Piccs and midlines are in general a good choice for alternative central type venous access. However they are not risk free and newer literature in relation to long term venous access suggests considerably higher risks of DVT with PICCs (midlines similar entry site) than more centrally placed catheters (e.g.port or hickman type devices IJV/subclavian sites) in oncology patients.
Hope this makes sense.