Overview
Definition:
Peripherally Inserted Central Catheter (PICC)-related thrombosis refers to the formation of a blood clot within a vein adjacent to or surrounding a PICC line in pediatric patients
This is a significant complication that can impede catheter function, lead to venous occlusion, and increase the risk of systemic complications like pulmonary embolism.
Epidemiology:
PICC-related thrombosis is a common complication, with reported incidence rates in pediatric populations ranging from 5% to over 30%, depending on patient population, catheter characteristics, and duration of use
Risk factors include prematurity, underlying critical illness, prolonged immobility, hypercoagulable states, and catheter dwell time.
Clinical Significance:
Preventing PICC-related thrombosis is crucial in pediatrics to maintain the efficacy of essential therapies (e.g., antibiotics, parenteral nutrition, chemotherapy), reduce patient morbidity, avoid the need for premature catheter removal, and prevent serious sequelae
Early recognition and effective management are vital for optimal patient outcomes and successful examination preparation.
Risk Factors
Patient Factors:
Prematurity and low birth weight
Underlying malignancy or critical illness
Sepsis
Congenital heart disease
Known or suspected hypercoagulable disorders
History of previous VTE
Female sex.
Catheter Factors:
Catheter material (e.g., polyurethane vs silicone)
Diameter and length of catheter
Number of lumens
Insertion site (e.g., antecubital fossa vs basilic vein)
Catheter tip malposition
Dwell time.
Insertion And Maintenance Factors:
Catheter insertion technique
Local trauma at insertion site
Repeated venipuncture attempts
Poor aseptic technique leading to infection
Infusion of irritating solutions (e.g., hyperosmolar solutions, chemotherapy)
Inadequate flushing and locking protocols
Blood draw frequency and technique.
Prevention Strategies
Catheter Selection And Insertion:
Use of smallest gauge, single-lumen catheter feasible
Appropriate tip placement confirmed by imaging
Insertion in areas with good collateral circulation
Minimizing manipulation of the catheter during insertion.
Aseptic Technique And Care:
Strict adherence to aseptic technique for insertion and all subsequent manipulations
Regular site assessment for signs of infection or inflammation
Use of sterile dressings and daily site care.
Catheter Maintenance And Flushing:
Regular and thorough flushing with saline according to institutional protocols, typically using pulsatile technique after each use and at least weekly if not in use
Proper use of locking solutions (e.g., heparin, citrate) as per guidelines, considering patient age and clinical context
Avoidance of blood draws from the PICC unless necessary, and then using appropriate technique.
Pharmacological Prophylaxis:
Consideration of low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) in high-risk pediatric patients, especially those with known hypercoagulable states or prolonged immobility, based on risk-benefit assessment and consultation with hematology.
Patient And Family Education:
Educating caregivers about early signs and symptoms of thrombosis and infection, and emphasizing the importance of reporting these promptly
Instruction on safe catheter care practices.
Clinical Presentation
Signs And Symptoms:
Swelling of the limb distal to the insertion site
Erythema and tenderness along the vein
Pain in the arm or chest
Palpable venous cord
Dilated superficial veins
Restricted range of motion of the affected limb
Fever or signs of infection which may be attributable to thrombosis.
Diagnostic Approach:
Clinical suspicion based on the above signs and symptoms
Doppler ultrasonography is the gold standard for diagnosis, demonstrating non-compressible veins and intraluminal thrombus
Other imaging modalities like venography are rarely used in pediatrics due to invasiveness.
Differential Diagnosis:
Cellulitis or local infection at the insertion site
Phlebitis without frank thrombosis
Allergic reaction to dressings or infusate
Nerve compression or injury
Musculoskeletal pain or injury
Edema from other causes (e.g., fluid overload, hypoalbuminemia).
Management Of Thrombosis
Initial Steps:
Discontinue infusion of potentially thrombogenic agents
Assess patient for signs of systemic embolization
Consider catheter removal if there is significant thrombus burden, infection, or if the catheter is no longer needed.
Anticoagulation Therapy:
Initiation of anticoagulation, typically with LMWH or UFH, guided by pediatric hematology recommendations
Dosing adjusted based on patient weight and renal function
Close monitoring of coagulation parameters (e.g., anti-Xa levels for LMWH).
Catheter Management Options:
If catheter is essential, consider thrombolysis with alteplase (tPA) or urokinase instillation to lyse existing thrombus, followed by continued anticoagulation
If catheter is not essential, removal is often preferred, with anticoagulation continuing until thrombus resolves
Insertion of a new catheter in an contralateral limb may be necessary.
Supportive Care:
Pain management
Elevation of the affected limb if tolerated
Gentle physiotherapy to maintain range of motion once pain subsides and anticoagulation is established.
Key Points
Exam Focus:
Understand the multifactorial nature of PICC thrombosis risk
Recall specific preventive measures: proper catheter selection, meticulous aseptic technique, effective flushing, and appropriate locking solutions
Be aware of the signs and symptoms and diagnostic modalities, with Doppler US being paramount.
Clinical Pearls:
Proactive prevention is key
once thrombosis occurs, management is more complex
Always consider patient-specific risk factors
Communicate with vascular access teams and hematology for complex cases
Emphasize the importance of correct flushing technique to dislodge fibrin sheath.
Common Mistakes:
Underestimating the risk in pediatric patients
Inadequate flushing or locking protocols
Failure to recognize early signs and symptoms
Inappropriate selection of catheter size or material
Delay in initiating anticoagulation or thrombolysis.