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PICC Referral Form


PICC Referral Form:


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PICC Referral Form
Patient Details
Patient Details
Medical History
Medical History
Any mediastinal disease : »
Tick to confirm that none of these contraindications below exist: Allergy to polyurethane »
Suspected untreated bacteraemia »
Previous irradiation of insertion site »
Previous venous thrombosis or vascular surgery at insertion site »
Localized tissue infection »
Anatomical distortion from surgery, injury or trauma Significant mediastinal disease with potential venous compression »
Neurological conditions affecting the proposed limb »
Impedance to venous return in the designated limb e.g. lymphoedema, bilateral axillary node clearance, paralysis »
Significant history of Deep Vein Thrombosis especially those whilst anticoagulated »
Severe tissue oedema »
Solutions with a final glucose concentration of greater than 10% »
Solutions with a protein concentration of greater than 5% Previous or present IV drug user »
Radiotherapy/Surgery to chest or axilla : »
History of thrombosis : »
Are platelets likely to be below 50 at time of line insertion : »
Drug History
Drug History
Is the patient fully anticoagulated : »
Allergies »
Planning Details
Planning Details
Has the patient been screened for MRSA (inpatients within 7 days, outpatients within 4 weeks) : »
Are they MRSA positive : »
Patient informed of need for PiCC line : »
Your Details
Your Details