When accessing a mediport and no blood return is obtained despite repositioning of patient, what is the next step. Should you desccess and reaccess, instill cathflo or get an xray or dye study?
Repositioning the patient is ok but this is a red flag warning that pinch-off sryndome is occuring if the catheter was inserted via the subclavian vein. If you have a question about the access procedure, it is certainly reasonable to remove it and reaccess with a new needle. The choice between doing a contrast injection under fluoro or injected tPA is a matter of several factors including catheter history and how it has performed, what has been infused or injected through the catheter recently, if proper flushing was performed between multiple infusions, etc. If you have reason to believe that this is a thrombotic occlusion, then tPA may be a reasonable place to start. A contrast injection would also determine if the tip has migrated or become malpositioned in any way. This should be guided by your facilities practice guidelines and policy. Lynn
If I was at the bedside with the scenario you describe, I usually also have the patient cough deeply and try to withdraw at the point of highest positive pressure of the cough. That will sometimes work. I am not a huge proponent of replacing the needle, esp if you can see the port outline and that your needle is right in the middle. A question to ask yourself is how sure are you that the needle is in the port? If your confidence level is low (deep port, tipped port), reaccessing may be appropriate. But unless you have an idea of what to do to rectify it with the next stick, I might get someone with more experience. If you flushed the needle set prior to access, you know it's not a needle obstruction (defect). I would next review the most recent CXR to see if I could see any sort of catheter deviation, which could indicate a pinch off, and also review the op/implantation report. I remember one recently that said something to the effect of "we could not get a blood return, but since it flushed OK, we closed the incision." Depending what I found out from those two reports, I would either proceed with tpa (most likely) or a dye study. I also think if patient is having pain with flushing, I would reaccess. If pain still, proceed to dye study, letting interventionalist know there may be a leak so they don't flush lots of contrast.
Repositioning the patient is ok but this is a red flag warning that pinch-off sryndome is occuring if the catheter was inserted via the subclavian vein. If you have a question about the access procedure, it is certainly reasonable to remove it and reaccess with a new needle. The choice between doing a contrast injection under fluoro or injected tPA is a matter of several factors including catheter history and how it has performed, what has been infused or injected through the catheter recently, if proper flushing was performed between multiple infusions, etc. If you have reason to believe that this is a thrombotic occlusion, then tPA may be a reasonable place to start. A contrast injection would also determine if the tip has migrated or become malpositioned in any way. This should be guided by your facilities practice guidelines and policy. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
If I was at the bedside with the scenario you describe, I usually also have the patient cough deeply and try to withdraw at the point of highest positive pressure of the cough. That will sometimes work. I am not a huge proponent of replacing the needle, esp if you can see the port outline and that your needle is right in the middle. A question to ask yourself is how sure are you that the needle is in the port? If your confidence level is low (deep port, tipped port), reaccessing may be appropriate. But unless you have an idea of what to do to rectify it with the next stick, I might get someone with more experience. If you flushed the needle set prior to access, you know it's not a needle obstruction (defect). I would next review the most recent CXR to see if I could see any sort of catheter deviation, which could indicate a pinch off, and also review the op/implantation report. I remember one recently that said something to the effect of "we could not get a blood return, but since it flushed OK, we closed the incision." Depending what I found out from those two reports, I would either proceed with tpa (most likely) or a dye study. I also think if patient is having pain with flushing, I would reaccess. If pain still, proceed to dye study, letting interventionalist know there may be a leak so they don't flush lots of contrast.