Does anybody have any evidence that a central line that has been previously used for other infusions should NOT be used for parenteral nutrition?
I know everybody has strong opinions about this, but I am looking for some real evidence before changing practice.
Thanks, Carol
What practice are you trying to change? Using a previoulsy inserted CVAD for PN or requiring that a new CVAD be inserted for PN?
I have never seen any evidence that a new or so-called "virgin" catheter is required for any formula of PN. You should check the standards and guidelines from ASPEN, but the last time I looked at those, they did not have any information about this either way.
Yes a used CVAD will have biofilm. Does that mean that the risk of CRBSI is greater if you begin infusing PN through it? Never seen evidence either way.
Then you must consider the risk of CVAD insertion. Should a functioning CVAD be pulled to make way for a new one for PN? Never seen evidence either way.
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
Thanks, Lynn. This came up because somebody infused 3 units of blood instead of infusing the parenteral nutrition through the pt's new PICC, and some staff thought that the pt needed a brand new PICC before the parenteral nutrition could be started. I just wanted an expert opinion and some evidence before changing or updating our policy (which currently doesn't address this issue).
Carol
I probably would have started the PN through the PICC and inserted a PIV for the blood. But my reason for doing this is because the length of the PICC adds so much resistance to flow that viscose blood can take a long time to infuse. Of course, this would have been based on the patient's peripheral vein status. I do not see a problem (other than flow rate and infusion time for blood) with blood through the PICC then the PN. 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
I have a question regarding infusing TPN through central lines. Our facility has a very outdated policy that says once a lumen has been designated for TPN infusion that lumen cannot be used for anything else. Because of this policy, a patient the other day unnecessarily was forced to get a new line after CT disconnected the line to use the power lumen for CT contrast (triple lumen power PICC).
Does anyone have any documentation to support either way?
Shana
Shana Taylor, RN, BScN, MN:ANP, NP
Clinical Educator
Vascular Access Services, Colposcopy, Cystoscopy, Endoscopy,
Medical Outpatient Procedures,
In the first place, why did they need to disconnect the PN through a triple lumen catheter of any kind to inject contrast? There were 2 other lumens available, right? Did they inject contrast through the lumen receiving the PN? If they did, there is no justification for that and they should be educated not to do that. Interruption of the PN line is a major factor in contamination. I think you policy was either written poorly or misinterpreted. If PN is still infusing, that lumen should never be used for anything else while the PN is infusing. The issues are compatibility of solutions with the PN and infection from attaching and detaching piggyback sets. If the PN is no longer infusing, the same lumen can be used for any type of infusion needed as long as there is no PN running through it. A dedicated lumen for PN does not mean a so-called 'virgin" lumen. A multiple lumen catheter also does not mean that all lumens are reserved for PN. Maybe I am not understanding your questions correctly. There is an ASPEN recommendation for a lumen dedicated to only PN, but there is no documentation that a lumen used for PN can never be used for anything else or that PN will always require this "virgin" line or one that has never been used for anything else. 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
Although I don't know anything about the previously-mentioned incident where CT disconnected the pt's PN to power-inject through, I do know that the Bard 6 fr triple-lumen power PICC only has one power injectable lumen, so if PN was infusiing through that one lumen, you would have to disconnect the PN to power inject.
Lynn, do you know what the ASPEN guidelines to "dedicate a lumen to PN" are based on? Do they have some evidence that infection rate is lower if one lumen is used consistently for PN? I looked at their website, but couldn't find anything specific.
Thanks,
Carol
ASPEN has a set of standards and guidelines. You may have to purchase those documents to find their specific information but I am certain they are evidence based. I don't have time now to pull mine. 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
Did you find the answer to your question? I am looking for evidence also but have run into a brick wall. Can you send me any evidence that you have found regarding the use of a dedicated lumen for TPN administration. Does dedicated mean "virgin"? Please send to [email protected] .
Dedicated does not mean virgin!! It just means you should not infuse other fluids and meds with the TPN, however that line may have been used for other fluids prior to TPN. 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
I totally support your claim that dedicated does not mean virgin, but is there literature to support your interpretation? I am constantly going toe to toe with physicians who insist on a new lumen (PICC) for TPN. I can not find the evidence to support my position. Can you provide resources?
I have never seen the term "virgin line" in any publication. I would place the burden of finding the literature to support the need for this so called virgin line on the physicians who are requiring it. Why should you go an a goose chase through the literature to find information to refute what they are wanting? Set the expectation that they should supply you with the evidence that this is required. Go to the ASPEN standards and guidelines. That is the primary source for anything related to parenteral nutrition. The physicians will not be able to find this, or at least I don't think they will. Then take the information you find to the appropriate committee in your hospital. Let the committee decide rather than individual arguments with physicians. 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
We have had the very same issue and are going through a debate right now. Our issue is that traditionally, we have exchanged over a wire PICCs that have been used when there is a new order to initiate TPN. Not sure when the practice started, but it has been that way as long as I have been on the IV team. (10yrs) Our policy only states that TPN needs to have a "dedicated" lumen. We are attempting to change our practice as to not exchange these otherwise nicely functioning catheters. We feel that the risks of complications from exchanging or placing a new picc outweigh the percieved benefit of lower infection rates. CRBSI's. We have had zero CRBSI in over 3 yrs with our picc lines.
We are getting push back from several ICU and medical units and our practice council is asking for evidence to change practice. I've looked, there isn't any evedence to suggest a "virgin/sterile" line is associated with better outcomes. There is very limited evedence that even a dedicated line is associated with better outcomes. CDC stops short of Recommending a dedicated line for PN. Although andecdotally this seems to make much more sense that fewer line breaks and manipulation reduces chances for contamination.
The strongest evedence that I can find relates to extraluminal site and insertion care. The majority of central line infections come from skin/to vein track and biopatch for us seems to be working very well. I would emphasize the stringent conditions that are impelmented to minimize CRBSI. PICC line insertion bundle with maximum sterile barrier, upper arm site location with U/S guidence to minimize trauma, needle stick attempts, and site flexion, CHG dressings, meticulis dressing care, and staff education strategies for hub matinence, site care, and PN line precautions.
BTW, which way are you arguing? I assumed you were in agreement with my assertions, but reading your question again, you could be looking the other way. Curious
Good Morning,
I am very interested in the opinions and maybe some guidelines/standards/policies on a practice that has been going on in my hospital system. I am an RN on an IV/Picc team/Vascular Access Team. I was asked to look into a problem that started occuring in our system of MD's ordering picc lines to be placed on pt's with ports. The rationale was that the port was placed for another reason/medical problem and the MD was not going to risk infecting the port by using it, but would order a picc line to be placed instead.
So in 2009, I started looking into this. There is nothing really in any literature addressing this issue. I also spoke with other hospitals with IV teams in the United states, more specifically the CNS's of these teams and the response was pretty much the same. "Your MD's need to be educated, as their choices are putting the pt more at risk." I agree wholeheartedly. I also called the manufacturing companies of picc's and port's and the response was the same.
One more thought before I go. We also have MD's refusing to have pts' ports accessed and poking pt's inappropriately for the same reason as stateg above. The bone marrow transplant department will not use ports to infuse bone marrow cells because......"it's protocol", with no protocol in writing. Please help, this is really poor patient care!!!!! Thank you.
It sounds like you have already done the work to find published literature and benchmarked against other hospitals and checked with the VAD manufacturers. I hope you have all of this documentation. Standards and guidelines that you will need are the Infusion Nursing Standards of Practice from INS, Guidelines and Standards from the American Society of Parenteral and Enteral Nutrition (both of these can be purchased online at their websites) and the CDC guidelines which can be downloaded free from the CDC website. The other thing you could do is the request that the physician provide documentation from literature/standards, etc information to support his/her request. You should also involve your infection preventionist and risk manager in this process. Then you will need to take this to the appropriate hospital committees for a decision on what practice they deem best. So I don't think there is anything that we could help you with. You have already done it in what sounds like a thorough way. What remains to be done is within your hospital management and committee structure. 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