I am need of expert advice. I logged in to the INS site looking for an answer as well and still have not found one. I have discovered that I am wrong on the topic of blood return prior to medicaiton delivery. There is no INS Standard that requires blood return prior to delivering a medication through a peripheral IV. Why? I can find evidence to support blood return is needed for any central line prior to medicaiton delivery and if it is a chemotherapy vesicant (ONS).
The new INS PIV checklist document is good but does not address the delivery of infsates which I was hoping for.
Here are my questions?
Do PIV's never have to have a blood return to give an infusate?
Do PIV's have to have a blood return to give a vesiant espeically if manufacturer or Gahart Intravenous Medications recommends it?
Does a midline have to have a blood return since it is a PIV in essence?
Any references, standards, etc would be helpful to me.
I even went to Lynn Hadaway blog to look for INS Standard number I was hoping to find as she is an expert in this area.
Any help I thank you in advance
kathy kokotis
Bard Access Systems
Yes, a blood return is necessary for any VAD including short peripheral catheters. Infusion Nursing Standards on Flushing and Locking and Parenteral Medication and Solution Administration both state a blood return is necessary. Neither of these standards identify one type of catheter over another, so it would apply to all types of catheters. Extravasation injuries from peripheral catheters is the most frequent complication I see in lawsuits. Mandatory blood return is a significant component of the complete clinical assessment of any VAD including short peripheral catheters. 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
In ideal circumstances, a short term peripheral should yield a blood return, but in life, many things aren't ideal. I would NOT sacrifice and remove a peripheral IV catheter as long as it did not show any s/s of infiltration/extravasation, or any infectious issues just because of the lack of blood return. I find that many times within 12-24 hours your short term, less than 3 inch IV catheters quickly become seeded with fibrin at its end, which creates the ability to flush, but not aspirate a brisk return. Small IV catheter, in a small vein, yeah, many times that return isn't readily available, but as long as the infusion is not problematic nor are there any s/s of any other complications, it stays. Lynn, are you suggesting that if the peripheral IV catheter doesn't yield a return, at any point, that that peripheral should be discontinued?
I am not suggesting anything. I am stating what is written in the Infusion Nursing Standards of Practice, a document used to measure clinical practice in a wide variety of circumstances. These statements do not differenientate the type of VAD that these statements apply to, therefore it applies to all VADs. You must assess for a blood return. If giving a known vesicant or irritant med, I would not give it unless there is a blood return. I would do everything possible to obtain a blood return before removal. This could include a tourniquet above the site, attention to what this tourniquet does to a gravity flowing infusion, thorough site assessment, etc. If no blood return still and I am giving a nonvesicant or nonirritant, I might proceed. Vesicants that leak into SC tissue can easily produce tissue damage, nerve damage, etc. Irritants produce thrombophlebitis. I have seen situations where the edema from the inflammatory process produced compression of nearby nerves and led to CRPS. This same inflamatory edema in the vein wall could prevent a blood return yet giving another dose of irritating med could exacerbate this infilammation, making bad matters worse. So this comes down to a judgement call that needs strict attention to detail when documenting why you chose to use that catheter. 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
Blood return in a peripheral IV is rare after usually just a few hours in place, is the INS suggesting that PIVs should be changed every few hours?
For commenting... Yes, I too would not give a vesicant via peripheral IV catheter if it did not yield a blood return.
But if it is not a vesicant, and a blood return wasn't there, the other factors need to be assessed for sure.
In addition to physical exam and clinical judgement, another tool to assure intravascular catheter position is to use the U/S. This may be a consideration to include when the next set of standards are written.
David Bruce RN
Good idea but what evidence is available to support this practice? Standards require evidence. Also, who is trained on using the US - infusion/VA team only? If so, do they have time to troubleshoot a peripheral catheter when called by a staff nurse? 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
THe INS has some challenges to overcome if they intend to gain enough support for this practice to make it a standard of care. Primarily, blood return is a very poor diagnostic tool for assessing PIVs. There is a high rate of false negatives; IV's without complications often don't have a blood return beyond the first few hours, as well as false positives; infiltrated and extravasated IV's can still produce blood return. As a result blood return is of little use in asessing peripheral IVs.
Unfortunately, the apparent failure to recognize these issues only impairs the relevence of INS recommendations to actual practice.
Blood return is ONE component of a complete site assessment. Short peripheral catheters should not be assumed to have a blood return anymore than we should assume that it will not produce a blood return. But it must be assessed as a significant component of a complete assessment. This has been established as a part of the standard of care in numerous lawsuits where I have testified as the expert. We can not ignore the need to assess for a blood return regardless of what type of catheter we are using. 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
How would you define the "standard of care" legally speaking?
The standard of care (SOC) is the action/intervention that would be taken by a reasonable and prudent nurse in the same or similar situation. Courts now generally accept many types of "learned treatises" that can be used to establish the SOC. For infusion/VA legal cases, this group of learned treatises would include the INS SOP, position papers, and textbooks; standards, guidelines, from other organizations like AVA, ANA, ONS, ASPEN, APIC, CDC, JC, etc; drug or device instructions for use/product label; other applicable research studies. 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
The broadly accepted practice, not learned treatises such as practice guidelines, is what establishes the standard of care. Learned treatises are admissible only for the purpose of defining what an expert witness is testifying is the generally accepted practice. A practice guideline that isn't broadly accepted isn't a standard of care. An explanation can be found here.
So by claiming this to be the standard of practice, what you are claiming is that it is broadly accepted among practitioners that for a PIV to be used, blood return must be present, which wouldn't appear to be the case.
Kathy,I just wrote on this in a later forum topic....see if you can find it.
Jack Diemer, RN BSN, VA-BC