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Matt Gibson RN ...
Vascular access devices and blood return

 Currently  I am having a debate between coworkers about short peripheral and midline catheters. The way some interpret the INS standards is that blood return is an essential part of the device assessment and should be present prior using either device. Others say short peripherals and midlines are not expected to always give a blood return, but can be safely used.

Any opinions?

lynncrni
 I have spent a great deal of

 I have spent a great deal of time thinking about this issue mainly since I have worked on the INS Standards for the past 2 revisions and am currently working on the next revision. So here are my thoughts:

Blood return is an important aspect of catheter functionality for ALL types of VADs including peripheral and midline catheters. I do realize that this simple test is not completely diagnostic of the peripheral or midline catheter but it still must be performed. 

There are simple additional steps that can be used to evaluate these peripheral devices including 1) careful attention to the aspiration technique being used with slow gentle aspiration on the plunger, 2) use a smaller syringe as this will exert less pressure on aspiration, 3) a tourniquet placed above the catheter tip, 4) attention to the quality of the GRAVITY drip, 5) using gravity infusion with the tourniquet, the infusion should stop if there is not leakage from the vein but continue if there is leakage. Finally careful attention must be given to the characteristics of what is being infused, especially the vesicant nature. If you have performed all of these tests and still cannot produce a blood return without question of the site condition, and you are giving an irritant or vesicant drug, I would NOT use that site. 

The possiblity that you can not easily obtain a blood return is NOT a reason to ignore this critical step in site assessment. Many times the absence of a blood return is due to technique. 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

JackDCD
Do your nurses ALWAYS

Do your nurses ALWAYS aspirate a catheter before injecting anything. Does that go for peripheral IV's. We just had this discussion at a CLABSI meeting and a nurse educator made that statement that she wouldn't inject anything through a line she was unable to get blood return. She told me "that's nursing 101"...well I can tell you I have never seen a nurse pull back on a peripheral IV before injecting...I always would use the saying " A Midline will give you blood back...as long as a Midline will give you blood back." When it stops it's not an indication for additional procedures.

I agree with Lynn, alot of this may be corrected with the techniques she described, but not all the time. I do let them use a Power PICC cut to 15-20cm to inject CT contrast...We have never had an incident. We cut PICC's to length so why would a Midline mean less integrity on the line. The fact that it's cut shorter would mean it becomes even stronger ( less catheter).

I think there are alot of products hitting the market with an indication of "can be used for CT injection"...but if you notice there are no reports of damaged or broken polyurethane cut down Power Picc's. So, is it just another marketing tool for vendors?...Maybe...but hospitals are not looking to spend money on something they may not need.

So Matt, I would just say I have never had a clinical reason NOT to use a Midline (Power rated) to inject. So until someone can prove it to be a wrong hypothesis...Then I would say it can be used.

 

Jack Diemer, RN BSN VA-BC

 

ShanaT
Hi Matt, We've had the same

Hi Matt,

We've had the same arguments going on for awhile.  There is an article regarding contrast media that covers this topic (blood return in vascular access devices, more specifically PIVs).  The article is

Earhart, A & McMahon, P (March/April 2011).  Vascular Access and Contrast Media. Journal of Infusion Nursing, 34(2), 97-105.  I hope this helps.

 

Shana, MN-ANP, RN(EC)

Shana Taylor, RN, BScN, MN:ANP, NP

Clinical Educator

Vascular Access Services, Colposcopy, Cystoscopy, Endoscopy,

Medical Outpatient Procedures,

Ann Williams RN CRNI
Hi Matt!!!

Hi Matt!  I'm late seeing these, but in total agreement that nurses need to check for blood return before any infusion.  And I love Lynn's response!  She covers it very well!  Hope all is well with you!

Ann Williams RN CRNI

Deaconess Home Infusion

Evansville, IN

WadeBoggs26
 I've been unable to find any

 I've been unable to find any reference on how blood return should be incorporated into a PIV assessment, I would hope the proponents of including this component can point me in the right direction.  How should blood return be used in the assessment of a PIV?  If there is no blood return but other assessment paramaters indicate a safe/functional IV, should the IV be D/C'd?  If the assessment indicaties infiltration, should the site be considered safe if there is some amount of blood return?  Given an otherwise normal IV assessment, how should a lack of blood return be incorporated into decision making?

lynncrni
 Reopen the pipeline for I.

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

WadeBoggs26
 I appreciate the links, the

 I appreciate the links, the sources seem less nuanced than your recent statements on the subject.

My hospital system at one time charted the presence or lack of blood return as part of the IV assessment.  I managed to track down the audits and committee findings on the charting action:

Blood return was present on all successful IV starts.

At the first finding assessment after the start, usually about 8 hours later, less than 20% of PIV's had blood return, and at 24 hours less than 5%.  These were the "post-intervention" numbers after education on how best to acheive blood return.

I can't really go to my "powers-that-be" and argue that we should be changing IV's in more than three-quarters of patients three times a day, a five day stay would result in 15 separte PIV's.  If there was some acknowledgment that having such a standard would result in a drastic increase in PIV rotation, and that this increase was warranted, I might be able to at least present an argument.

lynncrni
 I can apprecaite your QI

 I can apprecaite your QI assessments but your description brings up many questions. You mentioned that there was education about how to achieve a blood return but we don't know what that included. What size syringes were used? 10 mL would produce those outcomes, smaller syringes would be more successful. Where were these sites? If hand, wrist or ACF I would not doubt your numbers at all because those sites have greater complications than the forearm. Those are just 2 questions that would definitely alter the rates of blood return on a short peripheral catheter. I have seen numerous patients receiving peripheral infusions that had documented superficial vein thrombosis from the hand or wrist extending the entire length of the arm. Infiltration is not the only complication that prevents blood return as thrombophelbitis can easily cause the same lack of blood return. 

All of this means that we can not abandon the complete assessment of a peripheral IV site which includes a blood return. This must be done before the administration of a medication and is not limited to the routine patient assessment at the beginning of the shift. Blood return is a vital component of this assessment and will tell you a great deal of information about the site condition. Eliminating the aspiration of blood return is not the answer. No one is recommending that the lack of a blood return on a short peripheral catheter requires immediate removal and restaring of that catheter. It is ONE component of a complete assessment which means looking at the site for changes in any appearance, palpation for temp changes and indiuration or presence of pain with palpation, aspiration and flushing, and listening to all patient complaints. If I found that only fluids were infusing and a cephalosporin antibiotic, and the site was free from all signs and symptoms of all complications and there was not blood return, I would continue to watch closely for any changes. One the other hand, if that antibiotic is vancomycin or nafcillin (vseicants), or if you have to give promethazine, I would do a complete assessment and also look at the length of time the catheter has been in place. Catheters older than 24 hours are not recommended for several infusions such as chemotherapy or contrast administration in radiology. I would never give any vesicant through any type of catheter without a blood return and the site is totally free of all signs and symptoms. I just see too many times when nurses tell patients "that drug always hurts" or telling the patient they are giving the medication slower when the patient complains of pain during medication administration. Neither of these are appropirate and all are below the standard of care. 

This brings me to the fact that we can not look exclusively at the catheter without considering the fluids and medications being infused. All nurses must accept the accountability for their actions, which includes a thorough and complete assessment of each catheter immediately before each dose of an IV medication. This does include the checking for a blood return. It requires knowledge and critical thinking to make the correct desision to proceed with that catheter or to start a new one. Any nurse not willing to accept this accountability should not be performing infusion therapy. Our healthcare system has given this responsibility to most all primary care staff nurses without the knowledge and critical thinking skills they need. 

As with anything I write, you must understand that I am an infusion nurse. Vascular access is a critical component of infusion therapy and those 2 can NEVER be separated. 

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

WadeBoggs26
    "...No one is

    "...No one is recommending that the lack of a blood return on a short peripheral catheter requires immediate removal and restaring of that catheter..."

From your linked article written by you in a previous post: "If you still don't get blood return, replace the catheter."  

You have at times implied that this isn't always the case, but at other times seem to clearly state that no blood return=replace catheter, regardless of other aspects of the assessment.  Maybe you could clarify.

     The sources for our educational reinforcement on how best to achieve blood return has broken links since we no longer subscribe to Lipincott, but based on the information in the link itself it would appear your article entitled Reopen the pipeline for IV-therapy was included.

The success rates were broken down by both site and IV guage.  The most common site for successful aspiration was the AC by a large margin, the hand and forearm were nearly identical to each other.  

This was a system-side audit that included 7 different hospitals, some used 10cc syringes to aspirate, some used 3cc syringes, no apparent difference is success rates was noted.

The highest rate of successful aspiration was in catheters that were also found to be infiltrated.  

artiehansford
PIVs and blood return

 Thank you for this topic.  My concern with INS current standards is that it states that blood return must be present from all IV's including short peripheral IV's.  I do not agree with this but do agree with a more thorough assessment.  See the quote below from Lynn.  It would be good to have the new standards written to include continued use of a PIV if assessment shows a patent and uncomplicated site despite a lack of blood return and includes the properties of the infusate.  When people see a standard, it is black and white.  The scenario of lack of blood return in a PIV is not black and white.

Quote from Lynn:

"Eliminating the aspiration of blood return is not the answer. No one is recommending that the lack of a blood return on a short peripheral catheter requires immediate removal and restaring of that catheter. It is ONE component of a complete assessment which means looking at the site for changes in any appearance, palpation for temp changes and indiuration or presence of pain with palpation, aspiration and flushing, and listening to all patient complaints. If I found that only fluids were infusing and a cephalosporin antibiotic, and the site was free from all signs and symptoms of all complications and there was not blood return, I would continue to watch closely for any changes. One the other hand, if that antibiotic is vancomycin or nafcillin (vseicants), or if you have to give promethazine, I would do a complete assessment and also look at the length of time the catheter has been in place. Catheters older than 24 hours are not recommended for several infusions such as chemotherapy or contrast administration in radiology. I would never give any vesicant through any type of catheter without a blood return and the site is totally free of all signs and symptoms. I just see too many times when nurses tell patients "that drug always hurts" or telling the patient they are giving the medication slower when the patient complains of pain during medication administration. Neither of these are appropirate and all are below the standard of care." 

I have worked as an RN for 35 years and the first 15 years in Peds ICU, ED, BMT which included being highly skilled in vascular access and IV therapy.  The remainder of my years has been spent as an infusion and vascular access nurse mainly with adults.  I have seen many times an IV that will last for days and have no complications that does not have a blood return after the initial blood return obtained during insertion.  My assessment includes the ease of flushing (removal if there is resistance), signs of infiltration (removal), discomfort (removal), redness or induration (removal), leaking at site (removal).

I've placed multitudes of IV's using ultrasound and have occasionally seen venospasm occur after the vein is puncutured.  The vein can sometimes be significantly smaller or scarecely visible after the puncture.  Often I am able to feed a wire despite the spasm and place the IV over the wire.  I can then see fluid flowing into the vien via ultrasound and if it is not in the vein the fluid is seen entering the tissues.  If the IV is in the vein, my experience has shown that giving the vein a time to "relax" before using it, it will show resolution of the spasm.  I insert IV's for radiology for patients with difficult IV access to be used for CT power injection.  The CT study is often completed successfully when there is no blood return but evidence of patency via ultrasound.  

My initial experience of this phenomena was when inserting a PICC for a highly anxious patient.  Her vein went into immediate venospasm once it was entered.  I was not able to feed the wire. The vein was not visible on u/s after the initial puncture.  We decided to stop the procedure and resume after getting an order for sublingual ativan to help her relax.  During the time it took to secure the tray, leave the room and coordinate an ativan dose, I was away from the patient for about a half hour.  When I returned to her room, and there was time for "relaxing", the patient got up to use the BR and the vein that was used had resolved it's spasm and there was bleeding from the site.  I looked at the vein on u/s and it was back to normal size.  

Because I do have access to u/s it is fascinating to see the vein after access.  Occasionally I have seen no blood return right after access, only to find blood return later in the day.  Again, blood return for PIVs, in my opinion is not black or white.

Hopefully this information is helpful to the writing of new standards.

Thank you.

Artie Hansford

Artie Hansford, BSN, CRNI, VA-BC

jill nolte
look at outcome...

 What this discussion so far has left out is post infusion phlebitis.  Just because the catheter infuses well does not prove it is safe to dwell in that vessel.  We have to look at the entire picture for that patient, to include the health of the vein once the catheter is removed.  It would be nice to have excellent blood return on every IV every time but I think we can agree that will not always happen.  However, I would suggest that if you are not getting a good blood return, the catheter could be too large for the vessel and cause problems for the patient. Just because you can get the device in doesn't mean you should.

artiehansford
I practice and believe in

I practice and believe in using the smallest size catheter for the vein and therapy.  The indication of discomfort could be a prelude to phlebitis.  And the IV should be dc'd with ANY discomfort.  There shouldn't be post infusion phlebitis if the IV is removed with discomfort, redness, leaking at the site or any other untoward S&S.  

The examples in my previous post are there only to help people see other possibilites.  They are not to demonstrate anyone can get a catheter in any size vein.  That would be cruel and not in the best interest of the patient.  Just presentng the possibility of venospasm which could prevent blood return.  We don't really know what is happening to the vein when a catheter is in a vein beyond speculation and perhaps visualization with u/s.  Is the tip lying against the vessel wall or at a valve preventing blood return?  Some of the patients I see have incredibly difficult access and travel for hours for a CT.  If a PIV doesn't work for this then I use a longer catheter that does work.  I don't see post infusion phlebitis in the IVs I start and monitor.  I follow the practice of the Interventional Radiologists who used to insert these difficult to place IVs prior to my arrival.  The outcomes are good.  

Mostly, the most important piece here for me is to have a standard that allows infusion through a PIV despite no blood return if other untoward S&S are not present.    Because blood return does not happen consistently.  People look to the INS standards as the regulatory authority of infusion therapy.  I would like to see  a different standard that does not require a blood return with PIVs.

Artie Hansford, BSN, CRNI, VA-BC

jill nolte
disagree

 You probably won't see or know about post infusion phlebitis.  I personally have had an iv on my right hand that infused just fine.  There were no s/s (or masked by pain meds) however, for several days post my hand was sore and today the vein is gone .  Patients will tell you about iv's they have had that were sore for days, weeks, even longer.  I strongly disagree another set of standards is needed, these are well researched and safe.

artiehansford
 i'm sorry you experienced

 i'm sorry you experienced this.  Since the flow rate and hemodilution is so low in the hand veins, my question is what was infused through the IV, was there a blood return and most importantly, what could have been done to prevent the outcome you experienced?  

Artie Hansford, BSN, CRNI, VA-BC

jill nolte
thanks Artie

The iv was used for a pca and a broad spectrum antibiotic, I can't recall which one.  Following the guidelines and a complete assessment of the site including blood return probably would have prevented the issue for me.  It's not a problem as I'm a healthy person but some of our patients can't afford to lose those vessels.  We have to be vigilant for them.

kathykokotis
vesicants and blood return

I will only pose this

When reviewing manufacturer guidelines recently on vesicants and irritants there are some drugs that state "determine absolute patency of the vein" before administration

Not sure what that means but it means absolute patency before administation of the drug in a court of law where an adverse event occurred.

I assume if it is not documented you did not perform whatever nursing procedure to determine absolute patency of the vein. 

We need guidelines to define aboslute patency and infusion practice.

Kathy Kokotis

valoriedunn
INS standard 61. B states

INS standard 61. B states "The nurse SHOULD aspirate for a positive blood return from the vascular access devise (VAD) to confirm patency proir to administration of parenteral medications and solutions".  Personally, I would be scepticle about infusing if I didn't get a blood return?  And short peripheral catheters are VADs.  Valorie

Valorie Dunn,BSN, RN, CRNI, PLNC

lynncrni
 The language of "determine

 The language of "determine absolute patency ---" comes from the handbook Intravenous Medications published annually by Mosby. The authors are a nurse and pharmacists and this book has been the "bible" for IV medications since the early 1970s. I use this book in all lawsuits involving any question about a drug, frequently pointing out this sentence. 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

artiehansford
Point of Clarification

 I totally agree that blood return is necessary prior to infusion of a vessicant.  Point of clarification:  are you saying that INS standards require a blood return prior to ANY IV medication/fluid in ANY IV access device, regardless of the assessment that may negate any problems?  If so, as the lead VAD nurse in my facility, I will put this memo out to the clinicians tomorrow.  I'm not in a court of law, prosecuting others, and desire for safety for the patient and for the clinicians I lead.  And if this is the mandated assessment, to acheive blood return, even knowing blood return does not exclude infiltration, extravasation, phlebitis, and thrombophlebitis, then a memo will be submited.  We all know this is not this black and white.  But to yield to standards I willl quote INS standards.  And I think the standards need to be updated to include assessment skills of the clinician.  Evidence based practice is needed.

If I found that only fluids were infusing and a cephalosporin antibiotic, and the site was free from all signs and symptoms of all complications and there was not blood return, I would continue to watch closely for any changes.  Lynn Hadaway.

 

Artie Hansford, BSN, CRNI, VA-BC

lynncrni
 See page S60 Fluching and

 See page S60 Fluching and Locking Standard #45. Practice Criteria E and G. Read the standard statements first which identify VAD assessment as one of the purposes. 

PC E. The nurse should aspirate the catheter for blood return

as a component of assessing catheter function prior to

administration of medications and solutions (see

Standard 61, Parenteral Medication and Solution

Administration) 6-8 (V)

 

G. If resistance is met and/or no blood return noted,

the nurse should take further steps to assess

patency of the catheter prior to administration of

medications and solutions. The catheter should

not be forcibly flushed (see Standard 56, 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

WadeBoggs26
 "If resistant is met and/or

 "If resistant is met and/or no blood return noted,

the nurse should take further steps to assess

patency of the catheter prior to adminstration of

medications and solutions.  The catheter should

not be forcibly flushed"

 

The just seems to go even further in the wrong direction.  Just because a catheter has blood return does not mean other steps to assess patency don't need to be performed.

 

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