The INS recommendations for blood return appear to have changed but I can't get the 2011/2016 crosswalk to load properly, anybody able to explain the new recommendations?
2016 definitely increased the emphasis on blood return from all types of VADs. Blood return now appears in multiple standards and there is a definition of blood return in the glossary. So the change is there is much more emphasis and importance on blood return in assessment of all VADs. Lynn
It's mentioned in a few standards, not just 44, and the comination makes it hard to tell specifically what is being recommended. Put it this way, previously the recommendation was generally interpreted to require blood return only prior to strong vesicants, chemo for instance. We don't use blood return as an assessment component in PIV's for general use since neither the precense of blood return or the lack of blood return is a reliable indicator of IV infiltration, extravasation, etc. If this policy was continued would it be considered compatible with the new "emphasis" on blood return in the 2016 standards?
Blood return should be regarded as a signficant component of a complete assessment for ALL VADs including short peripheral catheters. I would agree that a blood return ALONE is not totally a diagnostic tool, and thus the emphasis on a complete assessment of all signs and symptoms. Even with infusion of non-vesicant medications, the lack of a blood return can be a critical sign of impending or actual compartment syndrome. We must eliminate this concept that blood return means nothing from a peripheral catheter. It is a signficant part of the assesssment.
The Standards of Practice are not the same as a "policy". It is the responsibility of each organization to establish their internal policy based on their assessment of patient populations, staffing mix, etc.
If the goal is to eliminate the concept that blood return means nothing from a PIV, then what are we saying it should mean? How would a nurse assessing an IV incorporate blood return? For instance, you've got an IV that has no abnormal assessment criteria, but no blood return, should it be considered unusuable? If the assessment includes findings consistent with compartment syndrome, then the IV is discontinued, it's not going to stay in just because it returns blood, same goes for an IV that is infiltrated, extravasated, acute phlebitis, etc, so it's not clear how blood return would affect any decisions based on those assessments.
I realize that the recommendations are not a policy, but if the recommendations are to be used to help form policies and guide what we consider to be acceptable practice then clarifying how they would be integrated into practice would help achieve those goals.
You have mis-stated the goal as it is NOT to eliminate the concept of assessment for a blood return from a PIV. Far from it, but rather the goal is to emphasize the need for this step as a component of a complete and thorough assessment. No abnormal assessment criteria? If there is no blood return then there IS the presence of abnormal assessment criteria as blood return is one criterion. The nurse must look at the entire clinical situation - patient, VAD, medication, all clinical factors, etc. I would not say that the compartment syndrome would always be identified and a catheter always removed. That has not happened in numerous lawsuits I have worked on. For clarification on writing organizational policies, see the new INS Policy and Procedure book also written by the same standards committee. Lynn
I think there's been some confusion because I was quoting you directly: "we must eliminate the concept that blood return means nothing from a peripheral catheter".
Whether or not lack of blood return in a peripheral is the root of the problem, because based on everything I've seen it is pretty clearly not abnormal. We used to include blood return in our standard PIV assessment charting. The majority of PIV's did not have blood return at the first assessment after insertion (within 8-12 hours) and almost none had blood return at 16 hours. There was no correlation between lack of blood return and other adverse findings. As far as I can tell, there is no evidence that our findings were unusual. So my question is if there has been some evidence that this is actually a reliable assessment component for predicing adverse issues related to the IV.
I'm not sure what you're saying should be done related to compartment syndrome, if you're saying lack of blood return may be the only sign of compartment syndrome then would that mean lack of blood return should be considered possible compartment syndrome, and wouldn't that mean that lack of blood return should generally result in removal of the catheter?
Basically, if a nurse asks me; "the assessment of my patient's IV is normal except I get no blood return, what's the expectation" what would an answer be that is consistent with the INS recommendations?
Elliminate the concept that blood return means nothing from a peripheral catherer means to get rid of this idea, meaning that it a significant component of a complete site assessment. Given your last question from a nurse with no blood return, the next step is to answer many other questions. Size of syringe used? Smaller is better. Force applied? Less is better. Did she try a tourniquet above the site? Then try that. What is being infused through the site? What happens when it is flushed with saline only?
I don't know where you are getting your information about lack of blood return. Please quote your published sources on this research. Lynn
I doubt there's much interest in doing true research on the prevelance of lack of blood return from a PIV, there doesn't seem to be that much of a question about whether or not PIVs will reliably return blood for very long after the initial insertion. It would be like asking for research that it's safer to jump out of an airplane with a parachute than without. This is one of the main selling points of midlines, that while they won't always return blood after a few days they are still more likely to return blood than a PIV. There are also a number of threads on iv-therapy where it's pointed out that PIV's often don't return blood except for on insertion. Is there any evidence that blood return is a reliable indicator of PIV adverse events?
At least based on the currently available information, blood return does not appear to be a useful addition to a PIV assessment as it plays no role in altering the appropriate course of action of a PIV. It still hasn't been determined how blood return would affect decision making about the IV, except that it would be a superflous assessment, all actions would be based on other findings.
During the period of time we were documenting blood return, we did initiate educational interventions include everything you mentioned to increase the chance for blood return. We did find many nurses for whom at least some of this was new information to them, although it had no significant effect on the ability to get a blood return.
As my final comment on this thread, I just want to call your attention to how many other organizations support the inclusion of aspirating for a blood return from a peripheral catheter as part of the complete assessment. This includes the Oncology Nursing Society chemotherapy guidelines and the European Chemotherapy Guidelines. Additionally, if would have to investigate why there are so many peripheral catherters NOT producing a blood return. There is plenty of pathophysiological evidence about changes in the endothelium caused by phlebitis/thrombophlebitis and infection. Edema from inflammation and the presence of thrombi could easily prevent a aspiration of a blood return. This means the vein is damaged and should no longer be used for any infusion. The presence of any level of pain at the site is an indication of venous damage and reason to remove the catheter. All of these reason for vein damage can easily prevent aspiration of blood from the catheter. So lack of blood return could mean a second hole in the vein, the catheter tip is positioned outside the vein, or there are changes to the vein wall from other complications happening. We also know from research that the greatest catheter failures from complications are going to occur in the hand, wrist and ACF. If you are talking about failure to obtain a blood return from those sites, I can well understand why there is a low number of catheter that yield a blood return. But that gets us back to the same risk of severe complications.
Finally, there is research on this issue. Here is a link to one study that I quickly found:
So I stand firmly behind the need for a blood return before using a short peripheral catheter. I would agree that many times technique is the cause of no blood return. Slow and gentle aspiration is needed. If that fails, use a smaller syringe size. If that fails apply a tourniquet above the site to see if there is blood return. If all of that fails, remove the catheter.
Lynn,
WadeBoggs is correct. Most short peripheral IV's do not see blood return after 24 hours but continue to flush easily. Therefore, they are used. If we pulled every peripheral IV for lack of blood return everyday there would be massive numbers of discontinued access which would lead to more sticks...which would add to operational costs...which would dramatically decrease even further, patient satisfaction. If you read that study, you would have quoted it stating NEWLY INSERTED peripheral a blood return would suggest intravascular OR easy flushing without pain and no blood return would also suggest intravascular.
I find that right in line with common practice and what wadeboggs was stating.
I respectfully disagree with both of you. There are now many studies supporting obtaining adequate blood samples during the dwell time for a PIV. No need to continue this discussion though as I am certain neither of us will change our position on this issue. Lynn
2016 definitely increased the emphasis on blood return from all types of VADs. Blood return now appears in multiple standards and there is a definition of blood return in the glossary. So the change is there is much more emphasis and importance on blood return in assessment of all VADs. 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
Is the recommendation now that a PIV without blood return should not be used for any reason?
Not stated in that way. See Standard 44 VAD Removal. 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
It's mentioned in a few standards, not just 44, and the comination makes it hard to tell specifically what is being recommended. Put it this way, previously the recommendation was generally interpreted to require blood return only prior to strong vesicants, chemo for instance. We don't use blood return as an assessment component in PIV's for general use since neither the precense of blood return or the lack of blood return is a reliable indicator of IV infiltration, extravasation, etc. If this policy was continued would it be considered compatible with the new "emphasis" on blood return in the 2016 standards?
Blood return should be regarded as a signficant component of a complete assessment for ALL VADs including short peripheral catheters. I would agree that a blood return ALONE is not totally a diagnostic tool, and thus the emphasis on a complete assessment of all signs and symptoms. Even with infusion of non-vesicant medications, the lack of a blood return can be a critical sign of impending or actual compartment syndrome. We must eliminate this concept that blood return means nothing from a peripheral catheter. It is a signficant part of the assesssment.
The Standards of Practice are not the same as a "policy". It is the responsibility of each organization to establish their internal policy based on their assessment of patient populations, staffing mix, etc.
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 the goal is to eliminate the concept that blood return means nothing from a PIV, then what are we saying it should mean? How would a nurse assessing an IV incorporate blood return? For instance, you've got an IV that has no abnormal assessment criteria, but no blood return, should it be considered unusuable? If the assessment includes findings consistent with compartment syndrome, then the IV is discontinued, it's not going to stay in just because it returns blood, same goes for an IV that is infiltrated, extravasated, acute phlebitis, etc, so it's not clear how blood return would affect any decisions based on those assessments.
I realize that the recommendations are not a policy, but if the recommendations are to be used to help form policies and guide what we consider to be acceptable practice then clarifying how they would be integrated into practice would help achieve those goals.
You have mis-stated the goal as it is NOT to eliminate the concept of assessment for a blood return from a PIV. Far from it, but rather the goal is to emphasize the need for this step as a component of a complete and thorough assessment. No abnormal assessment criteria? If there is no blood return then there IS the presence of abnormal assessment criteria as blood return is one criterion. The nurse must look at the entire clinical situation - patient, VAD, medication, all clinical factors, etc. I would not say that the compartment syndrome would always be identified and a catheter always removed. That has not happened in numerous lawsuits I have worked on. For clarification on writing organizational policies, see the new INS Policy and Procedure book also written by the same standards committee. 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 think there's been some confusion because I was quoting you directly: "we must eliminate the concept that blood return means nothing from a peripheral catheter".
Whether or not lack of blood return in a peripheral is the root of the problem, because based on everything I've seen it is pretty clearly not abnormal. We used to include blood return in our standard PIV assessment charting. The majority of PIV's did not have blood return at the first assessment after insertion (within 8-12 hours) and almost none had blood return at 16 hours. There was no correlation between lack of blood return and other adverse findings. As far as I can tell, there is no evidence that our findings were unusual. So my question is if there has been some evidence that this is actually a reliable assessment component for predicing adverse issues related to the IV.
I'm not sure what you're saying should be done related to compartment syndrome, if you're saying lack of blood return may be the only sign of compartment syndrome then would that mean lack of blood return should be considered possible compartment syndrome, and wouldn't that mean that lack of blood return should generally result in removal of the catheter?
Basically, if a nurse asks me; "the assessment of my patient's IV is normal except I get no blood return, what's the expectation" what would an answer be that is consistent with the INS recommendations?
Elliminate the concept that blood return means nothing from a peripheral catherer means to get rid of this idea, meaning that it a significant component of a complete site assessment. Given your last question from a nurse with no blood return, the next step is to answer many other questions. Size of syringe used? Smaller is better. Force applied? Less is better. Did she try a tourniquet above the site? Then try that. What is being infused through the site? What happens when it is flushed with saline only?
I don't know where you are getting your information about lack of blood return. Please quote your published sources on this research. 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 doubt there's much interest in doing true research on the prevelance of lack of blood return from a PIV, there doesn't seem to be that much of a question about whether or not PIVs will reliably return blood for very long after the initial insertion. It would be like asking for research that it's safer to jump out of an airplane with a parachute than without. This is one of the main selling points of midlines, that while they won't always return blood after a few days they are still more likely to return blood than a PIV. There are also a number of threads on iv-therapy where it's pointed out that PIV's often don't return blood except for on insertion. Is there any evidence that blood return is a reliable indicator of PIV adverse events?
At least based on the currently available information, blood return does not appear to be a useful addition to a PIV assessment as it plays no role in altering the appropriate course of action of a PIV. It still hasn't been determined how blood return would affect decision making about the IV, except that it would be a superflous assessment, all actions would be based on other findings.
During the period of time we were documenting blood return, we did initiate educational interventions include everything you mentioned to increase the chance for blood return. We did find many nurses for whom at least some of this was new information to them, although it had no significant effect on the ability to get a blood return.
Can't argue with that......he's right. Nice job explaining that
As my final comment on this thread, I just want to call your attention to how many other organizations support the inclusion of aspirating for a blood return from a peripheral catheter as part of the complete assessment. This includes the Oncology Nursing Society chemotherapy guidelines and the European Chemotherapy Guidelines. Additionally, if would have to investigate why there are so many peripheral catherters NOT producing a blood return. There is plenty of pathophysiological evidence about changes in the endothelium caused by phlebitis/thrombophlebitis and infection. Edema from inflammation and the presence of thrombi could easily prevent a aspiration of a blood return. This means the vein is damaged and should no longer be used for any infusion. The presence of any level of pain at the site is an indication of venous damage and reason to remove the catheter. All of these reason for vein damage can easily prevent aspiration of blood from the catheter. So lack of blood return could mean a second hole in the vein, the catheter tip is positioned outside the vein, or there are changes to the vein wall from other complications happening. We also know from research that the greatest catheter failures from complications are going to occur in the hand, wrist and ACF. If you are talking about failure to obtain a blood return from those sites, I can well understand why there is a low number of catheter that yield a blood return. But that gets us back to the same risk of severe complications.
Finally, there is research on this issue. Here is a link to one study that I quickly found:
http://europepmc.org/abstract/med/25634149
So I stand firmly behind the need for a blood return before using a short peripheral catheter. I would agree that many times technique is the cause of no blood return. Slow and gentle aspiration is needed. If that fails, use a smaller syringe size. If that fails apply a tourniquet above the site to see if there is blood return. If all of that fails, remove the 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
Lynn,
WadeBoggs is correct. Most short peripheral IV's do not see blood return after 24 hours but continue to flush easily. Therefore, they are used. If we pulled every peripheral IV for lack of blood return everyday there would be massive numbers of discontinued access which would lead to more sticks...which would add to operational costs...which would dramatically decrease even further, patient satisfaction. If you read that study, you would have quoted it stating NEWLY INSERTED peripheral a blood return would suggest intravascular OR easy flushing without pain and no blood return would also suggest intravascular.
I find that right in line with common practice and what wadeboggs was stating.
I respectfully disagree with both of you. There are now many studies supporting obtaining adequate blood samples during the dwell time for a PIV. No need to continue this discussion though as I am certain neither of us will change our position on this issue. 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
So, by me initial read of the new standards, are you saying it is now acceptable practice to draw daily, routine labs from existing PIVCs?
Yes, read the phlebotomy standard. 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