Hi everyone,
Our infusion team just had an issue with no-blood-return port. Several patients were referred to them from another Oncology practice. They have ports but none of them has blood return. These patients stated that their ports had been like that for a long time. They did try TPA at the other facility but it did not work. One of them had a port study by IR a few weeks ago which confirmed the tips in SVC. This week these pt's were coming in for transfusion (ABX, Chemo,...). Our infusion nurses were very worried so that they did not use the port due to abscence of blood return. Our policy also stated that if there is no blood return, nurse should not run chemo into that port.
Now everything delays. The oncologist was upset. pts were angry. Infusion nurses still dont want to violate the policy.
Does anybody have this kind of situation before? What would you do if you were the nurses in this situation?
Thanks a lot. Have a nice day.
We have just developed a policy that states if no blood return you must get a CXR to confirm tip location or in port a cath situation a portagram. Recently had this happen . The port was in good position with documentation by radiologist with contrast infusion. Pt. returned to the outpt. setting and recieved her chemo.
Darla Tarvin RN VA-BC
Mercy Clermont Hospital
I changed our policy several yrs that we can not use a port without a brisk blood return being seen. I have seen too many bad things happen without this policy in place. They are to refer the problem to IVT and they we go from there
Did you also have the presence or absence of a fibrin sheath documented? and the extent if there was one? I have occasionally used a port without a blood return for some things after knowing this information, but I will then make an appointment with the patient to come in and let me try to declot it. There are a couple of ways to use cathflo (drip or direct instilation) on tough ports, and I have had a couple that took overnight to get a blood return, so the fact that someone else tried to declot them wouldn't deter me from trying again. I have had a few people get angry, but most everybody calms down once you are able to get that blood return. (so far, I have been able to get the blood return each time ).
Gail McCarter,RN CRNI
Gail McCarter, BSN,CRNI
Franklin, NH
Thank you so much for your replies. Question: How much TPA and the volume?
Cathflo is packaged for declotting catheters in a single use vial. All their instructions are on the web, and the reps are more than willing to help. I believe that using it in a drip is still off-lable, but you can find a number of references to this in the forum.
Good luck
Gail McCarter RN CRNI
Gail McCarter, BSN,CRNI
Franklin, NH
The ONS Chemo and Biotherapy Guidelines are extremely clear about this. Do not use a catheter for infusion without a blood return. This document goes into how to explain the delay to patients. A regular chest xray may show that the tip is in the SVC but you need a dye study under fluoroscopy to detect a complete fibrin sheath, the greatest risk of leakage of infusing fluid at the insertion site. The dye study will also detect catheter damage, fracture, and leakage into other intrathoracic structures. The infusion team nurses are correct!! Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I agree with the repsonse earlier. I would re attempt the cathflo; may even require 2 doses since cxr shows tip in svc. But...how about the clavicular area, do you see any evidence of "pinch off"? This would affect blood return and also could cause damage to the catheter which would cause leakage of meds as mentioned earlier as well.
I also have had patients who say they have had attempted to declot it and it " has always been this way" after explaiining they allow us to try cathflo again and are delighted when it is successful.
Gina Ward R.N., CPAN
Gina Ward R.N., VA-BC
An easy way to address the physicians issues is to ask the nurse manager for the unit to address it with your facility's risk mgmt dept. If it says in your policy you don't use CLs without a blood return AND all of the professional nursing organizations guiding infusion practice (INS & ONS) state it shouldn't be done they would be fools to allow this practice. It opens up your facility/nurses/ordering physician open to liability.
I have in the past refused to infuse through a port in this situation, spoke with my manager about why I refused to do so, citing our policy & national standards. It worked.
You decide. Its' your name in that chart!
Nina Elledge, RN, MBA, CRNI
[email protected]
If someone can tell me how to attach a photo I have a good one of a port with a fibrin sheath attached. I can't seem to find the 'attach' place on this site. This picture gives an idea of where the infusate may be delivered if the port has an attached fibrin sheath. I'd love to share.....
Alma Kooistra RN CRNI
Alma, contact the webmaster, Sarah, at [email protected]. She can post pics in the gallery.
If you open a free account at one of the photo hosting sites (I use photobucket). You can then upload a photo to your account. From there you copy the picture URL and then click on tree icon above and paste the URL on the appropriate line and title it if you like.
Peter Marino R.N. BSN CRNI VA-BC Hospital based staff R.N. with no affiliation to any product or health care company.
I sent my photo to Sarah and she will post for me. The picture clearly shows contrast media moving up the patient's left IJ. This Port flushed well but would not give blood return.
Alma Kooistra CRNI
The dark shading is the sheath enhanced via dye correct? Is there a hole in the sheath allowing the retrograde flow to go up the IJ? Or is that the tip around C-6/7? Hard to tell where the catheter tip is?
Peter Marino R.N. BSN CRNI VA-BC Hospital based staff R.N. with no affiliation to any product or health care company.
The picture is 'layered'. If you click on the photo there is a second one underneath. That shows the DSA view.
Alma Kooistra CRNI
I really appreciate the kind of topics you post here. Thanks for sharing us a great information that is actually helpful. Good day! John