Our current policy when drawing blood from Picc's is to flush after with 20 ml of NS. We are currently having cathflo reps inservice our hospital on the use of their product and they are telling that part of their assessment on pt's is to make sure every central line including picc's should be tested to make sure there is a brisk blood return. My point is this..... if you are bring blood into the lumen every 12 or 8 hrs to ensure patency, wouldn't you want to flush it with 20 ml as if you are drawing blood. That is not our current practice. The RN's only flush the lines with 10 ml NS on their assessment. They are not checking for a brisk blood return unless they are drawing blood. When they are flushing, they are making sure it flushes with ease---if not, they then investigate further to see if there is a blood return. What do you all think? Is it really necessary to aspirate blood up into the lumen of the catheter if you really don't have to draw blood. I think it can cause more problems in the long run. Any suggestions/comments are welcomed!
According to INS standards (#50, Flushing) practice criteria M and N address your question.
M. If resistance is met or an absent blood aspirate 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.
N. The nurse should aspirate the catheter for positive blood return to confirm patency prior to administration of medications and solutions.
PWO (Persistent Withdrawl Occlusion) treatment success outcomes improve with prompt intervention rather than when failed blood sampling occurs.
Hope this helps.
Timothy L. Creamer, RN
Clinical Specialist, Bard Access Systems
Timothy L. Creamer RN, CRNI
Clinical Specialist, Bard Access Systems
Florida Division
I found this topic interesting, but a bit confusing. Our practice is always to verify lumen patency before using it. But we do not routinely do so before administering every drug/fluid infusion if the catheter lumen is connected to running IV (except for IV push). They do need to check the IV site and verify with patient if there is other concern-related to the IV itself.
The INS - N recommendation sounds like nurses must check patency before every single drug administration even when the lumen has a running IV and the site is satisfactory. Is this correct? If yes, we need to update our policy to reflect this best practice recommendations.
Thank you - Deedee
In addition to the INS standards of practice, there are also statements from ONS about checking for a brisk blood return before each catheter use. So yes, you should include aspiration for a blood return as part of your total assessment of catheter function before it is used. There is no evidence to suggest that this blood aspiration and immediate flush creates a problem. There are numerous case studies and lawsuits where the absence of this blood return or the nurse's failure to check have caused serious problems with infiltration or extravasation injuries. Remember many drugs are vesicants, not just chemotherapy drugs. Vancomycin, KCl, promethazine, TPN are just a few. I think 10 mLs of saline flush is sufficient immediately after this aspiration.
Lynn Hadaway, M.Ed., RN, BC, CRNI
www.hadawayassociates.com
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 am a TPN RN clinician and when we train our parents we instruct them to check for catheter patency by checking blood return. One of the Infusion pharmacies we are using to provide for our patient are recommending not to instruct our parents to check for patency because they are concerned about by doing so, promoting thrombus formation and contributing to catheter occlussion. Do we have any literature or study on this topic. What are currentl practice in the Home TPN population world?
Rebecca Estanque, MSN, RN, PNP
Pediatric TPN/VAD Nurse Clinician
Pharmacy, Nutritional Support Team
(909) 558-4000 ext 42380 . fax (909) 558-4847
Pager (909) 558-1717,8327 . [email protected]
home care, so I am assuming cyclic PN with parents starting the infusion in the evening. If so, I think these parents should be taught to aspirate and flush before connecting the PN. It assesses patency while flushing in the last lock solution with saline. On the other hand if you are talking about continuous PN infusion, especially if this is a temporary situation, I might not teach parents to stop the infusion, connect a syringe to the injection port on the set, flush and aspirate, then flush the remainder of solution. This could be assessed weekly by the home care nurse. There is a lot of emphasis on assessing blood return in the lilterature on CVAD Malposition and this is heavily referenced in the INS SOP but I am not aware of any studies on checking blood return specific to home care. Most home care agencies I know of, have the nurse do this assessment weekly.
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
Kathy Kokotis
Bard Access Systems
You may want to read Sophie Harnage article "Achieving zero infection rate for central lines for 18 months" in JVAD. They flush every shift as part of the MAR and check blood return.
Makes sense to me. Blood on tip of catheter is very bacteria friendly for a home. A catheter that does not aspirate means something is wrong and it is not a functioning device as defined by the ability to withdraw blood therefore you cannot infuse meds.
Do we really know if our catheters meet the definition of the INS Standards (ability to infuse and aspirate both)? I think we are lax as a entire industry on this policy. Checking for blood return may in turn be equated to infection control in the future.
Kathy
Kathy Kokotis
Bard Access Systems
Definitely check for blood return before any use of any central line. It should be in the policy, and staff RNs need to be practicing it.
I think whether to flush with 10 or 20 might also depend on how much flushing you'll be doing during the shift. If I was giving a QD dose of Vanco and the patient had no other use of the PICC, I would flush with 20ml. Minimum 10ml.
Mari Cordes, BS RN
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
I found this topic interesting, but a bit confusing. Our practice is always to verify lumen patency before using it. But we do not routinely do so before administering every drug/fluid infusion if the catheter lumen is connected to a running IV (except for IV push). They do need to check the IV site, make sure the infusion run well, and verify with patient if there is other concern-related to the IV itself.
The INS - N recommendation sounds like nurses must check patency before every single drug administration even when the lumen has a running IV and the site is satisfactory. Is this correct? I thought we need to reduce manipulating the device and lines as much as possible to reduce risk of infection? Sorry, I may be misinterpret the standard here.
Thank you - Deedee
Practice Recommendation N in the INS SOP Flushing and Locking is about antimicrobial locking solutions, not the regular saline or heparin locking used most often. Before each and every intermittent medication you need to confirm patency by aspiration and flushing for inpatients. For any continuous infusion, this aspiration is done before you start the infusion and PRN when it is clinically indicated - pump alarms, blood in tubing, patient complaints. There is no standard, guideline, or data of any kind supporting an automatic aspriation and flush every shift or every XX # of hours. For home care, this is different because most patients do not easily understand how to assess the results of what they aspriate, what it means, and what they should do. Plus most home care patients are not receiving high risk vesicants. Therefore, most home care companies will have the patient flush before each dose and the nurse will do the full patency assessment on weekly visits. NO published studies about this, but this is most common practice for home care. A patient experienced with PN at home may be different and may understand what the aspiration means and how it is done and how to assess the results. This is based on your assessment of the patient, their knowledge and skill. As they become more confident in managing their PN and CVAD, the patient may assume this responsibility. But again, it is based on your assessment of the patient. There is also no evidence that aspiration with the same syringe used for flushing adds to manipulation and increases risk of infection or lumen occlusion. Blood is not allowed to sit in the lumen but is immediately flushed back into bloodstream. The benefits of aspriation for hospitalized patients (receiving many types of drugs, vesicants, irritatnts, etc) outweighs the risk of these complications.
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