I am interested if anyone knows of any ongoing studies related to using ports without a blood return and if INS is going to make any recommendations such as this.
The 2017 ONS standards states "If no other option exists after verification of VAD intactness, position, and patency and confirmation by imaging study of the lack of backflow, obtain a provider order to use a VAD when there is no blood return "(Polovich et al, 2014).
There is another published statement from an ONS author “Ongoing controversy persists whether or not to use a VAD when a blood return is not present. Although there can be no definitive recommendation made based on evidence, strong expert opinion consensus recommends that specific analysis is performed before any use under these circumstances”.
If a venogram fails to determine the cause of lack of blood return how should verification of use continue since catheter migration can occur at any time? This is perplexing me.
Also, if anyone has any policy links addressing this I would appreciate it.
To my knowledge, INS is not planning any additions, deletions, corrections, changes to the 2016 Standards. The next edition will be released in 2021, every 5 years. Your message is a little confusing about the ONS references. The statement from Polovich is a sound recommendation and goes a little farther than the INS standards but is not in conflict with the INS standards. You listed 2017 ONS that 2014 so I don't know what ONS document you are referring to. If radilogic testing does not produce verification of the cause of lack of blood return, I would not use that implanted port as there could be any number of things happening to it. Radiology should confirm the tip location and injecting contrast under fluroro should confirm the fluid flow pathway. I am not aware of any other tests that would show similar information
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
The 2017 ONS standards were release and the section on Access Device Standards, Recommendations, and Controversies has a question "What is the best evidence regarding use of a VAD without a blood return" and cite Polovice et al., 2014 as their reference for the answer I posted above.
OK, so you are reading from the new 2017 Access Device Guidelines. ONS does not call there's standards. Thanks 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
Here is the actualy quote from the 2014 ONS Chemo/Bio recommendations for practice by Polovich (pg. 127-128):
"10.b) For all CVCs: Verify catheter placement and function either by x-ray or fluoroscopic dye study prior to initial use per institutional guidelines. Check for blood return by aspiration. DO NOT administer cytotoxic agents in the absence of blood return. The following may help to establish blood return.
10.b) (1) Attempt to flush with normal saline, and gently pull back. Reposition the patient. Ask the patient to cough and take a deep breath.
10.b) (2) Obtain physician order for decloting procedure, and follow institutional protocol.
10.b) (3) Use x-ray or dye study to confirm proper placement of CVC and to rule out catheter malfunction or migration in the absence of blood return, according to institutional policy."
I'm not sure Polovich would support the same conclusion as stated by the Access Device author, at least not based on what she has included in the Recommendations. The physician order seems to be for the declot, not giving the chemotherapeutic agents into a catheter that does not aspirate blood. With each nurse being responsible for her/his own practice, I don't think a physician's order to proceed would convince me.
I defintiely agree. After a contrast injection under flouro and they still cannot determine the reason for no blood return, there is no way I would use that CVAD. If the contrast study confirms correct tip location and the flow of contrast through the catheter into the blood stream, this could be determined to be a fibrin flap. Aspiration will pull that flap over the catheter lumen and occlude backflow of blood. Alteplase instillation could reach all or part of this flap due to overspill from the catheter lumen. Retrograde flow back to the insertion site or tip location outside the vessel could be determined by a contrast injection. After all of this, a doctor's order would not be sufficient for me to use a CVAD when the cause can not be determined. 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