We are trying to figure out what is the best way to assess for patency in a cvad. INS says to check for the "ability to withdraw blood". We don't see anymore detail than that. So we are wondering if we could get opinions? When aspirating to assess patency is it best to just assess for blood returns into the catheter or should you draw the blood right up into the syringe then flush it back in. We have concerns about drawing blood into that cap with every access and also with flushing the blood back in to the patient. But is just getting it into the catheter a good enough assessment? We see that some policies state you require at least 3 ml - but we can't find that in any standards or guidelines.
What are your thoughts?
Thanks very much
As long as you can see enough blood to determine that it is the color and consistency of whole blood, that is all you need. There is no minimum or maximum amount and you do not need to withdraw it into a syringe. Most CVADs have an extension leg on the external part of the catheter where you can see this blood return. BTW, this applies to peripheral catheters also. You also must check for resistance when the catheter or lumen is flushed with saline and assess the entire system and site for signs or symptoms of any complication. I teach O-P-A-L and have published this method of assessment
Observe - the entire system from fluid container to the catheter, the insertion site and all surrounding area
Palpate the insertion site through the dressing for induration, temperature change, tenderness
Aspirate for a free flowing blood return followed by flushing with normal saline
Listen for all patient statements and complaints
I have this on posters that I distribute at all my presentations.
There is no data that indicates this practice increases the risk of bloodstream infection. You should not be disconnecting the saline-filled syringe during this aspiration process. Scrub the connection surface of the needleless connector for at least 15 seconds before connecting the syringe. Withdrawing blood samples to send to the lab is a very different process, requiring multiple attachments and detachments to the catheter hub. This amount of manipulation can increase the risk of contamination and this practice now requires a careful assessment about the need for using a CVAD for this purpose for each patient. The risk of not doing this aspriation and flushing increases the risk of severe extravasation injury from many causes with CVADs. There is also a need to document this blood return.
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
Thank you!
I could not find where I found what we use, but on my PICC order I state :
A patient catheter is one that can freely infulse and has a brisk blood return of 3-5 ml in 3 seconds. (maybe in cathflo info)
Now all the nurse has to do is state that the patiency check is done on the mar.
I teach nurses to draw back the first time 3-5 ml of blood and discard so they know what it looks like. Then since the blood entered the injection cap, to flush the line with min 20ml NS with push pause technique but not to bottom out the syringe. (we use positive displacement Maxplus cap for SL on our PICCs)
Then the next time since they know what a brisk blood return looks like. I tell them to draw back so they can see the blood in the catheter just below the cap. Then to flush 10 ml NS with push/pause.
Inject/infuse IV med,
Flush 10ml NS push/pause post med.
We do this even on lines that are continious infusions every 12 hr.
I hope that helps.
David
I could only find this in INS
- Standard 50 Flushing, Practice Criteria N. “The nurse should aspirate the
catheter for positive blood return to confirm patency prior to administration
of medications and solutions.”
- Standard 68 Parenteral Medication and Solution Administration, Practice
Criteria A. The same statement is repeated.
Sorry David, but your practice is not evidence-based. The statements in the INS standards are as far as the evidence allows. No min or max amount and I would never detach that saline filled syringe used to aspirate with the one exception of the each time an implanted port is accessed. Accessing can produce a small core which could be caputured in the syringe rather than being flushed into the bloodstream. 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 agree Lynn, The reason why we chose 3-5 ml in 3 sec is because the first question I got from nurse after nurse was what is the definition of Brisk. (I think I work with lawers, lol)
Since we were teaching Cathflo use and that was the definition the educator used we decided it would be best to be the same.
I was teaching just to do as you said and draw back into the clear part of the Bard cath but a new nurse then asked how will I know it is 3 ml? I told her the first time ever she access one, pull back 3 ml and see what it feels like. Then from now on you will know without having to draw back through the cap.
Our NS lock cap mfg recommends 20ml flush or till clear if blood is drawn back through the cap. Normally it is only 10ml.
I really want to do what is EBP but I can't find any without any practice.
So in the void of EBP, using the MFG recommedations we are tracking results to hopefully assist in forming some EBP?
So normally our process is:
wash/gel hands
glove
swab the injection cap 15-30 sec
attach 12 ml syringe with 10ml prefilled NS
Pull back to verify brisk blood return
Inject 10ml NS with push/pause technique
do not bottom out syringe
d/c syringe
Attach IV tubing or IV push
attach 10ml NS and flush with push/pause technique
remove syringe the clamp (positive displacement cap)
Thanks so much for all the feedback!