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Gina Ward
Being asked to do something that INS recommends not to do; how to respond approp , and bottom line


Hello there,


I have a colleague who is in charge of the OP department; this is where they do OP infusions, theraputic phlebotomies etc....  Basically they had a patient who had been to other facilities and to their unit once for a theraputic phebotomy, they were unable to access a vein at that one time and were therefore unable to perform the Theraputic phlebotomy.    Then, on there own the physician who ordered the phlebotomy, without our knowledge, referred the patient for a port to have the phebotomies done via the port.  so, the surgeon inserted the port.


We found out about it when the physicians office called back up to schedule the pt appt for phlebotomy.  We  began to research and basically find out that the INS says that using a port for theraputic phlebotomy should not be done.  We are aware it has been done in some settings but.....bottom line is that the INS;  who sets the standard , does not recommend it.  They are the decision makers for legal references etc....   We collected all data and presented it to our surgeon and Director of Surg, who is over the OP department.  At first they were like;  thats ok, you can still do it , it will be fine.  If the catheter clots off you just fix it with Cathflo like usually.  They want to keep the pt and the surgeon and MD happpy.

We told them that this is not a practice that needs to be done.  We reviewed how we practice evidence based medicine and there is currently no proof, outcomes, standards etc sayinig this is safe.  We realize it may sound  perfectly fine and safe but it has not been proven such.  If we start doing something that is not recommended and we are even told "should not" by INS we dont have a leg to stand on if issues arise.  Basically we are saying this is something we will not be doing; that this is not in the best interest for the patient to practice this way.   surgeon should have looked into this a little more before doing the Port, and maybe put in an apheresis cath or something I read about.

Medical doctor doesnt understand; says why not , if I write and order you should do it.  :)   Any way, I told her, the OP Director,  to go talk to our Risk Mgmt director and explain to the her what is currently being debated.  Now the medical Doc is going to talk to pt OOT oncologist.

Any recommendations?    thanks,  Gina Ward, R.N, CPAN,  PICC nurse at Raulerson Hospital



I would approach it this way.

I would approach it this way. If everyone said we will not do something because there is no science to support it, then practice would never expand or grow in any direction. There has to be risk takers. The INS SOP statement is based on 1 article only as that was all that could be found. This got a ranking of V, the lowest level. So there is plenty of room for growth in our scientific knowledge base. No port manufacturer will include this in their instructions because they have not done the testing on their ports for this procedure. So legally if there was a problem and if the patient sued, all of this would be considered as evidence against you. But all legal cases are totally dependend upon the actual facts in each case and no two cases are exactly alike.

I would consider other things also. Is this port being used for infusions of some type? How critical is it for these infusions to be given on time? Can you afford to wait for a declotting procedure? If there are no other infusion needs and this phlebotomy is the only reason for the port, will it really cause any harm to the patient if it does fail? How much volume needs to be taken off with each procedure? If the gravity flow fails, you can draw manually into 50 mL syringes. This is a risk vs benefits analysis again. I would see what your risk manager says, then contact the port manufacturer for their input, then take this to whatever medical decision-making power there is in your facility. If there was a lawsuit, it is the facility and the nurse that would be named. Since the port is already in and if no other infusions are needed through this port, I might try it. Then I would encourage you to write this up as a case study at least. So people in this same situation would at least have your experience to rely upon. No clear answer for a difficult situation. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257


Office Phone 770-358-7861

Gina Ward
Thank you very much for your

Thank you very much for your advice.


Gina Ward

Gina Ward R.N., VA-BC

Michelle Todd CRNI
Therapeutic phlebotomy Via Implanted Port

I too read this in the new INS standards and was actually sad to see it so I am very glad this has been brought up. I agree with all of Lynn's comments and also the patient can even sign something that says that they understand the issues and the experimental nature of it. As long as you have the ok from the risk management and possibly the medical director and the patient is aware of the issues and agrees, it would be a great study. It is likely that you have a policy that speaks to procedures that are considered to be experimental and it would have guidelines for you to follow. I have done phlebotomy from an implanted port in this exact situation (port placed for phlebotomy without any communication to our clinic) and I did do it by pulling it with a syringe and pushing it into a regular blood bag which I felt to be much safer than a proposed idea of using a vacuum bottle from pharmacy which has the potential of going the other direction and causing an air embolism. (Bottles used to be common in some institutions but I hope they are no longer used) You can just use the side port on a regular IV extension set attached to the blood tubing, a long 3 ft extension set or a stopcock. We already had our process of placing an IV catheter 16g (and sometimes 18g) instead of just using a regular needle attached to the blood bag so it was easy to use that bag set up for the port. You may need to get a different set up from the red cross if you only have the type of bag that is attached to a needle for a regular donation. Not sure how you do it but I found that doing an IV works so much better for therapuetic phlebomy because you can flush if you have trouble and place a hot pack or what ever when you are just going to discard the blood, not to mention pulling the blood with a syringe if there is trouble or if you have to place a smaller catheter. (I don't think you can use the IV technique with a unit that will be used for transfusion such as a regular donation, at least you can't flush and you have a very specific time frame to get it completed because no clotting is allowed and you wouldn't want to pull any blood in case of possible hemolysis.) I prefer a smaller 20 ml syringe just due to the strength needed to pull a 50 ml multiple times. It takes a little longer to draw the blood from an implanted port than a vein and gravity, but this does not matter because there is no issue with patient safety related to this.

Part of your concern was that the patient only had vein trouble once and didn't necessarily need a port, right? Well, alot of our patients really do need some type of access for their repeated long term phlebotomies when they have poor veins; and not doing the draws will lead to early death and lots of morbidity so we clearly have a higher benefit than risk for certain patients. Be sure to keep real good records such as exactly what worked best for the procedure, what equipment was used, how long each draw took, any complications, how many done. This will be great data to publish and I encourage anyone else with this situation to also do the same. This is a very important alternative for some patients and needs badly to be trialed so that people that really have no veins have another option. You have a wonderful opportunity. I highly doubt you will see any problem with clotting and I predict it will be a total success. You may want to have your supply person order 19g huber needles unless you already have them.

Michelle Todd, CRNI--Head PICC Nurse, Vibra Specialty Hospital of Portland [email protected]

Gina Ward
use of vaccuum container


The only way we have done any theraputic phlebotomy is via a vaccuum bottle.  In our research of this issue we have found talk of them using a blood bag.  Then,  a day or two later I recieved an email from INS with and ad for a blood bag of some type.  We are not familiar at all with this process.


What is the concern with the vaccuum bottle? 


Thanks so much for all your input.  We too really felt like we should try it but didnt know what the school of thought or history is with doing something against what the resources say not to.


Gina Ward

Gina Ward R.N., VA-BC

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