Forum topic

13 posts / 0 new
Last post
AshleyM
Blood return
We recently had inservicing and were told that any PICC/central line without a blood return should not be used, treated as a totally occluded line and treated with tPA to get a blood return.  I am concerned about a possible "overuse" of the tPA and wondering about the real need to treat every single line just because there is no blood return.  How practical is it? Are there studies out there to support this fact? How many are really doing this and do you find it reduced or stopped total occlusions? And if you do treat all lines with no blood return, who does it? Do you teach all RNs or just a few designated nurses?  In my years of practice I find many lines that have no blood return but are patent and allow the patient to complete treatments.  I realize that chemo and vesicants fall under different rules. Thanks for your help.
lynncrni
The prevailing thoughts of

The prevailing thoughts of experts now is that no blood return from any catheter equals a nonfunctioning catheter and requires investigation and treatment before it is used. This includes PICCs and all other types of central lines. This is plainly stated in the INS standards that a blood return is required before using a catheter for anything. Many years ago, I heard a nurse working at the National Instititues of Health state that their policy was to never even inject saline unless they could get a blood return. So nonvesicants are not treated differently than vesicants. All fluids and medications have the potential to do significant tissue damage if they escape into the subcutaneous tissue. This NIH nurse was one of the authors publishing on outcomes of infiltration due to a complete fibrin sheath. At the bedside all you know is that there is no blood return, but there is no way to determine why there is no blood return. It could be one of numerous causes with some putting the patient at signficiant risk for infiltration/extravasation. You can take one of 2 approaches - treat with tPA first to see if that changes the outcome or do a dye study through the catheter to determine the actual fluid pathway then treat with tPA if it is indicated. Many lumen occlusions occur because there is a fibrin formation around the catheter tip in the form of a partial or complete fibrin sheath or a fibrin tail. Instillation of tPA may or may not reach this because it is outside of the catheter. Infusion of tPA over 3-4 hours is being used instead of the instillation procedure. If you can document on fluoroscopy that it is a fibrin tail or a partial sheath, then you know that the fluid will not be escaping from the vein and you can use the catheter. You can read more about all of this in:

Hadaway, L., 2005, Reopen the pipeline for I.V. therapy: Nursing2005, v. 35, p. 54-63.

 

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

www.hadawayassociates.com

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

karrenberg
Earlier  on this forum it

Earlier  on this forum it was mentioned that infusing the tpa over 3-4 hours, as opposed to instilling it and letting it dwell, was off lable.   Is there any new info on this?

lynncrni
This may never be added to

This may never be added to the label as an indication that has been "approved" by the FDA. New indications for drugs may not be added for many years because of the huge expense of clinical trials required to get this language changed at the FDA. But there are many facilities do this infusion procedure and there are published reports of their outcomes. I have not seen anything recently.  

 

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

www.hadawayassociates.com

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

AshleyM
I may be way out of line
I may be way out of line here, but my question has not been answered. In most practices out there, is this being done? Are nurses checking for blood EVERY time they hang a med...say there is a bag of fluids infusing without any problems and the nurse hangs an antibiotic on the Continue flo, does she/he need to break the system to check for a blood return?  On a continuous infusion, where only the bag is changed, do you break the system to check for a blood return? The feed back I am getting  from those who attended the inservice was that it should be done? Is this practical?  I am not asking about vessicants/chemo infusions. 
lynncrni
Your question is not out of

Your question is not out of line at all. In fact, you have raised the many gray areas about the issues of checking for a blood return. My only additional comment is that you do not have to break the system to check for a blood return, unless you call attaching a syringe to a lower injection port breaking the system. I would definitely not do this by disconnecting the tubing at the catheter hub because of the concern about contamination. I would attach a syringe to the lowest port and aspirate and flush to assess patency.  So I would also like to hear what is the most common practice.

 

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

www.hadawayassociates.com

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

momdogz
We didn't routinely use to

We didn't routinely use to do this/teach this; now we are - for all of the reasons Lynn described.

It has the added benefit of one more way to raise awareness in staff RNs that vascular access is much more than the thing hanging off of the patient's arm/chest.

Mari Cordes, BS RN 

Nurse Educator IV Therapy
Fletcher Allen Health Care, Burlington VT
Educator, Bard Access Systems 

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

Cat Johnson
It is my understanding that

It is my understanding that if a catheter has any port without positive blood return, this places the pt at increased risk of septicemia.

Karen Day
Karen Day's picture
to answer your question, yes
to answer your question, yes we do perform this procedure at our facility.  Through much hard work and education, I have educated our staff to always check any central line for a positive, brisk return of blood prior to infusing any medications or solutions.  According the INS standards of practice, "the nurse should aspirate the catheter for positive blood return to confirm patency prior to administration of medications and solutions".    There are many times when a catheter will flush easily, but does not give a blood return.  In many cases, we have resumed patency by instilling tPA - in a few cases we have found that the catheter was malpositioned or in one case of a port - fractured with a portion in the patient's pulmonary artery (pt was completely asymptomatic).  If we had not investigated these lines b/c of no blood return, it could have lead to a potentially dangerous situation had the nurse infused medications or solutions.  As for who is performing this, it used to just be the picc team, but with education, we now have many staff nurses and educators who are competent to perform this easy procedure.  As for practicality, it is much more beneficial to the patient and cost-effective to both the patient and your facility to salvage a catheter rather than replace it.  In a catheter that fails to give a good blood return, I fear that it will only be a matter of time before it will not even flush at all due to a total occlusion.  While tPA does not totally stop or prevent an occlusion, it is a successful resolution to an occlusion problem.  Nearly 1 out of every 4 catheters will become occluded despite the best care given due to biofilm and fibrin adhesion.  Of these, 58% are due to thrombotic occlusions and 42% are due to catheter malfunction such as pinch off syndrome, fracture, or drug to drug precipitant.  I have read some published studies on this practice, I can't recall the exact names right now, but will post when I come across them again.  Cathflo.com is a great website for some information regarding this. 
kokotis
Kathy Kokotis Bard Access

Kathy Kokotis

Bard Access Systems

Sometimes I wonder if there is a link to no blood return and CR-BSI.  No one has studied it so maybe one of you will?  Fibrin tail means bacterial nutrition to me

Thought for the day

Kathy 

 

 

Kathy Kokotis

Bard Access Systems

mary ann ferrannini
Yes we are doing the
Yes we are doing the same...treating all PWOs with Cath-flo. it has taken us awhile to train the nurses as well as new hires. We have a quick competancy checksheet that we sign once they have successfully completed the procedure correctly.
tamster
Mary, Can you please share

Mary,

Can you please share your competency checksheet?

Thanks.  [email protected]

Gwen Irwin
I don't have the study

I don't have the study reference in front of me, but there has been a study that looked at the co-relation between occluded lumens in multi-lumen catheters in the ICU and the occurrence of CRBSIs.

We are currently looking at the occurrence of BSIs on an individual basis and the trend we are finding is that there are also links to occlusions or partial occlusions.

We plan to use this information to teach within our facility to teach the need to treat partial withdrawal occlusions and total occlusions.

Gwen Irwin

Seton Family of Hospitals

Austin, Texas

Log in or register to post comments