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SMHC IVTeam
Catheter occlusions
Our hospital converted to Invision-Plus neutral injection caps a year ago.  At that time, we also deleted heparin as a routine flush on all PICCs and central lines other than ports and HD caths.  Since then, our catheter occlusion rate, withdrawal and 2way, have skyrocketed in spite of repeated and reinforced inservicing.  We started placing mostly Power PICCs at that time also, however the occlusions are occurring on all the saline only CVADs.  Several team members and floor nurses have also noted that occlusions may occur within hours of aspirating for blood return followed by proper turbulent flushing, without any intervening entering of the lumen.  Many patients are getting repeat occlusions / tpa administration, which is extremely time-consuming and frustrating.  Is anyone else seeing this and what are you doing about it?   Thanks, Janet Brown-Wise, RN
kenwthomas
Janet, I don't see less

Janet,

I don't see less occlusiion rates with In-Vision then I do with Ultra-Sites, Smart Site Plus, or Clear Sites. I work in the LTC sites and I attribute the high occlussion rates due to extended wait times to flush after delivery of the intermittent ABT and poor power flush techniques. I see no evidence that it's better, and if it's needed the most it's the LTC sites due to poor flushing techniques.

Ken Thomas, RN

Institute of Nursing Excellence, Inc.

 

lynncrni
All needleless connectors
All needleless connectors remain an open conduit until the tubing or syringe is disconnected. So what Ken said is true. The length of time that the tubing is allowed to remain connected after the fluid has infused will allow for blood to reflux into the catheter and eventually occlude the catheter. This can not be blamed on the needleless connector because they are not designed to prevent reflux at this point. The positive-displacement needleless connectors will only displace the refluxed blood upon tubing and syringe disconnection. Lynn

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

Robbin George
At Phoenix AVA a new device
At Phoenix AVA a new device was featured in a poster presentation entitled "Occlusion Reduction and Heparin Elimination Trial using an Anti-Reflux Device on Central Intravenous Lines"--The device is described as an "Anti-reflux valve attached to Luer-access mechanical valve injection cap"--Perhaps the RNs who conducted this study at Doctors Hospital OhioHealth and the company that manufactures the valve could use this forum to enlighten the masses 

Robbin George RN VA-BC

lynncrni
I think you are referring to
I think you are referring to the poster that presented clinical work using the Nexus TKO which is the anti-reflex valve that can be used with any other needleless connector. You will definitely be hearing more about this product shortly. Lynn

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

ljasinsky
My name is Lisa I was one of

My name is Lisa I was one of the nurses at AVA that did the study for the poster.  Most of the nurses are noticing a occlusion with just a pressure devices alone.  When we added the Nexus antireflux device to our cap we reduced our occlusins from 30% to 10 % with Heparin and 12% with saline only.  During the month with saline only we also switched our prefilled syringes to 3ml and 10ml and some of our floors were not stocked with the 10ml.  Since switching the lines I am callled about usually have the wrong cap in place, multi lumen and have been poorly flushed, or come in from outside the hospital where the antireflux device is not used.    I dearly love the antireflux the device.  It works great.  I know people are trying to get us to switch to the max plus and I am praying this does not work I think it will only ask for trouble.  So my advice is to try this device even if you think it is going to cost a little extra, it really saves in the long run.  We also placed on our peripheral lines with great success.

By the way the device we are using has been pressure tested for ct scanners, I do not think the max plus is.  What are you institutions doing about the CT's

lisa

kokotis
Kathy Kokotis Bard Access

Kathy Kokotis

Bard Access Systems

Occlusion increases have so many reasons.  Is it the lack of heparin?  Is it the new needleless system?  Or is it the triad of virchow that causes extraluminal and intraluminal occlusions.  You have to separate the factors to identify the cause

 

 

 

Kathy Kokotis

Bard Access Systems

swensonals
At my hospital, we changed

At my hospital, we changed to MaxPlus caps and PowerPICCs at the same time, approx.

1- 1/2 years ago, also deleting heparin flushes on the PICCs and Triple lumen catheters.  We also have had problems with increased clotting, so we're looking at what we can do to decrease this trend.  We will be changing our (normal saline)flushing to q 8 hours (it was being done once a day, and before & after intermittent meds) and we have been doing reinforcement during competency fairs with all the RN staff. There was a lot of variation in technique that could have accounted for some of the problems. The other change for us is that the staff RN's do the flush now, whereas before we were doing it (if it was a heparin flush)--and we had groshong piccs that didn't require heparin. There were high hopes that a positive displacement cap would get rid of the heparin and save time and money with fewer clotted lines, but we're not seeing it working out that way.  I thought that the Invision-plus neutral cap might be an answer, but it doesn't sound like it from the problems you're having.

Chonna L. Barth...
The importance of technique

The importance of technique and following proper clamping protocal is always the challenge when the responsibility of line maintainence shifts.  The MaxPlus will effectively prevent occlusions with saline flushes if the nurses flush per protocol and disconnect the syringe PRIOR to clamping. 

If the staff continue to follow the old method of clamping before they disconnect, the positive displacement feature is eliminated.

Thank you 

 

kokotis
Kathy Kokotis Bard Access

Kathy Kokotis

Bard Access Systems

These fancy devices do nothing to the outside sleeve surrounding a catheter.  Catheters will clot it is called a fibrin tail, mural thorombosis, and fibrin sleeve.  Did you ever have a patient cough and all of a sudden get a miraculous blood return.  It is called a fibrin tail.  Clotting is a function of the patients risk factors just like thrombosis is.  I question those that say it is how the RN's maintain the IV line because that is only part of the story.  The inside occlusions.

kathy

Kathy Kokotis

Bard Access Systems

lynncrni
The truth is that we are
The truth is that we are dealing with both problems - clotting problems inside the catheter lumen and inside the vein around the catheter. There is no possible method for distinguishing between these 2 causes by the nurse at the bedside. All you know is that there is no blood return and that you may meet some resistance when flushing. Techniques and technology to address both are necessary, however the needleless connectors and flushing techniques can only address the intraluminal problems. We also do not have a good understanding through research of what percent of occlusion problems can be attributed to intra- and extraluminal causes. Lynn

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

Marcia DeRuiter
I tried to google fo nexus
I tried to google fo nexus and the antireflux device and couldn't find it.  Can anyone help me out?    Thank you
lynncrni
They do not have a website
They do not have a website yet and have not actively marketed this product throughout the entire country, but this will be changing soon. You can contact the company at 866-336-3987. Lynn

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

plsysinc
Occlusion is very complex. 

Occlusion is very complex.  One issue that might have been overlooked is the use of low rate primary bags often referred to as flush bags with secondary sets.  In between intermittent drugs the low rate (10 mL - 25 mL) is used to clean the IV tubing and catheter.  If you do the math 10 mL infused over one hour is not the same as a 10 mL manual flush.  In actuality the IV fluid pathway may have not been cleaned sufficiently.  In addition the low rate is not sufficient to prevent reflux with suctioning, coughing, etc. (anythin that increases negaive intrathoracic pressure.  Lastly, many patients in ICU  such as trauma, cancer, etc. already are at high risk for thrombosis.  Have you tried flushing manually every shift on lines that are continuously connected to pumps?  Also are you closing the clamps on the CVC,x or the extensions.  Just a few thoughts.  The InVision-Plus Neutral is not the cause of the occlusions.  It has zero fluid displacement, has 0.027 priming volume and a straight through fluid pathway.  It does not have any reflux at the time of connection or disconnection.  

 

Denise Macklin 

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