What do you do when you have a port in place and patient is on chemo and now needs TPN. Is it ever ok to put in a non tunneled multi med in to a patient with a port?
I am not sure what you mean by a "nontunneled multi med". If you are asking about a multiple lumen central venous catheter, percutaneously inserted, then it is possible and could be the best alternative. Is the TPN continuous or cyclic only at night? If only at night can you give the chemo during the day when the TPN is not infusing? Is the chemo a vesicant? What is the frequency of each dose per course and the number of course planned? What is the safety of using peripheral veins requiring a peripheral veinpuncture for each dose of chemo? There is a risk of thrombosis when there is multiple central vascular access devices inside the SVC, but this risk may be low when compared to the available peripheral sites, the patient's attitude toward venipuncture, and the risk of infiltration/extravasation. Without knowing more details about the specific therapy and patient, I really could not say which would be the lowest risk and most benefit. These are the kind of decision made by infusion nurses every day. If you facility does not have this specialty, perhamps it is time to rething that decision. 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
Yes you are right - it is a multiple lumen central venous catheter, percutaneously inserted. No we do not have anything at all in place for these kinds of decisiions. The surgeon booked the procedure with no discussion with anyone. We are concerned with having 2 lines in the SVC but it sounds like this can be an option after you weigh everything out. We have never done our TPN cyclic - but that is now something we can think about as it would have allowed us to do everything via the port.
With the increased risk of thrombosis should heparin be a consideration?
Thanks very much!
Do you mean a therapeutic dose of IV heparin for total anticoagulation? If so, there are no recommendations to anticoagulation the patient to reduce the risk of catheter-associated venous thrombosis.
If you mean heparin to lock the catheter after each use, this remains the standard of practice for all central venous catheters, regardless of their design or what needleless connector has been added to it. Again, see INS standard of practice on flushing and locking. Lynn
Many times....we place a PICC for the (short term) TPN ....saving the I-Port for chemo only.
At our community hospital, this situation comes up frequently.
Our solutions have been:
1. Schedule TPN cycling 12-16 hours in the evening. (IV/PICC Team will ask a nutritionist to make recommendations for optimal caloric intake)
2. If Chemo is to be administered around the clock, a PICC line is inserted into the opposite arm of the chest wall Port.
3. If Chemo is not a vesicant, provide peripheral access and keep the chest wall port for TPN.
My overall experience is that you need to assess the patient and the situation and find a solution to meet the patient needs. Sometimes the same solution is not the same answer for every patient.
Lois Long Rajcan, MSN, RN, CRNI
IV/PICC Team Leader - Clinical level 4
Chester County Hospital, West Chester, PA
Thank you - this is very helpful as well.
If all you have is the port - which the TPN is being administered through - what would you do with your prn meds - give through the port, flushing before and after or start a peripheral IV.
Thank you again
Definitely give the meds through a PIV site if at all possible. There are 2 reasons - contamination of the line leading to CRBSI (PN grows candida very well) and incompatibillity due to many additives in the PN. Lynn
Thank you very much
I would not start infusing TPN through any line that had been used previously for any type of therapy. In this patient's case I would have placed a PICC for the TPN and dedicated it to ONLY TPN. Should the patient develop a CRBSI from the port due to the TPN, it would require surgery to remove it. I think a PICC dedicated to TPN would be the safer choice.
This practice is not evidence-based. I have never seen any studies, guidelines, recommendations, standards, etc. that state this is necessary. The risk of inserting a new CVAD must be considered in this decision, along with the cost of replacing a functioning CVAD. I include PICCs in the CVAD group. Also, please note this is different from the recommendations to infuse PN through a dedicated lumen. This means that the lumen is only used for PN due to contamination risk associated with set manipulation and drug incompatibility. Lynn