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ladyanna119
Drawing blood through end caps?

I would like to know what is best practice re: drawing blood from central lines.  We currently use Max Plus end caps.  I've heard that drawing blood through the endcaps can cause hemolysis.  It's also not very easy to flush all the precipitate out of the Max Plus caps.  So I've been instructing staff to remove the caps and draw directly from the hubs, replacing a new cap afterward.  Does anyone have any thoughts about this?  Has there been any evidence based research out there?

Thank you!

Ann

Midland, MI

 

lynncrni
Yes, finally something with

Yes, finally something with some evidence to support the practice. For drawing blood cultures from any catheter lumen, remove the old needleless connector, attach a new one, scrub it with either CHG/IPA, alcohol alone, or tincture of iodine. Do not use povidone iodine. Draw the blood culture from the new needleless connector. That is the practice described by the 2 studies:

1.    Mathew A, Gaslin T, Dunning K, Ying J. Central Catheter Blood Sampling: The Impact of Changing the Needleless Caps Prior to Collection. Journal of Infusion Nursing. 2009;32(4):212.
2.    Sherertz R, Karchmer T, Ohl C, Palavecino E, Bischoff W. Blood cultures (BC) drawn through valved catheter hubs have a 10-20% positivity rate with the majority being false positives. Paper presented at: Fifth Decennial International Conference on Healthcare-Associated Infections, 2010; Atlanta.

The last one was a poster presentation at that recent conference where they found that up to 20% of blood drawn through used needleless connectors will actually grow many types of bugs. Dr. Sheretz said the practice at his hospital was to draw the culture sample from the new connector, but I suppose you could draw directly from the hub also. I don't know of any results about this. The first study drew from the used, the new connecter and from a peripheral vein, comparing results. Lynn

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

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Kristine Selck
end caps

 Mathew A, Gaslin T, Dunning K, Ying J. Central Catheter Blood Sampling: The Impact of Changing the Needleless Caps Prior to Collection. Journal of Infusion Nursing. 2009;32(4):212.
 

Does anyone know what type of end-caps were used in the above study?  Our IC department  wants to know if they are valve vs split septum and what brand was used.  They are in favor of not changing end-caps, their rationale being the more times the closed system is opened the more risk of contamination and if the end-caps are cleaned properly there should be no increased risk of contamination.   Would love your opinions on this topic.  Thank you, Kristi

 

We are developing a midline policy.  Do any other institutions restrict midline placement to a patient that's been afebrile for 48 hours?

Thank you,

Kristi

lynncrni
 I don't recall what was

 I don't recall what was used, however the Sherertz work used a variety of needleless connectors. Reference 37 on page S69 of SOP. Besides, the type of NC and the cleaning of the connection surface is not the point here. The primary issue is that biofilm is growing inside the NC and will result in false positive blood cultures when drawn through a used one. So you are far better off to change them before drawing a sample for culture. False positives mean unnecessary treatment. Lynn

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

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

artiehansford
Draw directly from the lumen vs the cap?

Please leave comments about the original question.  This is my question also.  We occasionally experience hemolysis when drawing through the cap.  I recently drew a sample from a PASV valve PICC with a MaxPlus cap in place.  The sample was hemolyzed.  I redrew removing the cap and drawing directly from the hub and the sample was ok.  (I scrubbed the hub with alcohol for 15 seconds after removing the cap.)

 

Is there any literature or evidence to simply remove the hub for blood sampling since there are issues with hemolysis and contamination of the injection cap?

 

Thank you!

 

Artie Hansford, RN, CRNI, VA-BC

 

Artie Hansford, BSN, CRNI, VA-BC

lynncrni
 The only published studies

 The only published studies that I know of are 2 studies showing that drawing blood cultures from a used needlelelss connector produces false posiitves on the culture results. This is contained in the INS standards that the NC must be removed for drawing blood cultures. NC are a known location of biofilm growth and have been implicated as the cause of CRBSI in numerous studies. The only studies on cleaning the connection surface are in vitro studies and not clinical studies, so we really do not know what length of scrub time, agent, or technique will actually reduce CRBSI. To my knowledge there are no other studies addressing hemolysis from any CVAD but I have not done a literature on this issue. From my understanding, hemolysis is also a technique issue. Were you drawing with a vacutainer or syringe? Lynn

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

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

artiehansford
Thank you Lynn for your

Thank you Lynn for your response.  Would you mind citing the 2 studies you are referring to regarding false positive cultures and NCs?  That would be very helpful.

Regarding the hemolysis, I was drawing using a syringe.  The flow was great.  It was a PASV valved PICC.  The sample drawn through the MaxPlus was hemolyzed and the sample drawn directly from the hub was not.  I wonder if there is increased resistance, turbulence and therefore hemolysis when the blood moves through a valve AND a cap?  I would suspect that the type of NC would not have mattered.  I recall several years ago when using the Groshong PICC and Clave NC, that hemolysis would sometime occur when drawing through the cap and not directly from the hub.  At my institution we also occasionally have hemolysis with peripheral sticks and with draws through other central lines and art lines.  There are many variables.  Just looking for a solution.

I extrapolate from my experiences with peds and adults, and the minimal  literature available, is that the best method for drawing any blood samples is to remove the cap, draw directly from the hub, scrubbing the hub with alcohol for at least 15 seconds prior to each syringe connection.  As long as the blood flow is brisk, this would decrease  the problems with both hemolysis and false positive blood culture results.  This would be a perfect opportunity to use the Bard Site-Scrub, to ensure disinfection.  I like that the alcohol is contained within a cap and not being manipulated by hands.

Regarding blood culture draws, it has never made sense to me to remove and discard a cap (manipulation), clean the hub (manipulation), attach a new cap (manipulation) and then draw through the new cap (manipulation) after cleansing it (manipulation and possible contamination).  So many steps and so much manipulation of parts.  And now a blood sample has gone through the cap.  We can never know if flushing the cap after a blood draw adequately removes all blood and fibrin.  It probably doesn't.  Therefore the studies suggesting false positive blood cultures drawn through a NC.   So after the draw we are setting up for potential infection with the blood and fibrin remaining in the cap.  My stance is to replace NC after blood draws for that reason.  Much less manipulation and after the draw, the patient is left with a fresh NC.

It would be great to have more research on hemolysis through CVC draws and and methods for drawing blood cultures to prevent false positives.

It would also be great to hear from more people about their experiences and methodas

Artie Hansford

 

Artie Hansford, BSN, CRNI, VA-BC

daylily
We have used the Max Plus

We have used the Max Plus clear since 2008 and have not had any issues with hemolysis.  We do not use the PASV catheter.  We also draw all blood cultures from the hub of the catheter and not through the connector due to the risk of false positives that have been shown when drawing through an existing connector.

artiehansford
 Hi daylily, Thank you for

 Hi daylily,

Thank you for the information. I would like to find supporting information for removing the cap before blood cultures.  I think this a far better approach than drawing through a cap.   Do you use a valved PICC - Solo or Groshong or an open end PICC?  Also I am curious what your CLABSI rate is and if you use an alcohol impregnated protector like Curos or SwabCap?  Lastly, how often do you change the caps?  Thank you!

Artie Hansford

 

 

 

Artie Hansford, BSN, CRNI, VA-BC

lynncrni
 For that evidence see the

 For that evidence see the references in Infusion Nursing Standards of Practice, both Needleless Connectors and Infection standards. Plus there are now 3 good studies supporting the protective disinfection caps.  Lynn

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

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Tom4Shield
Direct is best...

I’ve found that the most direct route when drawing blood is best. Simple physics would show that a torturous pathway either under pressure or vacuum can cause red blood cells to break.  Remove any caps off of the end of the catheter and use the prescribed vacutainer to obtain your sample; keep in mind you’ll need to ‘waste’ the volume equal to the volume of the catheter in order to obtain a clean sample.

Good luck,

Cheers,

Tom

 

Tom Burns, RN BSN

Clinical Nurse Edu

Kristine Selck
We are debating this issue

We are debating this issue right now at our institution.  This thread seems to have become about blood cultures.  What about routine (NON-blood culture lab draws)?  We have increased hemolysis with PICC line draws and there is a suggestion that all labs be drawn directly via the hub and the new caps be placed after.  This seems like a lot of manipulation of the line for a patient that may have several draws per day.  We are currently replacing the end caps and drawing from  new cap for all blood cultures. 

Thanks for any input,

Kristi Selck, RN

We are developing a midline policy.  Do any other institutions restrict midline placement to a patient that's been afebrile for 48 hours?

Thank you,

Kristi

lynncrni
 The ONLY scientific evidence

 The ONLY scientific evidence about needleless connectors and blood sampling is about drawing blood cultures from a VAD. There are no other studies assessing this issue when drawing blood for other lab tests, so your facility must make this decision based on your patients and staff needs. The idea is to eliminate or reduce the amount of manipulation of the catheter hub to reduce the possible introduction of microorganisms. Therefore, all patients should NOT have their catheters used for drawing all blood samples. See the INS standards on phlebotomy for the criteria to determine which patients could have their catheters used for sampling. All others should have blood draws from a direct venipuncture. Lynn

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

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Kristin Jacobs
Additional thought

It is always good to also check with the device manufacturer to see what is in their Directions for Use (DFU).

Thank you,

 Kristin Jacobs, MSN, RN, MBA, VA-BC

Sr. Clinical Resource Nurse

ICU Medical, Inc.

[email protected]

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