<p> I need some guidance.</p><p>We have a patient with a port that was put in place because of poor venous access.</p><p>We have been unable to get a blood return for over 2 months. We have instilled 2mg Cathflo X2 over 2 hours and have even left a dose overnight with no results</p><p>Fluroscopy shows a fibrin sheath. The orders from the surgeon are to continue to use the Port for meds when needed but no lab draws.</p><p>I am concerned about the increased risk of infection and thrombosis and discussed this with the patient and her primary physcian. The physcian discussed this with the surgeon who told the primary these where not risks. </p><p>Today just because I am concerned we are trying a 2hr 2mg alteplase gtt.</p><p>If this does not work does anyone have any other suggestions.</p><p>Carolyn Bonanno RN</p>
Refuse to use any VAD that has this much trouble producing a blood return!! You did not say what meds were being given but escape of any fluid or medication into the chest is not good. There is definitely a risk of extravasation/infiltration with this situation. Virtually all CVADs will have some degree of fibrin sheath. Thrombosis and infection are not the primary focus in this situation. Was this fibrin sheath complete or along the entire length of the catheter? Only part of the way or only a fibrin flap? The complete fibrin sheath is the risk because infused fluid can track between the extraluminal catheter wall and the fibrin sheath and leak from the vein at the point where the catheter enters the vein. Anything you do inside the catheter lumen is not going to reach this extraluminal pathway. Also where is the tip location? Is it correctly placed at the CAJ? If it is high in the SVC especially from the left side, you also have the risk of total catheter erosion through the vein wall. If this is a fibrin sheath, you will need to do a low dose infusion of alteplase to reach the extraluminal surface. To download an article about this, go to my website, www.hadawayassociates.com to the Resources page. Scroll down to find an article titled Reopen the Pipeline. This is an old article but still valid, lots of good drawings to show what I am talking about. Also, see 2016 INS Standards on CVAD Malposition. You will probably need to obtain several of those applicable references. Take special note that these are MEDICAL articles, not nursing. Point this out when discussing with these physicians. All of these articles put huge emphasis on blood return before any catheter is used. So this is other physicians saying this and not just nursing.
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
lYNN
This patient will typically receive fluids and antibiotics through this line as an inpatient. We see her when a monthly flush is due in our outpatient infusion department.
I have discussed this with my supervisor and she tells me it is essentially the doctors decision and won't advise me as to weather I should refuse to use it when I asked her if I had that option.
Also I personally watched the fluroscopy and if I am recalling properly the tip is in the higher part of SVC.
I looked at the article entitled Reopen the pipeline but I did not see the information on the low dose infusion of alteplase.
I did do 2mg of Alteplase in 50ml of NS over 2 hours today with no results.
Carolyn
Lynn
I did find the info on the low dose altplase gtt and it seems to be what we did today.
Lynn
I did find the info on the low dose altplase gtt and it seems to be what we did today.
Glad you found the information on alteplase infusion. My article has the drawings to show what I was talking about. In the clinical setting all you can determine is that there is no blood return but you have no way to determine what is causing this. Blood return and the importance of in assessing the functionality of all VADs has been in the INS Standards and ONS Guidelines for at least 10 years. I can tell you that in a lawsuit, the need to assess for blood return and to obtain diagnostics when it is absent is a point that is always evaluated. I have seen far too many cases where the patient had devastating outcomes when blood return was not checked or nurses followed the doctors foolish order to proceed without a blood return. The nurse is the final one to proceed, with or without a blood return, so the nurse, and only the nurse is held accountable for the bad outcome. In other words, the nurse looses regardless of what the doctor ordered. In some of these cases, the doctor was excused from the case long before it ever went to a trial and jury. Tip location high in the SVC is not the recommended tip location and is prone to more complications that the correct CAJ location. It sounds like this issue needs to go to your risk manager along with all the documentation and get a decision on it. A CVAD with a suboptimal tip location, without a blood return requires removal and reinsertion. Your infusion efforts with alteplase will not cause a permanent cure as the fibrin will redevelop over time. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I love that article!!
Sheila Hale, MSN, RN, CRNI, VA-BC, Austin, TX
Thanks for the information, just to clarify, a fluroscopy has been done and shows the fibrin sheath with good flow throw the cath.
If that is the case, it sounds like there is a fibrin tail or flap over the catheter tip. When you aspirate the flap covers the lumen. When you flush it opens. But if it also showed a fibrin sheath which is along with extraluminal catheter walls, this is the problem for risk of extravasation. I don't remember what drugs you are giving but any drug leaking into the venotomy site on the chest wall if a problem. You really only know what is happening when the fluoro is done. The sheath and flap can grow together to produce retrograde flow and backtracking to cause extravasation. Is this a left sided insertion? If so much greater risk with high SVC tip location. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Great information mentioned here. Thanks for sharing .
Two other things come to mind for me related to no blood return on this port: 1) which vein is the access site for the cath? Subclavian? Surgeons usually use subclavian; IR uses jugular in my experience. If so, are you getting some sort of pinch off where it opens when pos pressure is applied with flushing, but closes when negative pressure is used to draw blood? Sometimes when IR does their dye study, patient is in a different position than when you are working with the patient in the infusion clinic and it may not show what you are experiencing. 2) Could there be a kink in the catheter? I usually review imaging to see if there are any odd angles. Again, this might allow you to flush, but all the tpa in the world will not open a kinked catheter.