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Inotropic therapy

Can someone tell me if they have a better way of handling this issue? 

We are seeing a lot of patients on Inotropic therapies, and our question is this:  Using a CADD, our cassettes are changed q 48 to 72 hrs.   Currently, we tell the nurses to only check for line patency at the time of the cassette change.  We have them withdraw 5 mls of blood, and then perform a saline flush and then attach the new cassette.  Some nurses are concerned because on a 24/7 continous infusion, with PICC's having an internal diameter of 0.7 to 1.3 mls, that it means that the pt will go without this medication for the time that it takes for the new cassette to get it into the blood stream.  Many of these medications are Vesicants, and I say that absolute and positive line assessment must be made at intervals.  Does INS address this? I can't seem to find anything? Lynn? 

lynncrni
The INS SOP contains numerous

The INS SOP contains numerous places where the need for assessing blood return is included but does not address this specific issue in this detail. This is a major factor when assessing line patency. Since you mentioned a CADD, I am assuming you are in home care. If so, that would mean usually a lower dose of inotrope and very different from a patient in ICU whose blood pressure cannot be maintained without a steady infusion. IMHO, you are correct to only have this patency assessment done by the nurses when the cassette is changed. You really do not need to withdraw and discard 5 mL of blood. To assess for patency you just need to see blood that is the color and consistency of whole blood come back into t he external catheter segment. Wasting is not necessary. But you do need to flush that blood out of the lumen rather than leave it in the lumen. What is the rate of infusion? You are correct that it could take a while for the saline in the lumen to be displaced with the drug infusion and reach the bloodstream. Given the internal volume of the catheter (remember it will be less than what the manufacturer states because it has been trimmed to a patient specific length) and the flow rate of the drug, this could be take a while. If these are home care patients, I would not think they are so unstable that this would be a problem but hopefully some home care nurses will share their experience with this here. A 1 mL priming volume at a rate of 0.75 mL per hour would take 45 minutes to reach the bloodstream. Blood should not be allowed to sit in the lumen for that length of time as it will deposit fibrin along the walls at the very least. Can you have the new cassette already primed and ready to immediately connect and start as soon as the flush is finished? That might require 2 pumps, one to keep it infusing while you prime the new line. Or is the line primed in the pharmacy? The bottom line is are your patients exhibiting clinical signs of instability with your current practice. If not, I would only change the blood wasting and have the new primed cassette ready to go immediately after flushing. I really don't think there is a good answer to this issue. You could also take the approach that you would only assess for blood return when there is a clinical indication to do so - pain in the chest, neck, shoulder; pump alarms, etc. 

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

Thanks for your answers Lynn!

Thanks for your answers Lynn!!  We do not want to bolus them with the drug itself, so that is why we waste 5cc, rather than assessing for the return and reinfusing it.  We have the same policy when our patients are on pain management therapies. 

My only concern with not assessing for the blood return at cassette change is that if we have a line that is no longer giving you a brisk blood return at intervals, by the  time external s/s are seen, we have a much bigger problem.   If at cassette change the blood return is sluggish, or one only pulls back pinkish fluid, immediate treatment can be instituted if this is due due a partial withdraw occlusion.  To me, by the time s/s show, the line could have the fibrin being built up so much that now a thrombus has developed, and it may be seeded.  Have you seen legal cases where the patient was harmed because the nurse wasn't assessing for that brisk blood return, the color and consistancy of whole blood?  And since these are vesicants,  blood return is imperative, along with assessment of these other s/s.  

Also, we are servicing Skilled LTC facilities.  It is the floor nurses on that end that will be doing the assessment.

lynncrni
Good point about the bolus

Good point about the bolus without wasting. But you could reduce that volume of waste. Even 3 times the volume of most PICCs would not be more than 3 mLs. 

When to assess for blood return is a matter of weighing risk vs benefits for your patient situations. And skilled nursing facitlities changes things a lot. I would imaging this is primarily LPN/LVNs doing this task. Remember this group of nurses does not do assessments, according to their scope of practice. 

Blood return, primarily the total absence of any note about ever checking for a blood return, is seen in all legal cases. Most nurses do not understand the reason for this or know when and how to do it or how to assess the results. BUT, and this is a big but, I have not had any legal cases meeting the fact pattern of what you describe - inotropes, slowly infused on a CADD pump, in a skilled nursing facility. In the legal world, those facts are critically important when comparing cases. 

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

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