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stemc
Lab draws from PICC

We have had some issues in the past with lab values being off and contaminants with labs draws.  Education seemed to fix those problems.  Recently we had issues with contaminants again.  We have a new Infection Prevention Director, and she is changing our policy so that on all patients with central lines lab must try to stick the patient first, if they can't draw labs then we can get an order to draw off of the line.  Our current policy is that as long as we have a physician order than we can draw from the line.  Any thoughts or suggestions????  Thanks. 

lynncrni
 You are accountable to the

 You are accountable to the national standards and guidelines which are written by INS, CDC, APIC, etc. The Infusion Nursing Standards of Practice states that using a CVAD for drawing blood samples requires a patient-specific risk vs benefit assessment. You should never have a policy tht all CVADs are automatically used for blood sampling due to the increased hub manipullation and risk of contamination and subsequent BSI. You should never draw coag studies for any VAD that has been exposed to heparin as the data will not be accurate. You should always remove the used needleless connector before drawing blood cultures from the CVAD. On the other handif the patient has absolutely no peripheral veins, has a history of vasovagal reactions with venipuncture, or another valid reason, you should avoid sticking for every blood sample. Please note that "no veins" depends upon the knowneldge and skill of the nurse doing this assessment and most nurses are not taught how to do this. So what is no veins to one nurse is definitely not to another. The bottom line is that CVAD use for drawing blood samples should be avoided if at all possible due to the risk of contamination through excessive hub manipluation. There are many statements about reducing this manipulation in both the INS and CDC documents. 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

myrrheemarko
Lab samples from CVCs

Hi there, new member following threads about PICCs/CVCs and blood sampling from these devices.

I work in a hospital in the home program with children and as we aim to prevent traumatic procedures in the child's home we prefer to use CVCs as the preferred route to take bloods. These could be for general FBE, chemistry, cultures and drug level review (mainly for aminoglycosides). I see results from drug level blood samples taken by nurses on the road that vary greatly, often using the same site from one day to the other. The only assumption that I believe has the greatest logic is that of contamination.

I do note several comments that a hub change is strongly recommended. I assume you are describing something like a smart site/needle-less access port on an IV line?

 

anyone like to comment ??

 

Mark Spagnolo

Melbourne Australia

lynncrni
 The only published evidence

 The only published evidence about what to do with the needleless connector when drawing blood from a VAD is when drawing a blood culture. We know that the biofilm in these connectors can contaiminate the blood sample yielding a false positive for organism growth. This would cause treatment decisions based on incorrect data. So the INS standards of practice states that the used connector should be removed before drawing a blood culture. The same data is not available for other lab test.. We do have a few studies showing that blood samples can be contaminated by what is left inside the catheter lumen. So your thoughts are probably correct. We simple do not have the evidence to provide an true and correct answer. 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

alison57
labs from piccs

Help me out.   I thought that the beauty of the Picc line was not only to provide a good venous access but to prevent unecessary peripheral venous lab sticks.   To clarify,  are you saying that for a pt getting daily labs the Picc should not be used unless as a last resort?  

lynncrni
 Well, I think you have this

 Well, I think you have this a litte skewed. Any type of VAD can be used for blood withdrawal if it successfully yields a blood return. However, that does not mean that they should always be used to obtain blood samples from each and every VAD in all patients. So no, this is not one of the "beauties of a PICC". I am saying that each patient much have an assessment to determine the method of drawing samples that poses the least risk and the most benefit. Risks include increased hub manipulation leading to bloodstream infection, inaccurate lab values, excessive loss of blood from the waste, etc. Benefits would be avoiding additional venipuncture attempts in patients with absolutely no peripheral venous access or those with a history of vasovagal with needles/blood, etc. So you should definitely not be using all PICCs or other CVADs for obtaining blood samples routinely on all patients. 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

alison57
Wow.   Thankyou for the

Wow.   Thankyou for the information.   What referece do you recommend so that I can brush up on this  particular

knowledge.   I surely need to brush up.   Thanks again. 

Wendy Erickson RN
I agree with Lynn 100%!   A

I agree with Lynn 100%!   A number of years ago, we had a patient complaint reported to the state when a nurse refused to use the patient's implanted port for a blood draw (because she didn't know how to access it - didn't ask for help, just refused).  The knee-jerk reaction that resulted was a blanket statement:  "If a patient has a central line of any kind, ALL lab work WILL be drawn from it".  Guess what happened to our rate of clotted catheters and blood stream infections?  Soared!!

We now provide education to the patient and family about the risks and benefits of using the line for blood draws.  (If you post your email address, I will be happy to send you a copy of the tool we use.)  Once educated, the patient decides and the decision is documented and a sign is placed on the room door indicating "Lab Draw" or "RN Draw". 

We tell nurses that there are three scenarios where the line should be used for labs:
1.  There is no other place to draw from - no peripheral sites
2.  The patient is needle-phobic or pediatric.
3.  The patient requests it.

 

 

Wendy Erickson RN
Eau Claire WI

Kelly Tiffany
tool
malutzrn
Removal of needless adapter for blood draw in Pedi Patients

This questions is for Lynn - and thanks to all for sharing your experience and policies.

 

Our current policy for PICC's does not allow for any blood draw for PICC's 6fr or lower (we have infants with a 2fr PICC which clot frequently and have to be altepased.) When we draw blood in peditarics, there is currently a policy which states that in pediatrics we are not to remove the needless adapter when drawing bloods or blood cultures from a central vascular device. This was based on a high frequency of line infections, and also before we started using claves and antiseptic barrier caps. My question is: Are your recommendations to have all needless adapters removed at time of blood draw also for the pediatric patient?

Also, is there evidenced base literature supporting the removal of the needless adapter? If so, could you direct me to where I could access this info.

 

Thanks.

 

Marcia Lutz RN MSN CPN

Administrative Manager, Infants/Cardiology

Children's Hospital at Montefiore

[email protected]

 

lynncrni
 Start with the list of

 Start with the list of references in the INS standards of practice. That will always be my recommendation for where to begin searching for literature. At the time we wrote that, there was one published study and one poster presentation by Dr. Bob Shereretz which has since been published. Neither of these separated peds from adults, I don't think. And these were conducted before the use of disinfection/protection caps were being used. The research is based on the proven fact that all needleless connectors will grow biofilm and will produce false positive blood culture results. And we know that we can never clean a connection surface on a needleless connector to the point where it is sterile again. In my opinion, this is no different for peds vs adults, so the connectors should be removed before drawing blood cultures from the cathetr. Clinical decisions require the best lab data. Biofilm growing in the NC has been shown in 2 separate studies to produce false positives, which means you could be treating a patient based on erroneous lab data. So I would take them off for blood cultures. 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

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