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phampton
phampton's picture
Midlines and using if blood return not present

Our hospital has been trialing a new midline and we seem to like it, but the rep is telling the nurses that blood return is not necessary to assess patency. The only assessment for patency needs to be the ability to forward flush easily and the lack of pain at the site. I challenged her with the INS definition of patency which definitely includes positive blood return.

I am wondering what other hospitals that use midlines do when the they cannot get a positive blood return even if they try the Kamps manuever?

Thanks, Peggy

lynncrni
 What is the Kamps maneuver?

 What is the Kamps maneuver? Never heard of this. That sales rep is WRONG and you must ask her to provide this information in writing from her company. I would bet a huge amount of money that she can not do this because her company will not put it in writing. Anything that comes from the mouth of any manufacturers representative is considered to be labeling and I would bet that she is saying what she thinks you want to hear and has no clue about clinical practice and the national standard of practice. Blood return is necessary on all types of VADs, midline included. 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

phampton
phampton's picture
Kamps' Maneuver

Lynn, thanks for your response. It was my general feeling also but I was looking for confirmation.

I have a flyer from the Power Wand Company with a recommended Care and Maintenance Protocol.

Under blood sampling from the Powerwand, after they tell you to flush the catheter with saline per protocol they say to perform the Kamps' Maneuver:

Dangle arm in gravity-dependent position with palm of the hand facing upward

Pump fist

Attach syringe and gently withdraw blood

If no blood returns:

Apply light tourniquet

Repeat Kamps' maneuver

 

When the rep descrbed the procedure there was lots of moving the fist back and forth and releasing it but the flyer is much simpler. I had not heard of this technique and couldn't find anything other than this flyer for a reference.

 

thanks again for your answer. Peggy

Peggy Hampton, RN

Clinical Education Specialist

Yuma Regional Medical Center

djdempsy
Midline Replacement

If a blood return is necessary on all types of VADs, midline included, would you replace a midline that does not have a blood return? If an assessment  is conducted and the only thing found id that the midline does not have a blood return, should the midline be removed and replaced?

 

David Dempsey MS, RN

Angela Lee
It has been my experience

It has been my experience that midlines do not provide a blood return the longer the dwell time.  That has been the case for all the brands of midlines I have placed.  Certainly on insertion a blood return should be evident but it seems to be very unreliable in just a few days.  So yes, we do assess by function and patient feedback.  It is not practical to replace every midline as soon as a return no longer occurs when there are no other indications of malfunction.

It has also been my experience that the presence or absence of a blood return of a PIV is not a reliable indication of the status of the device but should be one criteria of several that is considered when doing an assessment.  As PIVs age, I have found that they also do not give venous returns.

I do agree that the absence of a return in a CVAD should always be investigated and corrected, but I don't think peripheral devices can be reasonably held to the same standard.

Angela Lee
I have not heard of the

I have not heard of the Kamp's manuever but I was puzzled about the tourniquet application.  Where should it be placed if the midline is at the level of the axilla (but not in the axilla)?

lynncrni
 That was also my question. I

 That was also my question. I think this is the practice of one nurse, but has not gained widespread acceptance as an evidence based practice. 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

phampton
phampton's picture
Kamps' Maneuver

I agree since especially since I could not find any supporting data in any search. I do however have a flyer from the company that describes this and recommends using it for blood draws. thanks again. Peggy

Peggy Hampton, RN

Clinical Education Specialist

Yuma Regional Medical Center

djdempsy
Midline Declot

At my institution a midline is not to be used for blood draws, but I am sure that it occurs. Would you declot a midline or replace it. I lean toward decloting it, but some of my peers have no idea.

David Dempsey MS, RN

Saharris
Declot Hazards of Midlines

David,
When we as clinicians choose to use products off label, which you do when using CathFlo for midlines, we must do so using sound clinical judgment and preferably with some body of evidence supporting our decisions. I would be very hesitant to declot a midline and I think there is significant legal hazard in doing so. If a thrombotic injury is brewing at the midline tip termination one of the early clues could be absence of blood return. Of course the vessel size is much smaller here when compared to central location which is what CathFlo is indicated for. In this scenario your clinical action of declotting could clear the way for a more severe injury.
I support off label uses of products if it has pt. benefit and a good safety record. If there was an actionable incident you would be hard pressed to find witnesses to testify to the safety of this practice.

Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness

djdempsy
Thanks for you comments

Thanks for you comments Stephen. In your response you state "clear the way for a more severe injury". I am not sure what that means. Can you elaborate on this for me.

Thanks, Dave

David Dempsey MS, RN

Saharris
More Severe Injury

There are many causative agents for vessel thrombosis. Specifically what I was referring to with declotting midlines was thrombosis due to vessel wall irritation. For example a midline is placed and Acyclovir is infused. After a while the vessel gets irritated and inflamed. As this vessel is narrowed due to chemical irritation of high pH it attaches to vessel wall in a fibrin matrix. It stops giving blood return. Right now we have a vessel wall injury that is minor and may heal if we stop infusing inappropriate drugs through it. The nurse calls the vascular access team and they declot the midline utilizing an off label use of activase. The midline is now giving blood return freeing the uneducated staff RN to continue to put Acyclovir through this midline, thus clearing the way for a more severe injury. Worst case scenario DVT leading to PE leading to death.

Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness

lynncrni
 Stephen description is

 Stephen description is accurate, however I would have to question why any drug with such a high pH is being infused through a midline in the first place. I am still in China and do not have access to my drug book, so I don't know the pH of the Acyclovir he mentioned. If it is greater than 9, a midline should not be used to deliver this drug, according to the INS Standards of Practice. The pH and osmolarity parameters for infusion through a short peripheral is the same for a midline, less than 600 mOsm/L and pH between 5 and 9. 

I think the original question was about information obtained from a sales representative about no need for assessing for a blood return. First of all, all information from a sales representative for all companies should be easily accessible in the written material he/she shares with you. For a sales rep to make such a statement should automatically drive up your sense of alarm. Manufacturers do not establish the national standard of practice. So always verify what any and all sales reps are telling you by looking for the same information in written documents from the manufacturer. I would bet a huge amount of money that no manufacturer would ever put such a statement about not assessing blood return in writing! 

Lets take this situation a little farther. Say the thrombus from Stephen's example grew worse and it developed into a very large thrombophlebitis, with or without a thrombolytic treatment. The associated edema can produce nerve damage so bad that it can produce complex regional pain syndrome. This is a very real situation as I have had numerous lawsutis with just this problem. And several years ago, a midclavicular tip location produced just this same situation and the patient won a judgement of over $7 million. In our example, the nurse who placed the catheter and all nurses using the catheter for infusion would be named in the lawsuit. During the discovery period, all nurses would be deposed about their actions, judgements, and interventions. If the high pH drug was not prescribed when the midline was placed, the inserting nurse may be dismissed from the case but this depends upon the lawyers and their strategies to win the case. So inserters you do need to make a thorough assessment of all prescribed therapies before insertion. You would also need to know if any cultures are pending and the chance that the prescription may change. Nurses administering the drugs would be held accountable to the information in the INS standards of practice. A good infusion nurse expert would use the INS SOP, drug literature, published studies, and hospital policies and procedures to established the standard of care and give his/her assessment of whether these nurses did or did not meet this standard of care. So the bottom line is do not let anyone tell you any action that is outside of the standard of care is acceptable. You do not want to be named in any lawsuit. 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

Saharris
Demonstrate a point

Acyclovir ph is very high, off the top of my head around 10-11. I used this as an example of inappropriate midline therapy causing vessel damage. I have found that most staff nurses have no idea what ph and osmo limits are for midline therapy. I am especially concerned because it is obvious that the NHSN CLABSI reporting guidelines are driving hospitals (and thus manufacturers) to explore midlines as a panacea. So we have a situation where all of us that consider ourselves experts have an expectation that all staff nurses that use IVs know the INS Standards of Practice......but you have to pay for that "intellectual property". Here's a Christmas wish, how wonderful if some manufacturers got together and sponsored INS to give out the SOP for free! Maybe online only and for a limited time! Then we could give RNs everywhere the knowledge they need to have a safer practice. Heck, I would donate to that cause! Sorry I'll get off my high horse now.

Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness

bcardin
Stephen, I soo agree with

Stephen, I soo agree with you!!  Staff nurses have no idea what they are giving because they choose not to look it up!!  I have found so much when making my rounds. I just don't know what hospitals do that do not have IV Teams!  And then, there are PICC nurses that "give up" too easily on getting a PICC in the SVC; they won't attempt the other arm and just get an order from the MD to use the line as a central line and leave it in the subclavian or brachiocephalic veins. It's amazing at the number of MD's that do not understand the pH and osmolarity with lines.

Bobbi Martin, RN

Archbold Medical Center

Thomasville, GA

 

Mickey
Midlines

First of all, I am glad that Lynn is back from China.  Second, I cannot seem to stay on the sidelines about Midlines.  Please understand that the "Midline" is just one of our options in the Vascular Access "quiver".  It is a peripheral-line, short or long, I do not care, it is a peripheral-line.  So, if you have no other vein to obtain labs, go for it, if it is a Midline, et al, blood is blood, just let Lab know where you obtained it from (reallly bad sentence, but y'all get it).  If you are placing a Midline because that is what he rep said to do than temper your options with what you know to be the standard.  If there is no blood return, than we don't know where the other end is, just sayin'.  (So glad Lynn is back from China)

Michelle L. Hawes, RN, MSN, CRNI, VA-BC

Chief Executive Officer

Vascular Access Specialists, LLC

Indianapolis, IN

317-888-0303

lynncrni
 Back from China and now back

 Back from China and now back from a short vacation, my first this year. A blood return the color and consistency of whole blood is required before ALL VADs are used for infusion. Patency is defined by the absense of resistance to flush, positive blood return, and the absense of all signs and symptoms of all complications. Nurses are risk managers. So why take the chance and increase the risk to your patient!! 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

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