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Port-a-Caths and blood return

INS and ONS clearly states that prior to giving medications especially vesicants that there should be a positive blood return obtained and our hospital policy reflects those standards.  However, there are a hand full of oncology patients that their ports have rarely/never given a good blood return.  Some have had dye studies showing good placement yet still don't return blood.  Cath-flo will help sometimes yet the next visit we are back square one.

I've been asked to help write policy to address these particular patients. To protect the hospital I think a dye study should be ordered Q 6 months or before the next round of chemotherapy to assess vasculature and tip placement. There is concern with reimbursement.

A formal list of patients is being collected for review to see if there is a common thread eg same surgeon.

Any advice/comments would be greatly appreciated,

Kathy Cutter, crni

Bristol, CT

lynncrni
In my opinion, these

In my opinion, these patients would be the ones at the greatest risk for extravasation injury. What is happening is probably a fibrin sheath around the catheter. Your tPA treatments are reaching the fibrin at the catheter tip but not reaching the remainder of the fibrin sheath. This could be a partial sheath (think of a sock-like covering) or it could be a complete sheath (think of an entire sleeve). If there is a complete sheath, your chances of retrograde flow from the catheter tip all the way to the vein entrance site is much greater. This is what leads to nasty necrotic ulcers on the patient's chest, etc. There are references to a low-dose tPA infusion to reach and remove the entire sheath, however this is usually 10 mg in 50 mL over 3 hours per lumen. Your instillation procedure is not sufficient to reach all of the sheath. A dye injected under fluoro will show this sheath and its extent.

Any catheter that has never produced a good blood return is highly suspect in my opinion and requires serious consideration for its continue use versus revision. You also did not say what is considered to be good tip placement in your facility. 

 

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

www.hadawayassociates.com

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

Donna Fritz
There are circumstances I
There are circumstances I have encountered where there is an ever so slight kink in the port catheter (usually as it bends to enter the vein).  So when you flush, because of the positive pressure, it straightens it a bit and you can flush.  However, when trying to return blood, that narrowed area further collapses with the negative pressure and you do not get blood return.  So how do you know if you have a fibrin sheath that has developed (as described by Lynn) or if it's the kink?  You don't unless you do a dye study . . . and then the sheath could develop at any point after the dye study.  This is a sticky wicket of a problem.  Surgeons are not likely to agree to replacement when THEY can flush it and it flushes fine.  I dont' think there is an easy answer to this dilemma.  TPA prior to each use, even though you know you won't get blood return?  dye study prior to each use?  Nothing??  A longitudinal study of these types of caths over time would be very helpful to determine the risk of some of these issues.  Sounds like you're developing a data base ("formal list of patients") that might be helpful to the rest of us.  Please publish your experience as you follow these patients.
lynncrni
Donna, do you think this

Donna, do you think this kink is located in the area of transition from the subcutaneous tissue into the vein or some other location? If at the point of vein entry, do you think this is related to surgical technique on insertion? Thanks, Lynn

 

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

www.hadawayassociates.com

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

momdogz
Another concern:  many of

Another concern:  many of the implanted ports have the catheter portion as an attachable piece as opposed to being manufactured already connected to the port.  These usually don't separate, but they have - and initially the only sign is that you have no blood return. Unless it's used for infusion - then - infiltration/extravasation.

Might be helpful to talk with one the AVA IR MDs. 

Mari Cordes, BS RN 

Nurse Educator IV Therapy
Fletcher Allen Health Care, Burlington VT
Educator, Bard Access Systems 

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

gmccarter
Gail McCarter,

Gail McCarter, BSN,CRNI

Franklin, NH

Here the oncology group has decided on the following for non-vesacant drugs given at the clinic: if no blood return try a power flush to see if moving the tip would give you the blood return, if no success infuse 500 ml of NS by gravity. If there is no blood return by this time, they will still give a non-vesacant treatment and observe the patient closely. The theory is that if there is a problem with the port, either the fluid would not infuse by gravity or the problem would be obvious after all that fluid.  They went through a period of time when they did dye studies and cathflo on all non blood returns, and often had to reschedule the treatments, not good for the patients.

When they do the cathflo they are doing 2mg in 50ml NS over 1 hour. Lynn, do you have a reference for the higher dose? 

I am not recommending this - just putting it out there for feedback.

Gail McCarter, BSN,CRNI

Franklin, NH

Thank you all for your

Thank you all for your comments.  Good tip placement depends on the surgeon/radiologist definition. But I voiced my concern to Quality and began tracking tip placement on all PICCs

  Since doing so there as been marked improvement from the radiologists to have the tip in the SVC.  As for the problem ports not sure where the tip lies.

I will be bringing all of your thoughts to the director of oncology.  I'll keep you updated on our progress

Kathy Cutter

Donna Fritz
Lynn, Generally, I have seen

Lynn,

Generally, I have seen this problem where the catheter goes from the subq tissues down into the subclavicular area.  I have seen it in a handful of catheters.  One lady I remember . . . the port was on her sternum . . . the cath was very visible in this cachectic lady running diagonally toward her R shoulder and actually was almost at the bony part of her shoulder before it turned down.  The only way we could infuse her was lying flat with her right arm up above her head.  The kink was very visible on X-ray.  The acute angle of the turn resulted in the kink.  Do I think it's from placement technique--ABSOLUTELY!  We generally have problems with these catheters from day 1.  Don't remember that I've seen any kink problems with IJ port cath placements which is interesting in that the angle the cath has to turn seems just as acute  . . . maybe because IR did most of those placements.

 Another situation with subclavian placements is first rib pinch syndrome.  Port catheters are not immune from this little problem either.  I have seen this in more than a few and it is apparent on the CXR and looks quite different from a kink.

lynncrni
Thanks! This is what I

Thanks! This is what I thought you might find. Great information when assessing ports. Since we can not actually see any of the catheter, our assessment is critical. Lynn

 

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

www.hadawayassociates.com

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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