Hello. We have a brain tumor patient with a port without a blood return. The patient had a dye study and the port is in the right place, no fracture of the catheter, and flows freely without any leaks. The physician is challenging me as I said a vesicant still cannot be infused without a blood return. Any advice? Can a vesicant be given if the dye study confirms no other issues other than a fibrin sheath?
What drug is being given? What is the hospital's definition of "right place" for the catheter? What was seen on that dye study? Did the contrast agent backtrack for any distance between the extraluminal catheter wall and the fibrin sheath? If so, how far did it backtrack or flow retrograde? Then where did the contrast go? There is some valid reason why a correctly place implanted port will not produce a blood return and my guess is it has not been found yet. Could be a mechanical problem like pinch off syndrome. Could be some other form of intraluminal occlusion. There is no answer anyone could provide with a thorough assessment of these questions, and the 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
Vincristine; Doxorubicin
Mary Lynn Rae, RN, MSN, CPHON
Clinical Nurse Educator
Ann & Robert H. Lurie Children's Hospital of Chicago
Here is the report:
PROCEDURE: The left chest wall venous port was already accessed prior to the catheter check. The catheter was injected with contrast using sterile technique.
The initial contrast injection demonstrated normal appearing flow from the venous port catheter tip; however, a second, more forceful injection, demonstrated eccentric directed at a 90 degree angle from the catheter tip. This irregular flow may be due to a small catheter tip thrombus, fibrin sheath or positioning of the catheter tip against the vessel wall.
Mary Lynn Rae, RN, MSN, CPHON
Clinical Nurse Educator
Ann & Robert H. Lurie Children's Hospital of Chicago
How many more courses of these extremely dangerous drugs will this patient require? You have this contrast injection to show where this dose is going - into the bloodstream. But this does not state where this VAD tip is actually located, which vein at what level? It states the flow exits at a 90 degree angle which would direct these drugs straight for the catheter wall. If this is not corrected, it will only be a continuing problem for each course in the future. Are you going to do a contrast injection with each course? For these drugs, I would never administer them without a blood return that meets the definition of blood return in the 2016 INS Standards. See the Standard on CVAD Malposition also. Emphasize to your physicians that this standard was written based on MEDICAL studies, so her/his physician colleagues are strongly supporting the need for a blood return. 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 didn't see it addressed in your post, but if the suspicion is that it's a fibrin sheath or clot, has tpa been tried? Another question I have is are you IV pushing these or infusing them over some duration? I feel your pain in dealing with this physician . . . too many experiences like this in my past. As the INS and ONS standards have evolved into being more explicit about obtaining blood return, in my practice, I can't remember when I last gave ANY chemotherapy without a blood return.
Also, I would get very nervous about giving vesicants through a line with a diagnosed mechanical obstruction (pinch off or kink) because both can result in holes in the catheter at the point of stress, even if you can position the patient to get a blood return.
I am certain many of you have encountered a physician telling you that the INS standards are just for nurses and not applicable to what he/she is telling you to do - such as "don't worry about not getting a blood return, it will be ok, use it anyway". My reply to that would be to have the standards with me, go to the applicable standards and show the references used to write the specific standard in question. More than likely, this will be references from the medical literature. In other words, research conducted by their physician-colleagues. Once you point that out, then how can they deny applying the specific standard in question. The medical literature on CVAD malposition is abundant with statements written by physicians about the need for a blood return from all CVADs. It is this medical literature, again written by other physicians, that emphasizes this important step. Armed with this information, it seems it would be impossible for your physician to ignore what was written by another physician! 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
While I appreciate arming yourself with the INS standards related to lack of blood return and malposition, who is liable?
Case example: Patient had a port placed on Friday and was not left accessed. Nurse accessed port on Monday for chemo regime. Inability to aspirate blood with multiple needle insertions as there was question by the nurse(s) as to whether they were truly in a brand new port. Placement x-ray shows catheter tip in the upper extreme of the SVC. The catheter comes in from the left and appears like a straight arrow with the tip embedded into the sidewall of the SVC. Concerns voiced to oncologist regarding location of tip and probable cause for lack of blood return. Oncologist writes a note stating vascular access nurse concerned regarding lack of blood return from port, "I am okay with this"! Oncology nurse made aware and proceeded to give vesicant chemotherapy.
Are there examples of litigation resulting in a scenario such as this? I understand erosion can occur to the SVC but this doesn't happen immediately. Is the physician liable? The nurse liable? The acute care facility? Our facility does not have a policy statement regarding central tip location but our practice is to get an order to use if a tip ends up brachiocephalic or innominate. Physicians will argue that tips in these areas are still in large vessels.
I don't want to stray off point but how do you convince someone or an organization before a bad event occurs?
I have seen significant discussion of left sided CVAD insertions in the published literature, well enough to document this problem exactly as you described. This tip location is not the recommended one and is known to cause thrombosis and vessel erosion resulting in extravasation into the chest. Read the 2016 INS Standard on CVAD Malposition. Pay attention to the significant list of references, all from MEDICAL journals, not nursing journals. This is the same evidence that an expert witness will be using in a lawsuit.
Have a discussion with your manager, the physicians, and risk management about this situation. In all of these MEDICAL journal articles, the need for blood return received an enormous emphasis from physicians. If all of this information does not move your facility to provide correct patient care, then your only option may be to refuse to use the catheter. Inform the physician that he/she will have to administer the drugs. Realize that this action could get you fired, so you might have to find other ways to act as a patient advocate. You know this is not safe practice, so how could you proceed with a suboptimal tip location knowing the documented probable outcomes.In a lawsuit, the expert is stating that the outcome was probable (more than a 50% chance of occuring) and not just possible.
As an expert, I will always testify about the need for complete assessment of the VAD performance which does include the presence of a blood return that is the color and consistency of whole blood. In a legal case, everyone is named - the nurses, the physicians, and the facility. As the case proceeds through discovery, some may be excused from the case, leaving the others to assume all liability. Or some may settle with the plaintiff, leaving the remainder to proceed or also settle. There is no way to predict the outcome of any case as each case has a different set of facts. But as an expert, I will always testify to the need for this complete assessment of VAD patency before giving the drugs. The nurse should be documenting this assessment also. If you document that there was no blood return but proceed anyway based on physician orders, you assume the accountablity for whatever outcome occurs. Nurses are not regarded only as a person performing the task. We are held accountable to the decision we make! 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
This is very important information for all of us! You and I have discussed this same scenario, Lynn. Nurses are equally liable - saying "the doctor told me to" does not mean a thing in a court. You need to know what is right. If a doctor told you to administer an overdose of a medication, you wouldn't do it, would you? I have told doctors that they will need to give the medication through a bad port. It is not an easy thing to do, especially if you are a newer nurse. You are the vascular access specialist - you know your stuff! Gather all the support you can, talk with your manager, involve Risk Management and Legal Services. If your nurse manager tells you to do it, hand her the syringe! You need to stand up for what is right, and then begin looking for an organization that supports its nursing staff and does what is right for the patient!
Wendy Erickson RN
Eau Claire WI
Another discussion point.
Many nurses do not understand tip location just know they should have a blood return and if they don't the repositioning of a patient and then cathflo. It seems that at my facility they have become complacent where cathflo worked and then it didn't and they are on a time schedule for administering their drugs. Maybe one dye study has been ordered but I've seen studies where there is no blood return, no fibrin, the catheter is simply brachiocephalic and its continued to use.
My question is....if the lack of blood return is due to a catheter tip sitting high (proximal SVC or brachiocephalic) or I guess for any reason - fibrin sheath. When should a dye study be performed again if its continued to be used.
Maybe I didn't explain this correctly. If cathflo is used and successful and then the patient is seen again in 5 weeks and cathflo is needed again without success and a dye study is performed and no fibrin is discovered. At what point do you continue to use cathflo and have dye studies repeated?
I'm presenting on this to our oncology nurses soon and I know this is going to be a question I receive.
Please read the INS Standard on CVAD Malposition. You are thinking only of fibrin sheath as the cause of no blood return. The list of causes is much longer. Worse case scenario is for a CVAD tip eroding through the vein wall, completely! This will mean you will be infusing into the chest, mediastinum, pleura, or artery. Blood return is critical. If the tip is properly located in the lower third of the SVC to CAJ has much less risk of vessel erosion and lack of blood return co9uld be fibrin sheath. Suboptimal tip location must be considered, brought to the attention of the LIPs and fixed. Nurses who give any IV meds through any CVAD are held accountable to knowing this information. 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