I am asking for people's position on the infusing of vesicant via both PIV and central line . Knowing what research and the standards state, what is the reality of practice. Specifically, I am asking about the pediatric population whose venous access is limited and devices are small.
First: If there is no return of blood from a PIV prior to a vesicant infusion - do you replace the PIV?
Second: If giving an intermittent or continuous vesicant through a 1.9F PICC line - do you check for a blood return? - we do not routinely check 1.9F catheters for a blood return after placement due to risk of occlusion.
Third - When giving a continuous vesicant through a central line - do you stop it to assess for a blood return? - and how often.
Fourth - Knowing that a central line should be inserted for a continuous infusion of inotropes - and knowing that you can not check for a blood return due to risk of bolus - physician refuses to place central line due medical instability of patient - how does the bedside nurse/VAS manage.
Thank you everyone for your input. We are trying our best to match the standards with reality of practice and appreciate any response.
First to ensure that you are using the most approrpiate technique, to aspirate always use a smaller syringe instead of a 10 mL size. Smaller is LESS pressure on aspriation. Always use very slow and gentle techniques to aspriate, no hard and fast pulling on syringe plunger rod.
For a short PIVC to receive a vesicant, I have seen too many lawsuits in neonates and peds about extravasation. You need to find some method to provide information about patency. A small catheter in the hand, foot or ACF of a baby is a high risk for extravasation. Does it flush easily? Can you palpate any swelling while you are flushing? Is the site totally free of all signs? Is the pump beeping any alarms? Does the baby show activity of pain or any discomfort? Can you place a tourniquet on the arm above the catheter to see if you get a blood return? If all of that does not work, I would not use the catheter for anything.
Regarding the very small PICCs, the INS SOP committee included 2 neonatal/pediatric experts and they did not raise any issues with blood return and occlusion for these catheters.
Regarding continuous infusion through a CVAD, you don't need to disconnect the infusion. Use the lowest injection port, stop the fluid flow and aspriate slowly. There is no specific amount you need to see in the tubuing. You just need to see enough in the catheter or extension leg to tell that what you aspriated is the color and consistency of whole blood. YOu do not have to aspriate enough to even reach the needleless connector.
There are no recommendations for a check at X number of hours, or any frequency or a schedule. For all continuous vesicant infusions, you would assess before you start the infusion, and then recheck when there is a clinical indication - eg pump occlusion alarms, blood backed up in tubing, etc.
If the patient is dependent on the infusate for their BP maintenance, you could not stop the infusion. But you do need to document site condition, absence of pump alarms and patient behaviour indicating pain.
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
Thank you Lynn for the response. I know that I can always count on you; so appreciative. For the most part we do utilize your recommended techniques. Your response, as well as the standards, will help us in finalizing our recommendations for practice.
I would still appreciate hearing from other institutions/practices for their management of such situations.