what is your policy when central line won't allow blood aspiration? - page 2

I was talking to a colleague about whether or not she uses a central line port for meds if she is unable to aspirate blood. I must have grown an extra head. She looked at me like I was nuts. I was... Read More

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    Our policy is that all PICC lines and QLC have a PCXR completed and read with a MD order before use. I have freq given meds in a port that don't aspirate blood. Unless of course I have reason to believe that the postion or integrity of the line has been compromised. I will look to see what our official policy is, but have never heard other wise. It is our policy not to draw blood from periph IV's. We also use a cath declotter (the name fails me currently). However, most of our patients recieve a PCXR each morning as the are post CABG or on vents and our pulm order daily chest x rays. I ahve found that the PICC's with the "power Picc" port that the other two lumens are sluggish anyway.

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  2. 2
    Any catheter that is centrally placed (tip in SVC) should yield a blood return upon gentle aspiration of the syringe. However, if it is a PICC, that catheter should be a 4 French or greater as the 3 French's inner lumen is such that it doesn't yield a blood return very easily. Remember as well that one should use slow, gentle aspiration of the syringe barrel in order to obtain that return so the catheter doesn't collapse. If a centrally placed catheter won't yield a return try some nursing interventions such as: 1. Have the pt turn his or her head and cough. 2. As long as it isn't contraindicated, have them take a deep breath and hold it. This increase in vascular pressure will sometimes free a catheter as it sucking up the vein wall. 3. Reposition a pt. ie, if they are lying on their side, have them lie on their back. 4. Raise the arm on the side that the catheter is in.
    Failure to get a blood return from a central catheter is a real problem.
    In the case of a Triple Lumen Catheter, each lumen should yield a return as each on exits into the vascular system at a different spot. When a catheter doesn't yield a return it may have a fibrinous tail or fibrin accumulation covering the exit site of that lumen. This fibrin is a mixture of formed blood elements, immunoglobulins etc. Fibrin development is inevitable, but you don't want it there. You may be able to infuse, but negative aspiration doesn't give you a return. This fibrin is a precurser to bacterial colonization and thrombus.
    The lumen that won't yield needs Alteplase (cathflo) to be instilled in it to restore patency.

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    I asked our picc line nurse about this issue as she was placing a picc yesterday. She said she would never use a central line (picc, tlc, etc) which did not return blood. Instead she said to get an order for tpa.
    Before I asked her, I asked my preceptor and got a slightly different answer- ie- check to make sure the line hasn't pulled out, measure, the tail, etc. This is consistent with what usually happens when I ask 2 people the same question...

    I'm typically paranoid about safety, so I'll be calling for an order the next time I can't get a return after a saline flush.
  4. 0
    In my unit most of the pts are on vents and get a CXR q am. I always pull up my CXR report as well as the CXR itself. For a long time, our hospital used a contract PICC team of which I was fortunate to be a part of. we have a standing order that we can use activase to clear our ports if they do not have a blood return. I am not sure if it applies to regular CVL's though. I'll have to look. We are getting away from CVL's and using PICC's more and more though. Cheaper and less risky. Fibrin sheaths will build up if the lines are not flushed properly and regularly though. A common misconception that many nurses have is "My line is infusing so I don't need to flush it." Yea, you do. It goes a long way in helping maintain your patency.
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    I agree with Binkey. If appropriate, and an Alteplase order can be obtained, this will help dissolve the fibrin sheath. It would be nice to have the line for labs available if needed, anyway. In most cases, if the established line has been cleared for use via x-ray, it is probably only fibrin. But things happen to lines all of the time, (I work on a Bone Marrow Transplant and Oncology critical care unit, and 100% of our patients have some type of CVC, if not 2 or 3.) Bottom line- what risks are you willing to take, what is the worst possible outcome of pt. getting or not getting the drug? what do you know about the drug- is it an irritant and what will it do if it goes somewhere besides the vascular area? Many experienced RN's have years of good luck- It's how you practice- what would you do if it were a loved one in that bed? Use your judgement. Nursing is not black and white...

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