Implantable Ports And Chemo

renerian, BSN, RN · Jan 22, 2003

We did not use them if they had no blood return. Our policy was the surgeon replaced them.

renerian

caroladybelle, BSN, RN · Jan 22, 2003

I believe the official ONS policy is no blood return - no chemo.

As most chemo pts need blood draws regularly, whatever access used should have blood return, for the pts good.

The only extravesation of a vesicant I have seen was a Groshong w/ a sluggish blood return, but definite blood return, no the less. Scared the crap out of me.

Lack of a blood return in a port (especially over 6 monthes in) are frequently fibrin sheathes or sludge. If cathflo/TPA doesn't clear it, it needs to be replaced. Neither fibin, or sludgein the port are good, and pose dangers to the pt

das · Jan 23, 2003

We have Official ONS guidelines and our policies reflect those guidelines, but we all know that reality and policies can be different. It is not always an option to replace a port or use venous acces for a vesicant when they have no veins. We just have had a couple of patients who have had PICC lines and no blood return. They have had a continuous 5FU infusions and we did not pull their lines and relpace them. We had line placement verification done. By replacing every line that does not have a blood return would dramatically increase the risk of infection. Interwstingly enough, we had a patient that c/o neck pain since last Oct/Nov and had inreasing difficulty turning her head. Groshong suddenly stopped drawing blood. MRI was done and she had an abcess in her neck the surgeon feels was related to her groshong. No temps, chills, ...

caroladybelle, BSN, RN · Jan 24, 2003

Das,

If you have sludge in the port, impeding blood return, you already have major infection risk. Similar problem with fibrin. Have you ever seen ports when they have been removed. There is an unreal amount of crap in there.

I know it annoys the heck out MDs/Surgeons but the ONS regulations are based on testing and evidence for prevention of injury/infection. Ports/Groshongs/PICCs/Broviacs/etc. need to be changed if there is evidence of impairment. And lack of blood return/ that cannot be easily fixed is evidence of impairment.

Also, frequently, there are surgeons, whose ports "never' have blood return. If there is no return - s/he has not done a very good job. If they finally are forced to do it right (and after enough redos, and MDs that get tired of their pts needing to have ports redone, and stop sending the pts to these surgeons, they will have to improve their technique - It is sad that we have to force this issue. but that is the only way to do the best for our patients.

Also the rad reports should have the exact placement of the line (such as tip in the superior vena cava, etc.) If the stated placement is not proper for that specific VAD, it should not be used. The line "The tip is in the bloodstream" or "Placement confirmed" is not acceptable. The tip MUST be at the specific place for that type of VAD or it should not be used.

There are other VADs than ports, also. If ports are a specific problem, then maybe MDs should order different VAD. Also, make sure the VADs are being heparinized.

Yes, MDs get ticked when we refuse to put chemo thru a port without a return. But if it is policy, and management backs Nursing (and if they don't, well there are better jobs out there), they will learn to do the right thing. It is sad that we have to train MDs to do the right thing but we owe it to our pts and their health.

caroladybelle, BSN, RN · Jan 24, 2003

PS,

Chemo pts, because of immune system compromise, frequently show few signs of infection until horribly septic. If you have no immunity, nothing is there to cause the changes that we associate with infection. That is why the ONS feels that it is important to remove malfunctioning VADs before the sludge/bacteria collecting/fibrin gets too far.

brae · Jan 28, 2003

We have a fewof those patients. m y understanding is that fibrin forms and acts like a valve. the chemo goes in withno complication but we cant get a blood return.

onco gal · Feb 2, 2003

Although it is against ONS policies, I have seen it done after dye studies confirm placement. However, I have also had lines that draw blood very well and were out of place!

brae · Feb 2, 2003

thanks for the reply, ive been anurse for 19 years (yikes) but just started onc nursing this month. like starting over. Now i have some guidlelines. thanks

bridget

ozzie sue · Mar 9, 2003

I also have experienced a no blood return via port in the pall. setting. My client had a no blood return from day 1, after all the checks it was found to be in the right position and we continued on with pall. chemo with no problems. She really wasnt in a position to have it replaced unless protocol indicated it ie infection, not patent etc and she was not keen to go through the procedure again at any rate! We ensured that the line was heparinised on a regular basis even after chemo was completed.