Did a dumb thing r/t dialysis port

[SoundofMusic]

So embarassed to even admit this here, but I am a relatively new nurse. Yesterday on our floor I was very busy, very overwhelmed and drew a blood culture out of a pt's dialysis line. She had just had a perma-cath placed the day before, and it was obviously getting infected (was red and tender to the touch). Doc ordered the culture out of the line and even asked me if it was ok to do and I apparently said yes, although I was so crazy that day I don't even remember saying it.

So, I drew the sample and then our charge caught it somehow. We heparanized the line and that was it.

But can someone fill me in, or point me to a good reference as to why we can't draw a blood culture or anything else from the dialysis line?

thanks -- feeling very stupid.

[land27]

Many units use heparin 1000units/ per ml , and draw up the amount needed to fill the volume of the catheter. 2ml or under is the average amount needed for each port. some current evidence suggest that just filling the lumens/ports of the dialysis catheter fwith NSS is adequate enough to keep the catheters from clotting. The important factor is to make sure you have enough solution to fill the volume of the lumens. 5000units/ per ml is an unecessarily high dose, and is not rotinely used in most dialysis units. Hospital units are more prone to use these higher does amounts, becasue hopital dialysis units have inferior knowledge re: dialysis comapred to for -profit dialysis systems; such as fresenius, or Davita.

Excuse me, I work for a hospital dialysis unit that is actually contracted to FMC. We use FMC Policy and Procedure....and we use heparin 5000 units/cc as our catheter fills. So I am a bit taken back by your comments regarding hospital based dialysis units comparison to dialysis giants like FMC and Davita. Infact many acute units are contracted to FMC and/or Davita because it is more economical to do so. Policy and Procedure is dictated by the contracted service provider with exceptions being noted in the legal agreement. I strongly suggest working in an acute unit prior to concluding thay have inferior knowledge. The actuality is that acute dialysis nurses must use critical thinking skills daily and have a sound understanding of hemodynamics in a very critically ill patient population.

[Aquamarine]

It seems like you really didn't make a mistake. We draw cultures in dialysis all the time from cath lines. I am not sure how to do it otherwise. We don't use "sterile" technique but "clean" technique, masks for you and the patient gloves etc.

I guess it is more detailed than I realize because I work in dialysis and it is second nature.

It would be nice if nurses in one area could do little inservices in other areas for the nurses not so tuned in.

We do cultures and give antibiotics right then and there before the results come back.

A cath isn't so hard, as long as you follow p and p. I got written up on my first nursing job for using a 3 ml syringe to put the dwell back in, that is what we use all the time now in dialysis. So I don't know what that was about.

You did okay, you learn through experience. I would look at your facility p and p, but also then look it up somewhere else, or ask someone that is in that specialty area...maybe a charge nurse in that area as everyone tneds to do things a little differently.

I am not sure where esle you would draw those cultures? as that is what we do...use the cath line. You arent going to clot a line by drawing cultures?

And yes it is thier lifeline in a sense but they do get clotted from time to time anyhow. We have patients allergic to Heparin, and they don't always clot. And when they do, we know what to do.

For most patients....We put in a dwell of heparin after the treatment according to the length of the cathedar...it will usually say on the cath line, 2.0 or 2.5ml and so you know how much heparin to instill after the treatment. We do this in dialysis with 3 ml syringes. we cap and cover the lines with gauze in our unit. The insertion is cleaned and covered with a sterile island dressing. both patient and rn masked, gloves of course. Not a sterile proceedure anymore but yrs ago it was.

When the patient comes back for his next treatment the dwell is drawn out with a 10 ml syringe from each port, and then flushed with ns using 10 ml syringes. the dressing changed and cleaned with special solutions.

If we are drawing bloods we do it after we withdraw the heparin, and before we flush the lines with normal saline, again using 10 ml syringes. You hook them up to the machine, they get thier treatment, then you flush the lines again with NS using the 10 ml syringes, and then replace the dwells with heparin using 3 ml syringes...the amount, again, should be stamped on the cath ends. We cap them off, cover with gauze and off they go until the next treatment. You teach the patients to use clean technique if ever they have to change a dressing if it should accidently get wet, I tell them to wear gloves, etc.

Infection is a huge possibility because they are immune depressed. I give them a first aid kit with tape, island dressings, gauze 4x4's, a pair of gloves and betadine packets, in case they should ever have a situation where it needs changing. I stress the risk of infection and our jobs are to educate them.The packet serves as a reminder also that it isn't to be taken lightly.

If you ever have a question just give a shout....You didn't do so bad. The MD can't get that upset. Good question and because I have been there I understand. It is a lot of details.

[Aquamarine]

Excuse me, I work for a hospital dialysis unit that is actually contracted to FMC. We use FMC Policy and Procedure....and we use heparin 5000 units/cc as our catheter fills. So I am a bit taken back by your comments regarding hospital based dialysis units comparison to dialysis giants like FMC and Davita. Infact many acute units are contracted to FMC and/or Davita because it is more economical to do so. Policy and Procedure is dictated by the contracted service provider with exceptions being noted in the legal agreement. I strongly suggest working in an acute unit prior to concluding thay have inferior knowledge. The actuality is that acute dialysis nurses must use critical thinking skills daily and have a sound understanding of hemodynamics in a very critically ill patient population.

At our unit we can't get 5000u/ml heparin anymore and use 1000/ml now and don't seem to have any issues with clotting, no more no less. We have been doing it for at least 6 months.

Who would ever say anyone has inferior knowlege? that's a bit off the wall. And I couldn't agree more that the units have excellent skills or they wouldn't be there.

[Valerie Salva, BSN, RN]

Yes, you may have messed up, but its not the end of the world.

Dialysis nurses draw blood and cultures out of the line ALL the time, so its completely possible to do so.

We just let dialysis handle it as its 'their line, not ours'.

On the pedi patients, a typical central line flush is 30 units heparin. A Dialysis cath (again, only done by them ) is 5000units heparin.

They just handle it so that we dont risk loosing the line.

You have learned a lesson, and you wont forget it now. We all make mistakes, its ok. You are learning!

Heparin packing, not flush for a dialysis cath!

And most units do use 5000u/ml heparin.

[Aquamarine]

A dialysis patients access is there life line. Without it they could die in in a few days to a week or so. Hemodialysis also requires that access to be able to handle blood flow rates up to 350-400ml/min and sustain that rate for hours at a time. So to say the least. For our patients, anything that might cause removal or damage to this access is not only another invasive procedure and all the risks that go along with them but also extended hospital stays for nosocomial line infections and delayed treatments due to clotted/damaged accesses. Most Dialysis units also use heparin 5000units/cc for locking the catheter between treatments, while reversable, it could be fatal to a head blead or surgical patient with bleading issues if a floor nurse accidently flushed those lines without first drawing a discard. I hope this has provided you with an answer to you question.

Although part of what you said is correct, it is thier lifeline, I agree. And remember, knowlege and practice...is what it takes. The nurses need to be given the knowlege then the practice, if not who is responsible for the lack of that education. I know the patient is the priority but should be to the facility also. Cath's do clot off, and they are replaced, and it happens all the time, and you try to follow policy and proceedures to prevent that but even still it happens. It isn't anything to fear, it is something to learn the details of so you can be a better more educated nurse. It is easy to learn and to know with experience, practice and attention to detail. That's all.

[Aquamarine]

A dialysis patients access is there life line. Without it they could die in in a few days to a week or so. Hemodialysis also requires that access to be able to handle blood flow rates up to 350-400ml/min and sustain that rate for hours at a time. So to say the least. For our patients, anything that might cause removal or damage to this access is not only another invasive procedure and all the risks that go along with them but also extended hospital stays for nosocomial line infections and delayed treatments due to clotted/damaged accesses. Most Dialysis units also use heparin 5000units/cc for locking the catheter between treatments, while reversable, it could be fatal to a head blead or surgical patient with bleading issues if a floor nurse accidently flushed those lines without first drawing a discard. I hope this has provided you with an answer to you question.

Why would they die if thier access clots? they go get a new access or get femoral in an emergency. No one is going to ignore a clotted access. Not everyone that skips dialysis treatments die anyhow....yes, the risk factor is there....but they don't die automatically. I have patients that refuse to come in regularly...they live to do it again. It increases mortality but they don't automatically die. And we hold heparin with a fall, or pending surgery, etc. yes, but heparin has a half life...did you know?

[soulofme]

Hospital units are more prone to use these higher does amounts, becasue hopital dialysis units have inferior knowledge re: dialysis comapred to for -profit dialysis systems; such as fresenius, or Davita.

:eek:HUH? I started out in acute and I really don't understand just why and where you got this idea. Many chronic HD staff float over to acutes. When I worked in the hospital, we did the 5,000 units but that was hospital policy...we use 1,000 units in our chronic clinic.

[dbeckner222]

Hi! I am an acute dialysis nurse and you are not the only one to have done this, I am sure. In fact, I know becasue the very same thing happened in the hospital in which I happened to be treating a patient. The reason that only dialysis nurses are to use those ports, are as stated before, it is the patient's lifeline. Sometimes, there are no other areas in which to put a catheter. This is the last location option. I have seen that happen, too. There is a proper procedure to follow when accessing these ports and if these steps are not followed, infection is a major problem as well as a clotting occurence. Infection & clotting are the top reasons for non-dialysis nurses to not use these ports.

[dbeckner222]

Some patients can not have anymore catheters placed. Their are no more veins/arteries suitable for dialysis. I have seen it happen. There are not limitless times that catheters can be removed and replaced. There is nothing worse than for a patient to hear that there is not other viable locations to place an access.

[Tish88]

The HeRO device can be used with patients with no other alternative places for a AVF or AVG.

Also, how about a leg graft, chest graft or necklace graft? Those are areas that you don't see used that often.

This would be the reason to keep the patients access patent, whether it be a catheter, fistula or graft. Access Monitoring is being looked at closing by CMS.

[traumaRUs, MSN, APRN]

I thought the HeRO graft was taken off the market? We do have thigh grafts and even trans-lumbar catheters.

Both are very dicey.

[Tish88]

No, HeRO is still available. Just had one placed in a patient.