Help me with a portacath question

[nsgnva]

I work in LTC. Several years ago a resident of mine went in the hospital for portacath placement. I went to visit her so I could observe the ICU nurses accessing and flushing, because if this resident ever needed flush/meds, I'd need to know how. The ICU nurse showed me how to access, withdraw blood to check placement, then she proceeded to administer the IV meds.When the resident returned to my facility, she never had any IV's or IV meds ordered, but required monthly flushes to keep the portacath patent.Since I was the primary nurse for this resident, it would be my responsibility to flush it every month. I trained and worked in a hospital that did not allow LPN's to work with portacaths. So I went to an RN and asked her what to do. She said our facility allowed LPN's to do this and she would be happy to give me hands on training. With this accomplished, I have flushed the portacath every month for over 2yrs. Well, I recently had problems with it and could not get a blood return, nor could I get the flush to go in. I reported this to my unit manager, and tried again the next day. Still no go! So I reported it to her again.She advised me to put a note in the MD rounds book, which I did. The MD on rounds said to make an appt. with the surgeon who put it in and see about getting it removed....seeing as how all she has received through it, for 2 years, was flushes. So I set up the appt. In the meantime, my unit had a change of managers. The new manager asked me what the appt. was all about, so I explained to her all that had transpired the past few months. She talked to me like I was an idiot. I have been a nurse longer than she has been alive, but excuse me for not having trained in portacaths until 2 years ago! She said "You NEVER aspirate blood to check for placement. There is no where for the portacath to go. It doesn't migrate anywhere, or infiltrate, so there is no need to draw back on it to look for blood in the line" Who is right? The ICU nurse at the hospital who showed me how to do it, the RN who gave me hands on training, or the new LPN manager???

[blondy2061h, MSN, RN]

We would get in trouble if we started to give chemo through ANY type of access without verifying blood return first. So at the very least, it's appropriate to check for blood return then, and certainly not doing any harm other times.

[1styearsucks]

From reading your story i am kind of curious as to why the pt. had a portacath to begin with since she was not recieving anything through it but flushes.To keep a cath patent if there is no fluids going we normally flush every day and we draw back for blood return to insure that the cath is still working as it should. Good for you for standing up for this patient!!!:yeah:If you cant flush it, then there is definitly a problem.

[GrumpyRN63, ADN, RN]

After working in oncology for nearly 20 years I must disagree w/your manager. We always aspirate for a blood return for ports they can clot off or become occluded for other reasons, you wouldn't infuse anything in it before confirming patency, and generally, if its a port that has been functioning properly and you can't get a blood return or flush it, or re-establish a blood return after alteplase, it needs to be checked for placement and patency in IR to confirm placement as it is threading through the superior venacava into the right atrium and yes can migrate . Also, I have had weird and crazy ports that are tilted and sideways and you must be assured you are in that port before each and every use, you were taught correctly by the ICU nurse ,( can't comment on the LTC RN b/c you didn't mention how she taught you), manager is WRONG, keep up with your standard of care

[mgababyko]

Your manager was the idiot, not you. Always check for blood return. Although it doesn't necessarily mean the port is malfunctioning if you don't get a blood return. You must check signs like patient discomfort while flushing and swelling around the site. Inform the MD and obtain an order for a dye study to check catheter placement. Ports can migrate or get dislodged or fractured (pinch-off syndrome). One time I reported to the MD about a port that seems occluded and the patient was complaining of pain during flushing. MD insisted TPA then OK to give chemo. But I have a gut feeling something else is wrong. Pt. went to IR and they found out it was a fractured catheter. The port had to be removed ASAP in the OR. Patient safety comes first.

[iluvivt, BSN, RN]

Just as the other posts have stated your new manager is wrong. I would definatly show her in written format that the standard of care is to verify for a brisk blood return. There was a huge lawsuit several years ago regarding this very issue. No one had documented a blood return on a patient with a very treatable Cancer receiving the vesicant Adriamycin. Unfortunately the catheter that was attached to the portal chamber was malpositioned in the pleural space. The patient had been receiving all kinds of other IV medications as well for about 6 days. The patient ultimately died from this serious complication. when they combed through the chart only the IV nurse that came to perform a weekly re-access noted a no blood return and also noted some strange chest tube drainage (looked like Adriamycin and not blood )

when a port is not in use you are correct in that it should be flushed monthly. Way to go!!!!!! now go educate that other nurse and bring the information in a written form. I will find the exact INS standard for you if you like.

[Valerie Salva, BSN, RN]

Your manager sounds like a clueless, bossy, idiot.

With every kind of central venous catheter, checking for blood return is always the first thing you do before you flush it, or give any meds through it.

I would google and try to find some documentation on accessing portacaths. You were doing things correctly. I've experienced an ignorant mgr trying to tell me how to do procedures they were clueless about, and it really makes my blood boil.

[Valerie Salva, BSN, RN]

Hey, I found some info you can print out...

"10. Checking Patency Prior to Administration

The system shall be checked for patency (blood return) prior to administration of any

fluids, medications, or blood. The needle shall be inside the portal chamber and against the

needle stop before starting the injection for infusion."

http://www.sh.lsuhsc.edu/policies/policy_manuals_via_ms_word/Nursing/P-81.pdf

A video

http://uk.youtube.com/watch?v=AdD3KSGJOHI

Another video

http://uk.youtube.com/watch?v=R5PzYHg3U-E

"42. Pull back on the plunger of the

syringe until blood comes into the

tubing. This lets you know the needle is

in the right place."

http://www.phoenixchildrens.com/emily-center/child-health-topics/handouts/Port-Access-810.pdf

[LouRN92]

Please always check for blood return as well as thoroughly assessing the site. i had a patient years ago who had the needle come out of the port and had actual infiltration into the tissues around the port. She complained of pain and the blood product she received was stopped but because she was a young, fragile peds patient the amount that infiltrated caused her problems and reaccessing the site was a night mare.

[imenid37]

It sounds like you were doing things correctly. You most ceratinly do aspirate for blood. There can be infiltration if there is a compromise in the device. If there is very forceful coughing or vomiting, the port can flip and not be accessible. This is rare but can occur. I have a couple of articles at work I can point you to as a reference. Be careful about what you do as an LPN. In my state only RN's can access these types of devices. I would hate to have the facility use you to do something that you should not. You are certainly capable, but don't accept unneccessary liability. I am sorry your boss is such a jerk! It sounds like she needs to look up some references or just take her foot out of her mouth.

[nsgnva]

thank you for your response. I should've been more specific about the RN's "hands on" training.The RN at our facility told me the procedure and then stood by me and talked me through it step by step so if there were problems or questions, she'd be right there with me.

[nsgnva]

I'd like to thank all the nurses who answered my questions about portacath procedure. I give due respect to new nurses, because I trained in 1973-74,worked in a hospital for 15 years, but was limited in things I could do as an LPN, but my gut instincts told me that my much younger,much less experienced manager was wrong to tell me that you should never aspirate for blood to check placement.