Port-a-cath question

  1. I guess I have really only seen port-a-cath's placed on the chest, not accessed. I was precepting another nurse the other day and we had a patient that had a port-a-cath already accessed with a huber needle in place (I have never seen this) and we needed to do a blood draw for sodium levels. It is a care home so my preceptor donned mask but not sterile gloves. She swabbed the hub (single lumen) flushed first with 10 mls NS, wasted 10 mls, pulled sample, and then flushed with 10 mls NS again, and 5 mls heparin, push pause but I don't believe she did the positive pressure clamp thing at the end. Then, she said every time they do this draw..every day or more freqently, they change the hubcap on this single lumen extension set. Every 7 days a nurse comes from the outside and does the dressing change.

    I've been researching best practice on this and was wondering if you could help me out with proper procedure. Would you really open this system every day to change hubcaps without even having sterile gloves on? Maybe I am way off base as like I said I have zero familiarity here but seems like a great, unnecessary way to introduce infection. In fact, after researching the patient chart, I found that this patient had a recent catheter infection (e-coli). Please help a dumb new grad, LOL
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    About Curious1alwys, BSN, RN

    Joined: May '04; Posts: 1,242; Likes: 287


  3. by   kids
    I'll defer to others with regard to sterile gloves because I've worked under policies that differed. I will say though that the cap should be removed before drawing blood and replaced with a new, sterile one, afterward.
  4. by   Asystole RN
    Your facility should have policies on this, unfortunately policies tend to differ on this subject.

    The theory behind changing the hub after drawing blood is to ensure that there is no residual blood left in the hub. Hubs tend to have nooks and crannies where blood stagnates and clots. Blood clots make nice homes for bacteria, providing nutrients and even protection from antibiotics and WBCs. Bacteria tend to burrow into these clots and grow. This is the reason why infection is a primary concern after using Cathflo on an occluded central line.

    You want to eliminate thrombosis not necessarily to retain catheter patency but to prevent CLABSIs. My facility utilizes hubs with a clear plastic so that we can visually inspect the hub to ensure no blood was left in the hub.

    BTW, you need to identify your particular hub type to determine if and when you clamp the catheter.

    Edit: Anytime you remove the hub it really should be sterile procedure. Why bother with a mask if you are only going to introduce bacteria with your fingers?
    Last edit by Asystole RN on May 21, '12
  5. by   Anna Flaxis
    I think I get what you're asking.

    Blood should be drawn from the line without the cap, not through the cap. It sounds like they're drawing through the cap, then replacing it with a new one.

    When I draw through any kind of CVC, I first wash my hands with soap and water, don clean gloves, lay out all my supplies on a clean surface, priming my new cap/extension set with NS. I remove the old cap from the line, flush with 10cc NS, then using the same syringe, draw my waste. Then I quickly attach a new syringe, draw the sample, and quickly attach the new cap/extension set and flush. The blood gets tubed AFTER the line is capped.

    Masking and sterile gloves are not necessary. Clean gloves, a clean working surface, and preventing contact of the business ends of the line, the caps, the flushes, etc. are all that are required. The gloves are to protect ME from the patient's blood, not to protect the patient from infection. Preventing all of the connecting parts from touching anything and minimizing the amount of time the line is open to air is how infection is prevented.

    Under normal circumstances, cap changes are done weekly, although if the person is getting daily blood draws, I would probably just go ahead and change the cap too, because you're already opening up the line, and I don't know for sure that the end of the old cap has remained sterile during the whole procedure.

    For accessing ports and doing dressing changes, you use a mask and sterile gloves/sterile technique.

    At least, this is the P&P at my place of employment.
    Last edit by Anna Flaxis on May 22, '12
  6. by   wooh
    Why should blood draws be done without the cap instead of through? (Never heard or seen that, so super curious!!) Should the flush immediately after the draw be without or through cap?
  7. by   Asystole RN
    The hubs were made to instill AND withdraw fluid for a reason...

    You want to limit the exposure of your patient to infection as much as possible and opening a closed system for an extended period of time may not be the best practice. Remember, when removing the hubs from any type of CVC you not only expose your patient to infection but also to air emboli. You want to preserve and protect any type of line but especially implanted ports. If a PICC becomes infected you can simply pull the line, not so easy with a port.

    CLABSIs are extremely expensive in terms of financial cost AND patient outcomes.
  8. by   ShantheRN
    The only time you should be accessing directly to the hub would be during cap changes....and that's only if you have issues with flushing through a cap, or your line is to be hooked direct. I'm baffled at the thought of doing cap changes after every lab draw. That doesn't make sense to me at all. On my floor, that would mean 3 cap changes a day for some patients.

    Clean gloves are fine for lab draws. Depending on the facility, cap changes can be sterile or clean. I'm in peds and all of ours are sterile. Same with dressing changes and accesses. However I did my role transition in the adult world and even with onc patients, cap changes were just clean technique. Policy seems to vary from facility to facility. Is this an adult patient, I'm guessing? 10ml seems like a lot for waste...but again, I'm used to the little crowd
  9. by   Curious1alwys
    Thank you all, but I think I am more confused than ever LOL! This is an adult patient.

    Hub changes...ok, get it that sterility might have been compromised with the blood draws so go ahead and change out every draw but if you scrub the hub for 30 seconds with an alcohol wipe and then do your business and finish with a heparin flush push pause, isn't that good enough for preventing stasis of blood in the hub? Additionally, they don't change the hubs every blood draw in the hospital, protocol was every so many days I thought (can't remember- 3 days maybe?) Why would this be different in the home environment?

    My main question is....isn't protocol for a port-a-cath and care the exact same as for other central lines, except for needle access? I've been searching all over for "blood draws and port-a-cath" and "hub change after blood draws central line" and I am finding all kinds of conflicting info. I wanted to go back to work totally prepared and knowing what to do!

    Also...do you flush with 10 ml THEN waste 10 ml? I don't get this whole concept since you are pulling back mostly the 10 ml of NS you just flushed in, not so much the patient's blood. Wouldn't you pull, waste first, then flush, then get your sample?
    I wish I had a picture for you all. I'll be sure to pay closer attention this week and also find out the type of hub used. Would be great if I could see the nurse coming for the dressing change but don't think I'll be there then..
  10. by   Curious1alwys
    No policies, it is a small group home....if there are policies I have yet to see them....that is why I was looking to find some reputable information on this so I could print it and post it for the other new grads that work there.....
  11. by   Double-Helix
    Red flag if you haven't seen the policies. Ask your supervisor where they are located and read them. Anytime you are working for an institution that provides medical care, there needs to be facility policies that dictate your practice. Policies are what give you guidance in these situations and what covers your butt if something adverse were to happen. If there are truly no policies at this place, then I would find another place to work- very quickly. You're setting yourself up to be sued if your performing skills without a policy that dictates your practice.

    Yes, you flush before you waste. Remember that you instilled heparin into the line with your last access. So even if you waste more than 5mLs, you're likely to have heparin still in the line when you draw your sample. Flushing first ensures that the line is still patent and removes any medication/old blood that was sitting in the line and could contaminate your sample. (In the hospital setting, imagine that you have D5 running through the line, and you need to draw labs that includes glucose. If you don't flush first to remove the D5 from the line, you could end up with a glucose level that's inaccurately high.)

    Yes, in general, ports are central lines and are managed in the same way. Again, though, your facility's policy will really dictate this practice.

    Patients in the hospital usually have fluids or medications going through their central lines throughout the day. They aren't hep-locked after every blood draw because there will be fluid through the line that will keep it patent and prevent any blood that might be in the cap from clotting and growing bacteria. Depending on what is instilled through the line will help dictate when you change the cap. For example, our lines get new caps when we have infused propofol (which breads bacteria). I'm guessing that your patient is getting daily cap-changes because he is going 24 hours between accesses.

    Finally, our policy is to use clean gloves when a line is being accessed, but when the line is being opened (changing the cap) sterile gloves and mask are required.

    The only way for you to answer the question with certainty regarding how you should and should not be caring for the central line is to find your facility's policies.
  12. by   Anna Flaxis
    I'm sorry, but the more I read your questions, the more concerned I am about nurses at your facility doing anything with central lines! I don't mean to sound itchy with a "b", but I'm concerned about patient safety in a facility that has nurses expected to perform procedures that they have little to no training in, with no policies and procedures in place.
    Last edit by Anna Flaxis on May 23, '12
  13. by   Anna Flaxis
    I came back to this thread because I really don't want to sound discouraging to the OP. It's good that you're asking questions and want to do the right thing.

    Institutional policies are usually based on practice standards, such as those by the INS (Infusion Nurses Society). The INS publishes their standards of practice. The INS standards of practice publication is available for purchase on the INS website.
  14. by   Curious1alwys
    Thank you Ashley. Everything you said makes sense.

    I just started, first day, and I work for an agency not the group home. I will ask next time about official policies and procedures. She showed me books and books but I didn't find anything specific. (Now I know why all new grads want to first work for big hospitals-you can go into the computer and find everything you need!)

    It's a group home so not sure they do anything with sterile gloves. We did mask however. So I think I have the first part down....flush 10-20 cc, pull sample, flush 5 cc hep, flush 10 cc NS, all push pause. As far as hub caps, this line is being accessed every AM for a blood draw, sometimes more frequent within 24 hrs. The line is definitely being opened as we are pulling off the hub and putting a new one on. Even the hub was equipment I hadn't seen and we had a very tough time getting the hub off for some reason. So I need to investigate equipment, look for P&P. I'll look through my nursing textbooks for written material as well.

    As far as concern for where I work, I can't make that call yet. I understand your concern, however. I've only been there one day and I need to see more of what is going on, ask more questions. Of course, I'll re-evaluate. As a new grad, I am happy to even have a job, especially one that works with my schedule!

    Thank you all for your help!