My multilumen central line has no blood return!!

[MyNurseIsaDude]

Hi guys,

There is a debate at my facility on what to do when a lumen has no blood return. We have a cathflo protocol that works well however we have run into the following dilema.

1. If one lumen is occluded in a multilumen device. Can you just simply use one of the other lumens? Say a patient has a triple lumen subclavian line. CXR shows tip in the SVC. 2 ports have good blood return. Should you use one of the good ports until the partially occluded port is repaired? How about for a triple lumen PICC? What if there is a fibrin sheath that goes way way way up the line?

I am getting conflicting opinions on this and I cannot find a set standard.

[IVRUS, BSN, RN]

Yes,

The other lumens can be used, but don't forget about that lumen that is without a blood return. You wouldn't want to withhold the patients IV med because of one, non-functioning lumen, but YOU do want that lumen to have Cathflo instilled in it ASAP.

Usually, when a fibrin sheath extends the entire length of the IV catheter, one may note the IV fluid or medication running back out of the injection site or exit site. In this case, then yes, the medication should be held and appropriate steps to correct or eliminate this problem should occur.

Hope this helps!

[iluvivt, BSN, RN]

Yes agree ! as long as you are not having any problems with the other lumens you can use them..it is a seperate lumen. You do however want to treat that PWO (persistant withdrawl occlusion) which is the ability to instill but not withdraw blood at all or easily or if you have a total occlusion. This is not just to restore function the pt is at an increased risk for infection if you leave it that way. Any good protocol on CVC line managment should address this but still many are not aware. You never want to label a lumen do not use and ignore the occlusion unless it is a precipitate or something you can not clear AND the line will be coming out shortly

[cxbf]

We are having the same debate at our facility and looking at our policy. Currently our policy states to use cathflo for occlusions. The question has come up - if you have multiple lumens, they all flush easily but cannot get blood return from one lumen, do you TPA it? No other problems, not sluggish, not leaking at insertion site, tip placement is correct from recent cxr, dressing and valves have been changed so no issue there. Technically not an "occlusion" plus throw into the picture that the patient is being discharged in the next day or two. Do you charge the pt to TPA a line that is being removed very soon? I understand the retrograde flow and risk of infection but does anyone know of supporting data to ALWAYS TPA a line that does not have blood return but flushes easily and has another working lumen? I am trying to look at all the data so that I can accurately present a recommendation that has supporting data either way. Thanks

[iluvivt, BSN, RN]

Yes the case you described is a persistent withdrawal occlusion (PWO) so you can easily instill but not easily withdraw or not at all. Yes, generally speaking these need to be treated. If it is happening a lot you need to look at your flushing protocols, the types of LAD you are using and the type of prefill NS you are using. There are special NS prefills on the market that are specifically made to reduce reflux into the distal end of any CVC (all kinds of course). What brand and name of NS are you using? There is a whole new technology to catheter flushing now and you need to look at the VAD as a whole unit to include the catheter the valve type and flushing procedures and flush type. The trend is going to a zero tolerance on all CVCs, So we must do all the things that help us achieve very low or non existent catheter related bloodstream infections. On occasion I will not not treat a PWO on a percutaneously placed CVC if I know for certain it is coming out tomorrow. Current literature and studies indicate the link between thrombotic occlusions (complete or partial) and an elevated risk of infection. Remember Tpa will not work for any occlusions caused by a precipitation. So always get a quick hx of what has been given...so if they were using it for Dilantin and then suddenly its occluded.odds are its a precipitate and NOT a thrombotic occlusion. There are other agents to use on some of the lipid and mineral precipitates . I suggest them as needed b/c most MDs will not know this either

[cxbf]

iluvivt - you asked what brand and name of ns are we using?

why is that? thanks

[iluvivt, BSN, RN]

There are 3 brands that I know of the prefills syringes that have a redesigned syringe - Posiflush from BD, ZR Technology Syringes from Excelsior, and Monoject Advanced from Covidien all the other NS and heparin prefills will be in a traditional syringe which causes syringe induced reflux( into distal end of the CVC)..thus your occlusion incidence can be higher. There is a modification you can use if you are not using one of these brands.

[cxbf]

Great - thanks alot I will check into what we are using. Do not think it is one of the ones you mentioned. Seems like we have too many occlusions lately even 1 to 2 days after picc insertion. Using too much cathflo if you ask me. Beginning to think some of this could be avoided if we inservice the staff on the correct flushing techique with a positive pressure valve. Have a good day and thanks again.

[iluvivt, BSN, RN]

...Tx and you are welcome...Technically It is a positive displacement valve...and yes ......instruction may help.....if you ARE NOT using one of those syringes......you should NOT empty the final flush syringe...you should leave at least 0.5ml in it..and always flush...disconnect..and then clamp (if applicable)( either the PICC or any ext set you have added on)...you never want to clamp..then disconnect from a postive diplacement valve b/c you will defeat the purpose and lose the benefit of it...get it? If you need any more instruction on the technique let me know...but check out the prefills you are using OK