Port and TPN use

SoldierNurse22, BSN, RN · Oct 11, 2015

Consistently flushing the line is really important. In an inpatient setting, we flushed with 20-30mL NS twice a day at least. Outpatient, we flushed 20-30mL each time the port was access and prior to deaccess. We also heparin locked our ports when they weren't in use. We had very few issues with this system.

iluvivt, BSN, RN · Oct 11, 2015

Yes, many of my home care patients that are TPN lifers. It is important to instruct your patients or for the RN to flush in between bags or after bags if they just infuse during the night. Whether you have a 3 in 1 or you are piggybacking lipids they tend to cause nonthrombotic occlusion problems more so than the TPN and can be treated with ethanol (70%) or sodium hydroxide (0.1 mmol/ml).⁶

^{If you are having thrombotic occlusion then Tpa is the answer. Take a history of the port to ascertain if the patient has always had a problem with obtaining a brisk blood return. I tend to find the left sided ports to be a bit more problematic. Overall if they they are flushed and cared for meticulously they have very few occlusion problems or at least ones that can't be solved!}

IVRUS, BSN, RN · Oct 12, 2015

Soldier,

I disagree with the advice of flushing BID. Namely because the times you increase your manipulation of the line, introduces a greater chance of microbial introduction. The goal, IMO, is to keep the line patent, AND decrease the manipulation at the same time. SO, as ILUVIVT states, flush the line and ascertain a brisk blood return each time you hang a new bag, which would be daily if the TPN is not cyclic.

SoldierNurse22, BSN, RN · Oct 12, 2015

Soldier,
I disagree with the advice of flushing BID. Namely because the times you increase your manipulation of the line, introduces a greater chance of microbial introduction. The goal, IMO, is to keep the line patent, AND decrease the manipulation at the same time. SO, as ILUVIVT states, flush the line and ascertain a brisk blood return each time you hang a new bag, which would be daily if the TPN is not cyclic.

I certainly understand the logic behind flushing once daily when the bag is changed. However, to increase the number of times the line is flushed by one should not significantly affect microbial load, assuming proper care is taken to disinfect the hub before flushing and before re-attaching the TPN line. This was the protocol at one of my previous places of employment where we routinely dealt with central lines galore and severely immunocompromised patients.

Asystole RN · Oct 13, 2015

Much of the home TPN use I have seen when I worked for Coram was not a continuous 24hr infusion but rather a 12 or 16 hour infusion so flushing BID was possible.

Connecting and leaving connected a secondary bag of saline for the express purpose of flushing was not unheard of either, which would eliminate the issue of manipulating the IV tubing.

IVRUS, BSN, RN · Oct 14, 2015

Well,

Research points to the importance of decreasing manipulation of the line. So, it should be something that we all are taking seriously and we should not be dismissing its importance. Decreasing the manipulation allows a primary continuous IV tubing to be changed at intervals of 72-96, whereas Primary intermittent tubing is changed q 24. Why, because all of the manipulation of hooking up, and unhooking increases the chance of introducing microbes into the vascular system. Just because, "we've always done it that way" doesn't mean practices shouldn't change with updated information.

iluvivt, BSN, RN · Nov 4, 2015

The prescription for the TPN usually dictates the flush. Many are 3 in1 preparations of just plain TPN and are infused anywhere from 8 to 16 hours. Most can be safely administered over 12h hrs giving the patient a quality of life. So for example,the patient is going to run from 2100 to 0900. They are going to check for patency with a NS flush after a NC scrub) before hooking up.do their TPN infusion and in the am disconnect scrub the NC and then flush with NS and a final flush of Heparin. So again it is before hook pp of the TPN and after you disconnect you perform an NS flush and a final flush of heparin.

If a patient is on a 24 hour infusion then is still is before and after a bag change. If for any reason they need to stop it then I instruct them to make sure they instill the heparin. Patients must also be made aware that once the infusion is complete they need to disconnect and flush it immediately and not sleep through pump alarms,go to the bathroom and load the dishwasher. Many think they have all the time in the world to flush.

IVRUS is correct in that manipulations must be kept to a minimum since most catheter-related bloodstream infections come from hub manipulation and NC manipulations and this is even more so in long term devices!

Did you understand that the occlusion can be caused by the lipid build up? The patient should also be taught how to do a proper flush because many are doing this improperly

I really like the BD posi-flush pre-filled NS since it does all the work.

bethchpn · Nov 8, 2015

Thanks for all the feedback. One question. This particular pt is an outpatient that infuses 12 hrs a day. Do you all instruct pt to pull back for blood? I have read some instructions say to just have pt saline flush and not check for blood return and the RN's will check when huber needle is changed. I think the theory is they won't flush out the blood thoroughly.

Also for occlusions do any of you have the protocol for ethanol (70%) or sodium hydroxide (0.1 mmol/ml).⁶

Asystole RN · Nov 12, 2015

Thanks for all the feedback. One question. This particular pt is an outpatient that infuses 12 hrs a day. Do you all instruct pt to pull back for blood? I have read some instructions say to just have pt saline flush and not check for blood return and the RN's will check when huber needle is changed. I think the theory is they won't flush out the blood thoroughly.
Also for occlusions do any of you have the protocol for ethanol (70%) or sodium hydroxide (0.1 mmol/ml).⁶

I have never had an outpatient or home infusion patient check for blood return.

iluvivt, BSN, RN · Nov 12, 2015

No, the home care patients should not be instructed to assess for a blood return. They should, however, report if the flush becomes sluggish. Most patients and/or caregivers get used to the feeling of a normal flush for whatever catheter type and gauge they are using and will be able to report this. The nurse that performs a weekly visit should ALWAYS check the CVAD for a blood return on all lumens as well as performing the assessment for a patient on TPN such as,checking the patient's weight gain, blood sugar level readings, checking for symptoms of EFAD, and drawing labs.