Priming and blood return

Wow... First question is what does your facility's UNIT policy state on accessing central lines? That is a big concern right there. Did you have a MD's order to access the line? That is a CYA in itself. So documentation and speaking with the patient will be of great help. One of the first questions I ask a patient is, "Is there usually blood return from your port?" They know their port status very well. If they say "no," but the port is still functional, then fine. However, I don't care for the back prime because of the risk of air getting into the line by accident, still document the ease of pushing the flush and the lack of blood aspiration and waste if applicable. Remember ports are surgically implanted and should have had placement verification after it's initial placement and maybe on previous documentation, if not, speak to the MD and charge nurse/supervisor, (CYA). Any PICC lines or central lines, make sure placement verification has been completed (especially from an outside facility), the film read & dictated, has the okay per the radiologist for use, ask the MD if it is okay (put in an order) to use and chart it all! Lastly, after I became proficient with inserting IV's, I try to avoid central lines if possible. For me it is more of a patient safety issue and wanting them to stay free of central line infections. I hope gave you some help! ;o)

Wow... First question is what does your facility's UNIT policy state on accessing central lines? That is a big concern right there. Did you have a MD's order to access the line? That is a CYA in itself. So documentation and speaking with the patient will be of great help. One of the first questions I ask a patient is, "Is there usually blood return from your port?" They know their port status very well. If they say "no," but the port is still functional, then fine. However, I don't care for the back prime because of the risk of air getting into the line by accident, still document the ease of pushing the flush and the lack of blood aspiration and waste if applicable. Remember ports are surgically implanted and should have had placement verification after it's initial placement and maybe on previous documentation, if not, speak to the MD and charge nurse/supervisor, (CYA). Any PICC lines or central lines, make sure placement verification has been completed (especially from an outside facility), the film read & dictated, has the okay per the radiologist for use, ask the MD if it is okay (put in an order) to use and chart it all! Lastly, after I became proficient with inserting IV's, I try to avoid central lines if possible. For me it is more of a patient safety issue and wanting them to stay free of central line infections. I hope gave you some help! ;o)

Yes, thank you, its helpful to know that you always prime your line and don't always nee to get an order to infuse without blood return. Its interesting because at a previous hospital it was an absolute must we got blood return but as you say, pts will often tell you that they don't always get blood back. My assumption is that just because it is flushing, it doesn't mean its in the correct place. Its not as big of an issue in the ER bc we don't give chemo meds but we do access it and send pts to the floor where they could use it for any medication. (We also could give any vesicant of course)

We do not have a unit policy, we have a general central line accessing policy that doesn't address troubleshooting or blood return at all.

Do the ER nurses get signed off on this skill? In my system only the IR, IV team and chemo nurses are allowed to access a port. Other nurses don't do it enough and the risks associated with it increase (infection, infiltration, etc).

I prime the tubing rather than back prime so there's no air in the line at all. Also, some ports are locked with heparin so you should always do a waste on a patient that can't give you information on the type of port they have.

From an IR standpoint, if you can't get blood return, you should do a port dye study to assess the port. Maybe it's a fibrin sheath and tpa will do the trick or we can snag it off the tip, or maybe the port needs to be replaced. Maybe you accessed it incorrectly and you're not even in the port itself. Place an IV and use that instead in the mean time.

The national standard from the infusion standards of practice is that a central line is not used without blood return. That means that orders or not, if you do it and your patient gets hurt you are legally liable. So.. don't? Or do. Up to you.

I always prime my Huber needle and definitely I do not use the port if I cannot get blood draw. That just isn't safe. Believe it or not, I have had to alteplase a port before--only once in my life. And it worked. Sometimes it is also a positional thing. There was also a time when the patient had developed so much scar tissue above her port that we just couldn't palpate it so we got an order to get it visualized in IR.

Allow me to clarify a few things.Yes it is OK to access a port with a non-coring needle set if you are going to draw some blood and specifically if you are going for a culture to rule out the port as contributing.Of course,there is another method and that is to prime and discard the first several mls.If you access it dry you should never push any air into the port,only draw back and if you do not get a blood return you must then pull the needle out and access again so you can now flush it and assess functionality. To correct some misinformation,NO you do not need to pull back and discard any heparin that may be in the port.Ports typically are flushed with a low dose heparin of only 100 units per ml.On tunneled and nontunneled hemodialysis catheters you do as the heparin is 1000 units per ml. In the new 2016 INS guidelines there is an emphasis placed on verifying a brisk blood return consistent with the type of VAD in question on all VADS.So yes you need to verify a brisk blood return and then DOCUMENT it! If you do not get a blood return you must take action and not use the port until the issue is resolved.If the port still flushes with ease and the patient has a history of a positive blood return the odds are it is a thrombotic occlusion. You would not necessarily go straight to a dye study as suggested.As an IV specialist I get a history of the port, how long has it been in place,has it always given a blood return,when was it last accessed and flushed and did it have a blood return then,are there any other port related problems.Then I look to verify the tip location,how long as it been since the last chest radiograph.I also note if it is a left sided or right sided port and the location from which it was tunneled as it may be a mechanical or anatomical issue causing it.It may even be related to the size and type of port and the size and type of the noncoring needle and syringe size you are using. If the CXR shows the tip in good position and I have accessed it and it feels correct as if I am in portal chamber I will go ahead and give the Cathflo x1 with a repeat dose if needed and there are no other signs and symptoms of any other complications.If after all that I still do not get a blood return then I call the provider back and see what they want to do.Yes sometimes I have used a port without a blood return after I have done all this and documemted it all .It is usually a left sided approach that I have found to be more problematic.Also if a port has never given a good blood return from the start it never will! Forgive no paragraphs..my phone kept removing them.