RN Scope of Practice-Theraputic Phlebotomy via port

iluvivt, BSN, RN · Jan 14, 2010

Well that is a silly rule....There are so many pts will little or no veins and it can be very challenging if not impossible at times to get that much blood!!! Our therapeutic phlebotomys (TP) volumes to be withdrawn range from 250-500ml of blood..we often have serial ones ordered as well. I usually see the serial ones ordered for our CHF pts as we usually do the Hemachromatosis pts as an outpatient and they would rather do it all in one visit. What is there reasoning??? If you are unable to withdraw the blood in a traditional way...I see no harm..again you have to look at risk vs benefit. The risk for any CVC is going to be infection,thrombosis (the bigies).occlusion,breakage and on and on..so does the benefit of having the pts iron level reduced outweigh the risks if a peripheral site can not be obtained....the answer is YES...So you select the most appopriate VAD to do the job for that particular pt..You need to look at all factors..I can list them for you if you want. That is one function of VADS..to withdraw blood. I have done it countless times when we have been unable to get a PIV access . I actually prefer to get a PIV b/c with a VAD I usually have to use 60 ml syringes to withdraw it..and you have to set up and keep that blood moving or you can clot the line off.The use of a vacutainer or blood bag that works by gravity on some CVCs can be very tempermental You can also check the IFUs for the selected VAD and yes I have used a port as on off label use to perform the TP.

RNONC3048 · Jan 14, 2010

I agree it is somewhat concerning; the problem is the use of a VAD for theraputic phlebotomy is "off label use of the device" and not approved by the manufacturers or INS...the nurse becomes totally liable for any problems. I am trying to find out if any other states have the same opinion. NH did not specifically address this until WE asked the question, trying to protect our RNs. Thank you for your imput.

iluvivt, BSN, RN · Jan 16, 2010

Yes I am aware it is an OFF Label use....BUT so are a lot of other things in Medicine...and sometimes you have to do what you have to do....if no one can easily get access into a vein to draw off the needed amt....you have to go to plan "B"..look at tit this way...IF you did not go to plan "B" and find a solution for the patient would that be negligent..well YES it would. I will check in Ca for you. I really doubt many state boards will specifically state what they think should happen here...but I can check with a national expert and get back to you..she always answers me really fast OK

RNONC3048 · Jan 20, 2010

Thank You: we are trying to gather data to ask the BON to reconsider...so far, no luck from the manufacturer.

OnePICCchick · Dec 6, 2010

Have to be very careful with off labe use....advice from a lawyer. Puts you in a precararious situation legally.

mappers · Jan 31, 2011

KY has the same rule. I don't know why.

Makes me wonder though. We had a pt with very bad ascites needing frequent taps. Our Dr. had a port placed on the side of his abdomen. We'd access the port with a huber, hook it to the same bottles we use for phlebos and drain off anywhere from 2000 -3000 cc's. It usually took a couple of hours. I wonder what our BON would think of that?

CRNI(R) · Feb 27, 2011

I would not use a port for a therapeutic phlebotomy. I rarely draw blood from a port unless I am accessing it for the prescribed therapy and only if it is for a few tubes. The port is placed for a specific therapy and is "assigned" to that therapy, so to speak. I have worked with ports for >25yrs. They are expensive and they are finite in use (approx. 2000 stick life).

I give IVIG and I tell my patients that the port is "mine" and that no one should access it but me unless there is an emergency and they know port flush protocol. I had to call the charge nurse when one of my patients went into the hospital and educate him in port care! It is scary how many nurses do not know and do not educate themselves on port-a-caths.

Hope this helps. :twocents:

amyrae76 · May 14, 2011

I work in a treatment center where we treat hemachromatosis patients, and we're able to use a patient's port for a therapeutic phlebotomy with a doctor's order. I don't think our state BON addresses this -- it's our institutional policy. (I'm in Nebraska if you need that info to take to your BON)

Incidentally, I was surprised to see one poster say she rarely draws blood from ports. Our treatment center is a well-known oncology/chemo center, and that's one of the main reasons our doctors have their patients get a port.

amy

MunoRN, RN · May 16, 2011

By itself, off label usage of equipment or medications causes absolutely no increased liability for Nurses. On any given med pass, there's a pretty good chance you are administering a medication for off-label usage. FDA approved indications and usage only applies to how the product can be advertised and marketed, not how it can be used.

phymsa · Jul 11, 2011

I have been searching and can not find any research project or review article that has addressed the question of risks/benefits of therapeutic phlebotomy via venous access devices, which kinda' surprised me. Anyone found any good evidence? From this and other nursing sites, apparently it's a pretty common practice (? without signficant complications), but is not endorsed by the INS or listed on the IFUs for ports. If anyone KNOWs of published research, please advise, and if NOT - what an incredibly valuable project this could be!

Our hospitals use PowerPorts (love 'em) but we're stuck with nursing scope of practice that does not allow high volume phlebotomy per port.

Nurse_Extern · Jul 15, 2011

Have you found anything yet?