Research Aims

Method

Background

Results

Conclusions

• Sixteen articles met inclusion criteria

•Fifteen articles were selected for review

•Articles provided evidence supporting

establishing blood return during monthly port

flush

•Search of WaveNet revealed an established

policy, providing an assessment tool and

subsequent interventions in the setting of an

occluded CVAD

We had four overall research aims:

1. To determine the necessity of obtaining

blood return during monthly implanted port

flushes for patients with non-utilized ports

2. To determine appropriate assessment

criteria

3. To identify causes of central venous

access device (CVAD) occlusion.

4. To state complications caused by CVAD

occlusions

Implications For Practice

Gloria B. Ascoli, RN, CRNI, Amy C. Brown, BSN, RN, Jessica L. Cooper, BSN, RN, Allison N. Crawford, BSN, RN, CRNI

Is it Necessary to Verify Blood Return in Monthly Port Flushes?

Data Bases:

Google Scholar, CINHAL, and PubMed

Keywords:

Monthly flush, blood return, fibrin sheath, implanted port, withdrawal occlusion

Inclusion Criteria:

Adult population, implanted port, malfunctioning port, recommendations for treatment

• It is necessary to establish blood return during a routine monthly port flush 1

• Assessment includes multiple pathways for determining causes of occlusion (see chart 1)

2

• Major causes of occlusion include mechanical, non-thrombotic, and thrombotic(see chart 2)

3

• Major complications include infection, infiltration, etc. (see chart 3) 4

A literature search was conducted to

accomplish the research aims:

Infusion Nurses Society (INS) archives and

our internal policies (Sentara WaveNet) were

also searched

•Nurses in our outpatient infusion center see patients

with implanted ports requiring routine monthly

flushes for maintenance only

•Nurses were often encountering partial withdrawal

occlusions from implanted ports during routine monthly

port flushes

•Partial withdrawal occlusion – the ability to flush

easily but inability to aspirate blood

•Nurses questioned the necessity of a thrombolytic

agent to establish blood return when no therapy was

ordered

• Blood return must be verified prior to any therapy

via an implanted port, including monthly port flushes

•“Thorough assessment of the patient and the CVAD

for the potential cause of an occlusion will be

performed, and the appropriate intervention will be

performed to restore catheter patency (INS, 96)”

• Nurses should be educated about the importance

of the ability to aspirate blood from a CVAD prior to

use

Complete (unable to flush or

aspirate blood)

Contact Interventional Radiology to

assess

Partial (negative blood aspiration)

Assess for external mechanical causes

Assess for non thrombotic causes

Assess for thrombotic causes

Per protocol, instill catheter clearance

agent

Positive blood return, proceed

with catheter use

Complete occlusion (unable

to flush or aspirate blood)

Partial occlusion (negative blood

aspiration)

Assessment of Central Line Catheter Occlusion

Chart 1

Types of CVAD Occlusions

Chart 2

Types of central venous catheter occlusion

Mechanical

•External:

•Clamped or kinked IV tubing

•Tight suture at catheter exit site

•Non-coring needle dislodgement and misplacement

•Internal:

•Improper catheter tip placement

•Catheter kinking or compression

Non-thrombotic

•Drug precipitates

•Crystallization of total parenteral nutrition admixtures

•Drug-to-drug incompatibilities

•Drug-to-solution incompatibilities

Thrombotic

•Deposits of fibrin and blood components

•Intraluminal

•Fibrin Sheath

•Fibrin Tail

•Mural Thrombus

•Irritation from catheter rubbing against the intima of the vessel wall

•Portal Reservoir Occlusion 58% Thrombotic

42% non thrombotic

Risk for Infection

•Formation of fibrin deposits and biofilm is a natural response that can start upon catheter placement

•Attracts, encloses, and protects bacteria and other microorganisms

•Microorganisms can be released into the bloodstream causing central line associated infection

Infiltration or Extravasation

•Infiltration causes pain, discoloration, and swelling

•Extravasation is more severe, and can result in pain, edema, and tissue necrosis

Thrombosis

•A thrombus between the catheter and the cell wall can lead to complete blockage of the vein

•This can be a life-threatening condition with potential complications, such as pulmonary embolism

Delay in treatment

•Canceled or delayed procedures

• Increased length of stay (LOS)

• Interruption in administration of medications and solutions, especially vesicants

Central line occlusions compromise patient care

Complications Associated with Central Line

Occlusions

Chart 3

References

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Parenteral and Enteral Nutrition, 531-33.

Doughtery, L. (2011). Implanted ports: Benefits, challenges, and guidance for use. British Journal of Nursing, 20 (8), S12-19.

Genetech. (2014). Catheter management education. Retrieved from http://www.cathmatters.com/education/education-cvad-care.jsp

Harpel, J. (2013). Best practices for vascular resource teams. Journal of Infusion Nursing, 36(1), 46-50.

Infusion Nursing Society. (2011). Policies and procedures for infusion nursing.

Krywda, E. (1999). Predisposing factors, prevention, and management of central venous catheter occlusions. Journal of Intravenous Nursing, 22, 11.

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