Vascular Access Devices

lmatey

Welcome to the ONS Hot Topic Chat Series! Today's chat with Dawn Camp-Sorrell will begin at 8:30 AM ET. Thank you for waiting for us to begin! Once the chat begins and Dawn is introduced, you will have the opportunity to post your questions. To do so, direct your cursor to the entry bar located at the bottom of the chat window, type your question and click on the SEND button. We will begin shortly!

lmatey

Welcome to the ONS Hot Topic Chats! Today’s expert is Dawn Camp-Sorrell, who will be talking with us about access devices. Welcome Dawn!

dcampsorrell

Hello! I’m Dawn. Glad to have you here. I look forward to chatting about VADs.

dcampsorrell

Ask your burning question?

joyk

When drawing blood cultures from a central catheter, what do you recommend for disinfecting the port?

dcampsorrell

No scientific basis . CDC recommends chloroheexidine for accessing.

ka

Many ports seem to develop a one way occlusion, they flush well but do not have a blood return. Do you have a recommended protocol for when to do a port study?

katrinka

[b]I have another question about cultures from a central line. Do you culture the first blood drawn? or do you waste a spec before culturing?

joyk

How long should the chorhexidine dry before connecting the syringe

dcampsorrell

Great questioning-will answer in order

dcampsorrell

RE: occlusion: No evidence base. If declot procedure does not work. go for catheter gram

dcampsorrell

blood cultures: no evidence. some do, some don't .Theory is if you waste you will waste the organism.

joyk

One last question on cultures: if you draw from 2 ports, and one grows bacteria, the other doesn't, does that suggest surface contamination or a colonized line?

katrinka

[b]If you are having trouble with blood return, Do you try to declot first? or get a catheter gram before instilling med?

ascoli204

How long should a patient remain supine after any central line has been removed?

lmatey

Dawn is having trouble sending but I will answer her questions relayed to me- RE: chorhexidine: Solution should dry minimum 30 seconds before access.

lmatey

RE: Cultures question: Dawn says depends on the organism - it depends on what is growing in it

ka

I have a patient who developed a small amount of swelling at the supraclaviclular notch after accessing her port infusing some saline.No blood return. She had been successfully declotted 2 weeks prior. She complained of pain and pressure in her right neck area (the side of her port) The catheter gram was negative. We proceeded with premeds and she complained again. An angiogram was done and it was normal as well. I am completely puzzled.

lmatey

RE: having trouble with blood return: Dawn says try to declot first.

cbailey

Our hospital is trying to implement strict sterile technique, which includes mask, gowns, and surgical head covering to insert a needle into a port. We use clean technique. What are other hospitals doing?

joyk

Our large teaching hospital uses clean technique

lmatey

RE: pt. remaining supine: Dawns says there is no evidence base: clinical experience says approximately 30 minutes

ascoli204

Our VIR says they let them up immediately to decrease the pressure so as not to rupture the clot, any thoughts?

lmatey

RE: pt. with swelling: Dawns says do ultrasound of anterior chest, it sounds clinically like there is a clot in the superior veins

lmatey

RE: technique question: Dawn says procedures vary - no evidence base - no studies - aseptic technique is the most cost effective but there is nothing to say that it is better or worse

ka

A CT angiogram was done. Wouldn't that show a clot in the superior veins?

lmatey

RE: letting pt up immediately: Dawn says she has no thoughts on that since there is no evidence that she is aware of to support that

dcampsorrell

RE: pt w/swelling: clearly with this patient there is a problem. If they are experiencing symptoms. Would proceed with US ( ultrasound) and consider removal.

joyk

I get conflicting answers about pressure exerted on CVC when connecting syringes of different size. Our policy calls for no smaller than 10 cc. Would a 5 cc syringe actually draw with more force or just push with more force? And what about directly connecting a vacutainer and inserting blood collection tubes at the port?

dcampsorrell

In vitro studies show syringes less than 5ml places pressure on the catheter both push and pull.

ascoli204

INS says to clean the central line site before removing the catheter and to apply antibiotic ointment after removal. VIR objects to that as well. Do you have evidence to support that as well?

colleen

good morning...what is your institution's policy for dressing and cap changes for triple lumen and phereses catheters? Do you recommend only a transparency dressing?

dcampsorrell

No scientific basis for directly connect with vacutainer.

cbailey

It seems there is a growing concern regarding hospital acquired infections, while inserting picc lines we are being asked to use a sterile drape to cover the patient and masking the patient as well. Any evidence to support doing this?

dcampsorrell

No scientific basis for applying ointment after removal

lmatey

Great questions! Dawn will answer in order - thanks!

dcampsorrell

Recommend to change caps every week or when soiled. If you use multiple times, change.

dcampsorrell

Transparent dressing great. Change every week or when begins to pull up. No data on which is best gauze vs transparent

dcampsorrell

answering

dcampsorrell

RE: sterile picc insertions:Yes, their is data to support sterile procedure with all VAD insertions! It’s a must.

dcampsorrell

Great questions! Keep them coming.

lmatey

What do you recommend as flushing standards?

dcampsorrell

No scientific basis. No evidence base to date In general: Peripheral IVs 1 to 3 ml NS every 8, 12 or 24 hours Short term central: Heparin 100u/ml, 3 ml every day PICC: Heparin 10 to 100u/ml 3ml every day to every 3 days Tunneled: 100u/ml 3ml every day to every 3 days, 5ml three times a week, 5ml every week Groshong use 5 to 10 ml NS. Will not hurt the catheter to use heparin Ports: Heparin 100u/ml 5 ml every 4 to 8 weeks Pheresis: Heparin 1000 to 5000 u/ml 1 to 2ml/day

joyk

Any evidence on saline lock v hep lock for CVC? We have some pts w/heparin allergies or HIT.

dcampsorrell

No evidence for long-term VADs. Tons on short-term peripheral. If allergic go for the NS and consider ASA or coumadin.

lmatey

Please answer this controversial question! Use or not use a CVC without blood return?

dcampsorrell

RE: VAD use without blood return: No evidence basis Begin with repositioning the patient. Flush with NS. Replace huber needle if a port. Receive order for thrombolytic therapy. If no results after instilling thrombolytic therapy, proceed with radiographic techniques

dcampsorrell

Remember heparin allergies are rare. Heparin only prevents clots not dissolve them

dcampsorrell

Tell me about some difficult patients you have had?

dcampsorrell

For instance, I have a patient that actually heard bubbles with flushing. Guess what? the tip was in the jugular!

joyk

I've had several say they can taste the saline when flushing. Is that possible?

ka

When trying to declot a port, is possible to leave the thrombolytic agent in overnite and have the patient return the next day?

colleen

When drawing blood cultures from CVC what do you use to clean the cap? Do you waste before obtaining specimen?

dcampsorrell

RE: tasting saline:Have several that taste saline with flushing. Anything is possible. Nothing in the literature

dcampsorrell

Answering

dcampsorrell

RE: thrombolytic overnight: There is nothing in lit about leaving in over nite. However it is safe.

katrinka

I also have had several patients tell me they can feel the saline going in. This is after a positive blood return was obtained

dcampsorrell

RE: Drawing blood cultures: clean with chlorohexidine. CDC recommends all cleaning with this solution

dcampsorrell

RE: Blood cultures wasting: No evidence base for wasting. Yet, if you waste you may be wasting bacteria.

dcampsorrell

answering

joyk

Our physicians are quick to pull a line after a positive blood culture. Is that the recommended response?

cbailey

I have a port right now that I have used Cathflo on 2 times and it remains difficult to push, with occasional blood return. Dye studies confirm it is in place and patent. I can use a pump to push saline through at 700ml and but when pushing saline though it is difficult, Any suggestions?

dcampsorrell

Can you feel saline going in? Sure, its possible

lhmatey

Great questions! Answering in order

dcampsorrell

Answering

dcampsorrell

MDs quick about pulling line after pos BC. Depends on the organism. If staph, would try to give antibitics initially. If not better in 24 hours, pull.

dcampsorrell

Difficult catheter:If you have to use a pump to infuse, don't use. The problem could be inside the catheter for which you can't see.

dcampsorrell

Great question!

lhmatey

Dawn, what do you do if you have a port extravasation?

dcampsorrell

NO evidence base Stop the infusion. Aspirate residual drug. Estimate amount of drug extravasated, give antidote if indicated. Deaccess port. Apply cold or heat as indicated. Notify physician.

joyk

Do you know of any review article that summarizes research on the topics we've discussed so I can obtain references to buttress my suggestions for change?

dcampsorrell

Thinking

colleen

Any thoughts about allowing a lay family member to disconnect a 5FU infusion, flush and d'access a PAC at home (with some instruction prior)?

dcampsorrell

RE: literature: I would refer you to the ONS guidelines. Lit has been slow the last few years except with the power ports

dcampsorrell

Disconnect by family: If I trust the family, see them demonstrate, and have no other choice, Yes, I would proceed.

dcampsorrell

Great questions!

lhmatey

Dawn, can you leave ports accessed for more than one day?

ka

With regards to ports, Have you found less problems with power ports vs. regular ports?? What is the lit you are referring to with power ports

dcampsorrell

RE: Access more than one day:Yes, Make sure port is secure and isn't moving. Establish patency frequently.

dcampsorrell

Power ports: Purpose was to give contrast dye for CT scans, etc. The lit speaks to this, not of clots or infections.

cbailey

We did allow a family to disconnect 5fu pump during the holidays last year, it went well..Thanksgiving vacation we were closed. But they had one of our staff member numbers just in case we were needed

dcampsorrell

Do a lit search under power ports and there are some info out there.

dcampsorrell

Yea! Glad it worked well to have a family to help.

lhmatey

Keep your questions coming!

colleen

great idea with providing a staff number...thanks for feedback!

dcampsorrell

You never can be too cautious these days!

cbailey

I have also heard of patients going home with Adriamycin running via cadd pump. We did not allow this in our clinic. Just didn't feel comfortable with it.

katrinka

I have used two different brands of power ports. The first one had a lot of problems with fibrin sheath build-up. Tried another brand that I much prefer. Don't know if I should mention brand names on this site. I will say that the one I didn't like was purple.

dcampsorrell

Adria at the home is always difficult. If the port is secure and has a great blood return and the patient knows sx of problems, can do. Be sure to document everything!

dcampsorrell

Power ports: There are tons of ports out there. So, one may work today and another work tomorrow. No studies to compare brand to brand.

dcampsorrell

Some ports work better in some patients than others. No one knows why

lhmatey

Hi Jaz ask your questions

dcampsorrell

It amazes me that a patient with a port less than 1 week doesn't work. Pt comes in for 1 year follow up without a port flush and works great!

colleen

at our institution our pheresis catheters (Quintons) are flushed with heparin 3,000iu with clindamycin 210mg per lumen TIW and when used in between...any evidence that this lowers r/o catherer related infections?

dcampsorrell

Pheresis cath: no evidence to date. Several antibiotics have been tried with mix results. If its working, keep doing.

cbailey

Power piccs are new to me. There are one with clamps and with this I would assume open ended and use heparin. I was told this is no longer correct.

jaz

Sorry I am late. I work in pediatrics and want to know if you routinely clamp lines when you have a positive pressure adapter on the end. I did not do this in my previous job but this institution worries that the child will bleed out if the cap comes off. Is there any evidence to support either side?

dcampsorrell

Clamps: If cath has a clamp, it should be used and the cath is open ended.

dcampsorrell

Bleeding out from cath would be difficult unless SVC or low plts, etc. No evidence to use this adapter. Wonder what has happened in past for this to be standard in your institution.

wolfe

is there any special procedure/precaution to take when accessing/using an "old" portacath. One that may not have been used for several years since chemo was completed?

dcampsorrell

It’s standard if cath is open to use heparin. If NS is working, keep using.

dcampsorrell

Old ports, Use the same procedure as with current or new ports.

ka

Has anyone used a picc line for continuous 5 Fu home infusions? (Folfox)

dcampsorrell

No evidence to use anything different with old ports.

cbailey

All the time.

dcampsorrell

PICC for home infusions are used often.

joyk

Suggestions for replacing broken clamp on cath? I had one that cracked, VIR said no way to replace without inserting whole new CVC. Whenever cap changed, blood flowed freely from port unless kelly clamp applied.

dcampsorrell

With home infusions, make sure to give pt ed and document that the pt understands potential problems and who to call.

dcampsorrell

Broken clamps can be a challenge

dcampsorrell

Any type of device could be used ie hemostats, make shift clamps until the cath is pulled after tx

cbailey

We also send home a chemo spill kit with the patient

dcampsorrell

Blood flows freely is rare unless pt has SVC or low plt or DIC. Impt to ensure covered to pevent infection

dcampsorrell

Great idea to send spill kit home!

dcampsorrell

Did I answer your question about clamps?

jaz

My question-yes

joyk

Yes, we managed w/ kelly clamp for the duration but it was awkward!

dcampsorrell

It would be difficult to change a CVC everytime.

joyk

definitely! wish they made the clamps of more durable stuff!

dcampsorrell

You never know whats coming up next with VADs

lhmatey

Dawn, one last question: can you comment on the technique used for cleaning: circular versus side-to-side method?

dcampsorrell

Methods used to clean exit sites or implantable port access sites have not been studied. Generally, a circular technique staring at the insertion site and moving outward has been used. The manufacturer of chlorhexidine recommends repeated back and forth strokes for approximately 30 seconds. This is the technique used when the manufacturer submitted for marketing approval. CDC states let solution dry then access.

lhmatey

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dcampsorrell

Thank you for attending. HOpe you come again.

katrinka

appreciate this venue!

jaz

Thanks

dcampsorrell

Thanks glad it worked for you

cbailey

thanks for the great feedback

dajrn

We are an outpatient chemotherapy clinic that is part of our hospital. We are licensed as an outpatient clinic. What are the rules for doing chemotherapy while the Provider is away, either sick or on vacation? Anyone have some legal expertise?