Hello,
I have heard today that one of our physician wants the nurses to discard 3-5 ml of blood at each monthly flush (instead of just getting flashback and then flushing NS - then heparin) on the basis that it prevent potential flush of bacteria that would be sitting the lumen since it was not accessed for 1 month.
Has anybody come across a study that would justify such a practice?
I always try to minimize manipulations of the catheter and I feel it is probably increasing the risk as it adds a manipulation since they need to flush with 20 cc (2 syringes), then heparin after that blood "procurement".
Thanks,
France Paquet, RN, MSC
McGill University Health Center,
Montreal, Quebec, Canada
Since you are talking about monthly flushes, I am assuming you are asking about accessing and flushing an implanted port on a monthly basis. There are no studies that have reported this as a tactic to reduce the risk of CRBSI. First I would ask, why any catheter has been left in place when monthly flushing is all that is being done. When any vascular access device is no longer essential for medical management it should be removed.
Then I would ask, have you ever flushed a long term catheter such as an implanted port or tunneled catheter and had the patient experience an elevated temp, or chills following that flush? If so, this is a "shower"of bacteria that was contained inside the catheter lumen. This planktonic bacteria is what they physician is trying to remove and not flush into the patient. The older the VAD, the more likely for this bacteria to be present. This bacterial shower is documented in the literature but I am not aware of any studies suggesting what this doctor wants to do. Will it be harmful? Probably not. Will it be benefical? Possibily. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Hello Lynn,
Thanks for your reply, I'm happy you took the ime to answer my question. I notice that my subject did not show up in my topic... I was indeed talking about monthly flushing of a subcutaneous port.
To my knowledge, there are no guidelines on when to remove a subcutaneous port. Is there? How many months without using would be considered no longer needed? Many patients with chronic disease (e.g. Cystic Fibrosis) might have a good year and not need their port more than once in a year but that port will be handy the following year. For patient with recurrence of cancer, it is also tricky, when can we remove? I was under the impression that this was very patient related and that it may be difficult to have guidelines in terms of months of non utilisation.
To answer your question, I undersdand the risk of flushing a broth of planctonic bacterias and seeing the patient going into septic shock right before your eyes. Never seen it but I don't need to see it to believe that it happens. I am thinking that if this happens it is because the internal lumen of the catheter is contaminated. Right? If so, how much do I need to withdraw? By doing this, I'm bringing blood in the lumen for a longer period of time (true, seconds, not minutes - does that make a difference, I don't know), am I not contributing more to replenish the food supply of the bacterias that are sitting in there? I'm wondering because I am sure that even if I withdraw, the biofilm remains in the lumen and that bacterias will grow back.
On that basis, should we be doing that with every catheter? Some biofilms becomes mature very quickly. Will I be flushing the bacterias that have been introduced prior to my intervention?
Thanks a lot,
France
France Paquet, RN, MSC, VA-BC(TM), CVAA(c)
Clinical Practice Consultant, IV therapy and Vascular Access
Transition support office
McGill University Health Center
Montreal, Quebec, CANADA
You are correct about the lack of evidence as to when a long-term catheter should be removed. The statement in the new CDC guidelines is
"Promptly remove any intravascular catheter that is no longer essential [69–72]. Category IA"
It would be a judgment call as to when any catheter is no longer essential.
RE flushing, I am not talking about flushing that causes septic shock. I am talking about routine periodic catheter flushing procedures that produce an elevated temp and chills for a few hours then is gone. This is known as bacterial "showers" and is thought to be caused by the planktonic organisms freely floating inside the catheter lumen that have been detached from the biofilm. I would consider virtually all catheter lumens to be colonized and growing biofilm. It is the breakage of the biofilm in clumps, clusters or individual cells that then floats to the bloodstream that is thought to cause BSI.
As I said in my original message, there are no studies that have assessed withdrawal of any amount of blood from a long-term catheter or any catheter before it is flushed for this purpose. So there are no answers to your questions about the amount to withdraw. The standard of practice is to always assess for a blood return before using any catheter. I do not see any difference related to length of time between obtaining this blood return and withdrawing this blood sample. The difference would be in the additional hub manipulation with having to attach and detach more syringes to obtain that discarded volume. You are already flushing in bacteria with each use of the catheter. This bacteria then goes on to firmly adhere to the catheter wall, to fibrin or other biofilm where more biofilm grows. When it reaches a steady state, it can break and go to the bloodstream.
So, the bottom line is that withdrawing this amount of blood may not be a bad idea but there simply is no data on it - positive or negative.
Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Thank you very much!
France Paquet, RN, MSC, VA-BC(TM), CVAA(c)
Clinical Practice Consultant, IV therapy and Vascular Access
Transition support office
McGill University Health Center
Montreal, Quebec, CANADA
Lynn, I have been having our nurses withdraw and waste when accessing ports since the FDA announced that they had found a non-coring needle that was actualling coring (per their recommendation while they were studying 20 other brands). I did get updates on 2 more brands that were coring but have not heard any thing lately. Do you know if they are still recommending this technique? I routinely check their web site but have not seen any more info on this. Thanks!
Valorie Dunn,BSN, RN, CRNI, PLNC
I don't have any more information about that problem. I thought then and now that the aspiration must be immediately after accessing, and always before any flushing. And the chances of getting the cored out material to move back through the needle would be very small.
Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861