Our current chemotherapy policy states that blood return will be checked every 4 hours during infusions of vesicant chemo. We were discussing the increased risk of CLABSI for these patients whom often are receiveing 4 different agents on each admission and are severly immunocompromised. I am interested in hearing your thoughts on reducing the frequency of this blood return check on central lines to hopefully also reduce one factor that could contribute to CLABSI (the number of times we access the line and the number of times we pull blood up into the catheter lumen). What is your policy on this?
I am not aware of any scientific evidence linking checking blood return to CRBSI or CLABSI. Additionally, I have never seen a review artilcle suggesting that this could be an increased risk. I am assuming your are talking about attaching a saline syringe and aspriating. I would agree that increased manipulation of all injection ports would increase the risk of introducing organisms. But you must think of the risk vs benefits. Also there are other ways to assess blood return. Assessing the quality of the gravity infusion is one - is it rapid and unimpeded or halting and slowed? Dropping the fluid container below the insertion site will also allow for a blood return without breaching the line in any way. The downside is removing the set from the pump. But again, a discussion among the experts on your P&T and/or Infection Prevention committees should weigh these risks vs benefits to determine the least risk with the most benefit. Every 4 hours seems excessive to me, especially if there is no patient complaints of chest discomfort and no problems with the infusion pump and the blood return was properly confirmed prior to the start of these infusions. 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
The INS position paper on peripheral site assessment talks about the frequency of assess an peripheral infusion of a vesicant. It seems to me checking an infusion every 4 hours may increase the chance of extravasation. The hospital's policy is saline lock checks are every 4 hours, running IV non-caustic agents every 2 hours and vesicants every hour. We use Mosby's web-based policies and taylor them to our facilities. in the future we will be looking into more frequent assessments.
"The Oncology Nursing Society (ONS)
10 provides very specific recommendations in relation to
intermittent infusions of vesicant medications, recommending that the site be monitored for signs
of extravasation every 5 to 10 minutes, including a check to verify blood return."
Matt Gibson RN, CRNI, VA-BC
The original question seems to be about frequency of checking blood return during vesicant continuous infusion via CVC. Oncology Nursing Society's Chemo/Bio guidelines (2009) state (p. 102):
DO NOT use a peripheral IV site for continuous vesicant administration.
Use a CVC to administer any vesicant infusion longer than 30-60 min.
Check for blood return and patency periodically, according to institutional policy
We infrequently have continuous vesicants--always with a CVC. For either vesicants or non-vesicants via CVCs, at the very least, each shift should check for blood return so the nurse knows the line is working properly and can document that. CVCs are fairly secure venous access. I might check an infusion via an implanted port a bit more frequently (q 6 or q 4 hr?) as the needle can become dislodged with ipsilateral arm movement. The two most recent extravasations (short infusions, not continuous) I am aware of were both from CVCs: one was a displaced port needle (pt was up/down to BR alot from hydration) and the other was a bariatric patient who had a Groshong placed (difficult). On this latter patient, the post-placement CXR was taken with him lying down. However, when he sat up, all the extra tissue on his chest sagged south and pulled the tip of his line up. Not sure exactly what happened, but after looking at the CXRs, if the nurse used the proximal lumen, the slit valve was half in and half out of the subclavian.