I practice in a community Hospital Ambulatory Care Center performing OP Oncology Infusions for NW Oncology patients.
With ports inserted per orders of NW Oncology oncologist patients are informed that port flushing every 8 - 12 weeks is sufficient.
Hospital follows INS standards of port flushing every month preferred with ( 4 - 6 weeks range ).
I am deeply concerned with the NW Oncology protocol --
Despite attainment of linear blood return after 12 weeks; the potential for sludging of blood within the port creates a favorable environment for microbial growth and infection in these immunocompromised patients.
I am uncertain if the length of time between port irrigation contributes to fibrin sheath formation as well.
Please clarify if I am out of touch with any recent studies that validate the NW Oncology policy for port flushing.
Please read standard 28, Practice Criteria F.2- no recommendation is made for a time interval to flush an implanted port not in use. 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
3. Maintenance and Care
Adapted with permission from Access Device Guidelines: Recommendations for Nursing Practice and Education (3rd Ed.), by D. Camp-Sorrell (Ed.), 2011, Pittsburgh, PA: Oncology Nursing Society. Copyright 2011 by ONS.
INS 2011 Infusion Nursing Standards of Practice
CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011
Also -- I believe manufacturer's recommendations are that dormant ports are to be flushed every 4 weeks...
Every hospital I have ever worked has IV policies indicating to flush dormant port every 4 weeks--- where did that parameter come from?
2011 documents are very old. 2016 INS Standards are now the one to use and it does not state a time for accessing and flushing implanted ports. Studies have taken this out to more than 200 days and research has not arrrived at a firm recommendation yet. The original 4 weeks came from manufacturers instructions based on their knowledge of the catheter.
Also saline or heparin can be used for locking implanted ports - based on European studies, also in 2016 INS Standards. 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 Lynn -- I knew you would know about this.
Regarding a saline flush of port -- does this pertain to an open-ended port catheter (not a "valved" port )? Do they make "valved" ports?
I have been away from specialization in Vascular Access about 5 years and have transitioned back into Oncology with attainment of OCN.
But, I had such an excellent experience in VAS that I am always cognizant of the nuances that vascular access presents to the clinical situation.
Friday I accessed an oncology patient's port after 12 weeks since last heparin flush: initial return was quite unusual -- brownish tint to a liquid (pre-existing heparin?) then gelatinous blood and strands of clots.
I pulled back at least 10 ml x2 before even obtaining ordered labs. Then flushed x3 with 10 ml NS and Heparinized and de-accessed.
I assumed that I was pulling back the sludge hugging the wall of the port (substantiating the reason for the push-pause-push-pause method of flushing VS linear flow of NS) --
The whole situation unnerved me regarding length of time allowed between flushes --- so I thought I would ask about current practices & recommendations.
Yes implanted ports are made with and without intergral valves in the stem of the port body (PASV, Angiodynamics) and Groshong (Bard Access) at the catheter's internal tip. Research now shows no difference when locking with saline vs heparin. This step is definitely about locking and not flushing. What you saw may or may not support the use of push-pause flushing technique as there are no clinical studies about that practice yet. There are 2 lab studies showing that this technique flushes a greater amount of protein from the catheter lumen. This method does no harm and may do some good but we don't have the concrete clinical answer yet. Lab studies are able to control for many more variables than a clinical study can. The monthly flush/lock procedure recommended by manufacturers from the beginning of this device is not supported by clinical evidence and the 2016 INS Standards do not recommend a specific interval. 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
My suspicion is that monthly is easier for everyone to remember. These are the results from a study published in 2005: http://www.ncbi.nlm.nih.gov/pubmed/16305984
A total of 73 patients were included in the study. Compliance with visits for PAC maintenance varied considerably with the individual median accession times varying between 28 and 262 days with an overall median of 42 days. The individual means ranged from 29.5 to 244 days with an overall mean of 53.6 days. Seven patients in the group had episodes where the provider was unable to draw blood from the port during routine accession. The average intervals between accessions for each of these patients ranged from 38 to 244 days. The average intervals of accession among those patients who had no blood return during PAC accession was 79 days, versus 63 days for those without any difficulty. The difference was not statistically significant (p>0.05). Monthly maintenance of PAC is excessive, inconvenient for the patients, and expensive.
I have found that the propensity to clot in the oncology population seems very individual. Some patients seem to need alteplase each time they arrive; others, no fibrin or clotting issues at all. When a patient has just ONE experience with needing alteplase, some become very skittish and quite consistent in their desire to have it flushed sooner rather than later. I have one other study that was sent to me by a colleague and it had similar results to the one I cited. If I obtain her permission, I will also share it.