I know that every standard of practice insists that blood return be accomplished when accessing an infusa-port and before any chemotherapy can be given. However, if a patient started not having blood return, cath-flo was tried with no success, had a port-a-gram that shows the port is in the correct place, insurance will not pay for another port to be placed....what is the next step? Peripheral IV's are non-existent.
The bottom line is that no VAD of any kind should be used for infusion, especially dangerous cehmotherapy drug, vesicants, irritants, etc without being able to draw a blood return from the catheter. There is a problem somewhere. Tests have not shown where this problem is located but it is still present. This puts the patient at risk of serious complications including pinch off syndrome that produces catheter fracture and embolism, and extravasation, thrombosis, being the main ones. I think you need to continue advocating for this patient to get the appropriate care that is needed. But there is absolutely no possible way that I would use an implanted port for chemotherapy without seeing a blood return that is the color and consistency of whole blood before, during, and after each infusion. The risk for the patient are simply too great. Does the patient and family truly understand the risk of the situation? It sounds like everyone is throwing up their hands and saying we can't help. Not only is the patient at risk of serious complications, you, all staff, and the facility where you work are at risk of a lawsuit if these complications occur. What is the plan of care? How many more courses of chemo? This is a malfunctioning implanted port that should not be used,. Does this port function vary based on the patient arm/shoulder portion? Suspect pinch off syrndrome if the insertion site is thru the subclavian vein. Does it behave differently with a different position of the patient's head? Suspect a kink if the catheter was inserted through the IJ. I can't tell you about the reimbursement aspect of it, but I do know that this would not be an adequate defense if a lawsuit is filed due to a serious complication. 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
This was not a common issue but definately not unheard of when I worked in Outpatient Infusion/Oncology.
The issue is that in the real world there sometimes are no good answers. Text book answer would be to not use the port and replace it. If the insurance won't pay and the patient does not have the money then PICC or tunneled catheter right? Sometimes those are also not an option.
I had a chemo patient who loved to still be active and one of her serious hobbies (she taught and semi-seriously competed) required her to wear someone revealing outfits. Any other type of vascular access device available would have seriously damaged her self perception and ability to perform her normal activities, activities that were extremely important to her.
She had the worst port that rarely drew blood but we could not get it replaced (same issue as the OP), studies were unable to find issues, CathFlo didn't do much.
We educated the patient on the risks of using a port that did not draw, we documented that education, the physician spoke with her, and we had her sign a consent. We thought that the best option for this patient was to empower her to take control of her life and of her care and make an educated decision of what she thought was an acceptable level of risk.
Asystole RN, BSN, CRNI, VA-BC
Vascular Access Nurse, Infusion Nurse
I agree wholeheartedly with Lynn. If we have no blood return in any vascular access device we would not administer chemotherapy. If peripheral access is challenging, we feed, and hydrant the pt PO, and warm them with blankets. We always find a suitable space. I have also used a small metacarpal vein with. 24ga to administer a non vesicant/non irritant chemo. We would delay chemotherapy. Fortunately I live in Ontario, Canada where we don't have the issue of insurance companies affecting this type of care. ( We do have other issues though)
K. McDonald RN