Restoring Patency to Central Venous Access Devices

With Cindy Winfield, RN, MN, CON(C) and Tayreez Mushani

2010-04-30 09:05:38 Stephanie@ONS Welcome to the ONS Virtual Journal Club! Today we will be discussing Restoring Patency to Central Venous Access Devices with Cindy Winfield, RN,MN, CON(C) and Tayreez Mushani RN, MN, CON(C). Please ask your questions to our authors.
2010-04-30 09:06:59 Stephanie@ONS What is the clinical problem that is addressed in the article?
2010-04-30 09:07:50 mshell Where can the article be found?
2010-04-30 09:09:02 cwinfield We had learned that a number of oncology centres were defaulting to removing CVCs as a result of loss of patency due to blood clots. We therefore convened with a group of oncology educators from across Canada to get a more complete sense of the problem and propose a solution through the development of recommendations for declotting central venous catheters.
2010-04-30 09:10:07 Stephanie@ONS How did you collect the evidence about the problem of de-clotting?
2010-04-30 09:11:37 tayreez We looked at the research done on the safety and efficacy on the use of tPA for declotting central lines. The COOL-1 & COOL-2 trials were foundational to the paper.
2010-04-30 09:11:52 Stephanie@ONS Do any of you have questions about the article for our authors?
2010-04-30 09:12:34 mshell I am trying to locate the article.
2010-04-30 09:13:30 Stephanie@ONS You can find it at this link http://ons.org/Publications/VJC/Dates
2010-04-30 09:13:38 mshell thank you
2010-04-30 09:14:11 tayreez Can anyone comment on whether the administration of tPA to declot a central line is a specialized nursing competency in their facility?
2010-04-30 09:15:32 Stephanie@ONS Welcome to the Virtual Journal Club Debra!
2010-04-30 09:15:58 Debra Thank you- good to be here.
2010-04-30 09:16:10 cwinfield At the time of developing our recommendations, there was consensus amoung the educators that adminitistration of Cathflo should be a specialized compentency requiring organizational certification.
2010-04-30 09:18:23 shericombs Our institution is in the process of changing some protocols according to ONS guidelines. We now use Cathflo on all CVADs when a blood return is not present. After a 2 hr dwell time, we are still having patients with no blood return, but flush without difficulty or pain noted. Did you find this to be common in your research? We order dye studies, but some of these patients have been getting treatment for months without problems and we don't want to order dye studies on everyone.
2010-04-30 09:21:30 tayreez Our standard was to have blood return, however, we know of situations where the line is functional without blood return. Given that the Canadian health care system is universially funded, it is easier for us to order dye studies. Our protocol indicates that a chest xray must be done prior to instilling tPA to ensure correct line placement.
2010-04-30 09:24:07 cwinfield Do your organizations require a physician's order for Cathflo or is it a standing order based on nursing assessment? This question is one we struggled with as a group and at the end of the day recommended this be an aspect of the protocol. some organizations however were looking at standing orders for RNs.
2010-04-30 09:24:46 mgruernc Has anyone left a second dose of tPA in overnight and tried blood return after that dwell time?
2010-04-30 09:25:36 mgruernc tPA requires a MD order at MDACC
2010-04-30 09:25:45 tayreez We have left the second dose overnight and have had success after that dwell time.
2010-04-30 09:26:26 mshell With a physician's order, we would instill tpa and let it dwell overnight. I don't have numbers, but we had good results with restoring blood return.
2010-04-30 09:26:33 shericombs We have a standard protocol, but I am an NP and I write the order for the RNs in our infusion clinic.
2010-04-30 09:26:57 mgruernc We have also found the second dose to be successful. We would try the second dose, before suggesting a dye study or line removal, a CXR is also warrented in some cases..
2010-04-30 09:27:51 mgruernc Has anyone moved to flushing their CVC's with just saline alone in this group?
2010-04-30 09:27:54 cwinfield At MDACC is the Cathflo instilled by nurses (eg: on the unit or in the chemo admin area) or is this skill done in Interventional Radiology?
2010-04-30 09:28:13 mgruernc Instilled by the Infusion Therapy Team
2010-04-30 09:29:34 shericombs In figure 8 of the article was the second dose admisistered on the same day?
2010-04-30 09:30:31 cwinfield Yes. In this trial the instillations were all done on the same day.
2010-04-30 09:32:40 tayreez For those working in centers without an IV team, does tPA instillation take place on the units or in interventional radiology?
2010-04-30 09:33:26 mshell I worked in a medical oncology infusion center and we did the tPA instillations.
2010-04-30 09:35:00 mgruernc I have also worked in two other instutions.. One had an infusion team to instil, the second did not and we developed a competency to validate the critical thinking and tech skill of the nurse for the procedure..
2010-04-30 09:35:49 mshell Have there been any studies on using tPA instead of heparin to lock CVADs?
2010-04-30 09:36:22 cwinfield Was competency evaluation a one time event or was it repeated on a pre-determined basis - for example, yearly.
2010-04-30 09:38:03 tayreez In response to mshell's question, we have not seen any studies on the use of tPA to lock lines. This was one of the proposals that developed as a result of this article but we were not successful in getting funding for a research project to evaluate this.
2010-04-30 09:38:22 mgruernc I only stayed a year,, but I would consider the frequency of the task... I would for sure have new staff complete it, but would have to look at how often the staff are doing it and what other competency needs to be completed..
2010-04-30 09:38:23 Debra We are part of a nine office community based oncology service. We have standing orders for the RNs to administer Cathflo. We have instilled two doses on the same day. We've also sent patients home overnight to return the next day for assessment. My biggest problem, as I'm working to update our policy, is that I've found that we have some sites who deliver cathflo treatment after treatment, over and over again without sending the patient for a dye study. At what point is the dye study warrented. They will instill the cathflo, get good results, only to have to instill again with the next visit- still get good results, and this pattern goes on and on. What is the standard? Only get a dye study when you don't get good results from cathflo? Many thanks.
2010-04-30 09:38:44 mshell thank you
2010-04-30 09:41:34 mshell Our policy was to get the dye study if no blood return after the second dose. If a patient would return 3 weeks later for the next treatment and no blood flow, we would repeat the tPA protocol.
2010-04-30 09:42:17 tayreez We were not able to identify a standard as to how many repeated instillations can take place before you send the patient for a dye study. One of the discoveries we made that was nursing technique was one of the big reasons why lines were clotting. Having said that, we also know of patients whose lines are always a problem. At some point, there would have to be an evaluation of the line and a consideration for replacement, depending on patient preference.
2010-04-30 09:42:28 Stephanie@ONS Welcome to the Virtual Journal Club Chat LBA!! We are discussing CVA de-clotting with use of cathflo. Please ask any questions you have for our authors.
2010-04-30 09:44:24 cwinfield To tag on to Tayreez's comment, we were selective in how we used a patient's central line. If they required a blood draw, this was done peripherally so the line was accessed only for infusion. What are your practices?
2010-04-30 09:47:11 shericombs We use lines for drawing blood, but follow with saline flush and heparin. Did you find any difference in flushing with 20ml saline vs. 10ml saline prior to heparin?
2010-04-30 09:48:46 mshell We used the CVAD for lab draws.
2010-04-30 09:48:51 Debra We do use our lines for blood draws and infusions. That brings me back to Tayreez's comment regarding nursing technique. We're approaching our policy update from a prevention as well as management standpoing. Our lines are truly, heavily used.
2010-04-30 09:51:02 tayreez As we were not using the lines for blood draws, the advisory board, after much discussion, recommended a minimal 20ml flush post blood transfusion. Debra, developing policy from the prevention point of view is forward looking and it will be interesting to look at the number of line complications as a result of this new policy!
2010-04-30 09:51:27 mgruernc We require a MD order to use the line for blood draws.. but if I was a patient,, I would demand my line be used for lab draws..
2010-04-30 09:54:30 cwinfield I agree with you mgruernc and our RNs would not argue with you on some levels from patient point of view. But as a strategy to lessen the potential for blood in the line and the patient and nurse demands of that complication, this is a route we took. Initially there was a lot of dis-ease with this but it did become common practice in short order.
2010-04-30 09:54:38 Debra I'd like to change our policy to include a 20mL flush vs 10mL and to directly observe to make sure the flush incorporates a push pause push pause action. Right now, most of our nurses use a 10mL flush followed by a heplock flush.
2010-04-30 09:55:08 shericombs According to our policy, we check for blood return every 30 mins, if not return or sluggish, we re-instill dose and repeat every 30 mins. From the article, it looks like after the first 30 mins, you left it for the remaining 90 mins without checking. Was that the case, and do you think leaving it alone for 90 mins makes a difference in the efficacy?
2010-04-30 09:56:41 Stephanie@ONS Our time is coming to an end. Does anyone have any last questions for our authors?
2010-04-30 09:57:17 tayreez Yes, the studies showed that the longer dwell time for the second instillation yielded better results. There are times in the clinical setting where we compromised this time due to pressures of chemo administration.
2010-04-30 09:57:40 Debra Thank you all for your input. I found the related article worthy and will help me with further policy making.
2010-04-30 09:58:10 cwinfield You are very welcome. We have enjoyed this opportunity and hope you all have a wonderful day.
2010-04-30 09:58:17 Stephanie@ONS All of the chat transcripts will be posted on the ONS website next week. Make sure to check the website for the articles and dates of future Journal Clubs.
2010-04-30 09:58:43 mshell Thank you for the chat.