Vascular Access Devices

 lmatey 

Welcome to the ONS Hot Topic Chat Series! Today’s chat with Dawn Camp-Sorrell will begin soon. Thank you for waiting for us to begin! Once the chat begins and Dawn is introduced, you will have the opportunity to post your questions. To do so, direct your cursor to the entry bar located at the bottom of the chat window, type your question and click on the SEND button. We will begin shortly!

 lmatey 

Welcome to the ONS Chat Series! Tonight's speaker is Dawn Camp-Sorrell. Welcome Dawn!

 dcampsorrell 

Welcome! Do you have any questions?

 lmatey 

Dawn, to get the ball rolling, can you give us guidance about when to use an access device without a blood return?

 dcampsorrell 

Answering

 dcampsorrell 

No evidence basis. Begin with repositioning the patient. Flush with NS. Replace huber needle if a port. Receive order for thrombolytic therapy. If no results after instilling thrombolytic therapy, proceed with radiographic techniques.

 dcampsorrell 

Hi Nettie 24. Anything interesting with your patients and VADs?

 JanePasciuti 

Access devices become dysfunctional due to fibrin clots and to drug incompatibilities that precipitate. Do you know of drugs (in chemo therapies) that have been found to be incompatible, precipitate, and make CVC's dysfunctional?

 dcampsorrell 

Interesting questions. Several come to mind like heparin and 5FU. Be safe and flush always with NS at least 10 ml between drugs.

 lmatey 

What do you use to flush a port?

 dcampsorrell 

RE flushing: No scientific basis. No evidence base to date In general: Peripheral IVs 1 to 3 ml NS every 8, 12 or 24 hours Short term central: Heparin 100u/ml, 3 ml every day PICC: Heparin 10 to 100u/ml 3ml every day to every 3 days Tunneled: 100u/ml 3ml every day to every 3 days, 5ml three times a week, 5ml every week Groshong use 5 to 10 ml NS. Will not hurt the catheter to use heparin Ports: Heparin 100u/ml 5 ml every 4 to 8 weeks Pheresis: Heparin 1000 to 5000 u/ml 1 to 2ml/day

 dcampsorrell 

What questions do you have about VADs and patient care? Do you have any interesting cases?

 dcampsorrell 

For instance, I had a patient who presented just the other day. Lost to follow up for 1 year! Her port worked perfectly! I never would have thought this to happen.

 lmatey 

What's the difference between a port and a "power port"?

 dcampsorrell 

Power ports are the latest technology developed to accept increased pressure from power injector used for CT scans, etc. Non-power ports can withstand 40 PSI whereas power ports can handle 300 PSI.

 JanePasciuti 

When using access devices, how should the IV tubing be positioned? Our practice uses one primary tubing and continues to spike consecutive bags into

 dcampsorrell 

Primary tubing should be positioned not to pull on the needle.

 dcampsorrell 

What does your practice do?

 dcampsorrell 

What types of VADs do you use in your setting?

 nettie24 

Hi Dawn, we use currently chlorhexidine and alcohol for skin antisepsis, is this also the best agent for cleaning bungs? There are some concerns that after drying off, the clorhexidine residue may be introduced into the bloodstream and can potentially create sensitivity or allergic reactions.

 dcampsorrell 

Good question! CDC recommends to use chlorhexidine and no alcohol. Solution should dry for 30 seconds. It should not be wiped off prior to access. Does that help?

 dcampsorrell 

Good for you to come on a Friday night. What type of practice are you in? I'm here to answer specific questions you may have.

 JanePasciuti 

How should the tubing be set up for chemo delivery? Can ONE tubing be used, and each bag of chemo spiked into it one after another? Or should a primary tubing be hung with Normal Saline, and each premed and chemo be attached as a separate secondary tubing? (How many tubings should practices be using to deliver a chemo regimen that involves 2 premeds and 2 chemotherapies?)

 dcampsorrell 

Answering

 dcampsorrell 

RE: tubing: There are different methods used out in the world of chemo and no evidence base. Typically, primary tubing into NS and piggyback or secondary of pre-meds and chemo into the primary line. Could be hazardous the other way. Does this answer the question?

 dcampsorrell 

What type of VADs do you use?

 dcampsorrell 

PICCs, ports, or tunnels?

 JanePasciuti 

Can you comment on the use of CathFlo? Have you seen nurses in inpatient hospital settings being able to declot CVC's with Cathflo as an independent nursing action, or do they need to turn declotting over to a separate department?

 dcampsorrell 

answering

 dcampsorrell 

Cath Flo is great! Up to 88% of VADs will declot after initial use. Most RNs do not have a license to give this order unless they have a standing order from a MD.

 nettie24 

The issue of sensitivity to chlorhexidine when cleaning bungs was raised by an anaethetist when we distributed our CVAD policy for comment across the area health service. We could not find any evidence to support this in the literature, however, my co-writer contacted a Professor in the area of Infection Control in Melbourne, who supported the view that it may be safer to use alcohol only for cleaning bungs as it evaporates. In my area of practice we use PICCs, ports, tunneled and non-tunneled CVADS

 dcampsorrell 

Answering

 dcampsorrell 

Actually, the literature speaks more sensitivity with alcohol and less activity to clean more bacteria. Out of curiosity, what is bungs? And would you happen to be from Australia?

 nettie24 

Bungs are injection caps. Yes, I'm from Australia, g'day from downunder

 dcampsorrell 

The studies from the US show longer activity against organisms with chlorohexidine that has dried for several hours. The key is letting it dry.

 dcampsorrell 

How cool is that! Jane where are you from?

 dcampsorrell 

Now that I know what bungs are, no studies have given evidence as to the best solution. In the US, the majority of institutions continue to use alcohol.

 dcampsorrell 

What type of setting are you in? Inpt or outpt?

 nettie24 

Many thanks for this feedback, we are currently establishing a CVAD working party to update all our policies, and this is very helpful.

 dcampsorrell 

Anthing else? What are you most contraversial areas in Australia?

 JanePasciuti 

Thank you for answering about IV tubing. My practice is using ONE tubing, and spikes bag after bag into it. I am concerned about learning about drug incomptibilities. I have NO IDEA if any of these chemo's precipitate against one another or NOT. However, my last job used a primary tubing with NS, and multiple secondary tubings for each bag (which was NOT cost effective), but I have not abserved any difference in outcome between the practices. I am in an outpatient practice in Virginia.

 dcampsorrell 

RE: tubing: That's concerning for safety issues!

 lhmatey 

Welcome BC85RN! Ask your burning question!

 JanePasciuti 

RE: tubing: What do you think the safety issues are?

 dcampsorrell 

I'm wondering if you should look at the OSHA guidelines and I encourage you to come to the chemo ( pharmacologic issues) chats coming up soon.

 nettie24 

I work currently as acting DON/Operations Manager for the Capital Region Cancer Service in Canberra, we have a 23 bed inpatient are with 6 beds for acute haematology, an outpatient service and apheresis and autologous stem cell transplant service

 dcampsorrell 

RE: safety concerns: Issues surround respiking and mixing into other tubes which could lead to a "bad mix".

 dcampsorrell 

Wow! Big clinic!

 dcampsorrell 

RE: more on safety: Respiking also gives a lot of exposure to drugs. When you pull out and insert into the next bad, that's exposure. So often you are working over your head. Especially if you are short like me.

 dcampsorrell 

Hi BC85RN, welcome. What questions do you have?

 dcampsorrell 

Nettie24, sounds like a busy clinic.

 JanePasciuti 

Do you know of any disadvantages of power ports over regular ports? Why are regular ports still being inserted?

 dcampsorrell 

Answering

 dcampsorrell 

RE: power ports: To date, the studies are limited. Power ports still have the risk of infection and clots. Biggest advantage is being able to use power injects for scans. Folks are still using the old ports until the power ports become standard, I think. Just my thoughts on this.

 dcampsorrell 

What are your favorite VADs? I'll have to say, I like ports. I always worry that my patients my not do well with a PICC or tunnel at home.

 JanePasciuti 

Do you know the standard procedure for regaining functionality of mediports and PICC's (getting blood return) in most hospitals and practices?

 dcampsorrell 

Are you saying with no blood return?

 nettie24 

Can you advise on positive pressure fluid replacement devices? They have been in use in the impatient area for two years, and although they have lead to an improvement in regard to catheter occlusions, the infection rate has since significantly increased.

 dcampsorrell 

RE: regaining function of mediports and PICCs: All VADs including PICCs can be safely restored with cath flo.

 dcampsorrell 

RE: fluid replacement devices: These devices have been used for a while. I'm unaware of studies to comment on or to give evidence base practice. Concern is the pressure on the VAD and potential break.

 dcampsorrell 

I'm unaware of the use of power ports with positive pressure fluid replacement devices. I would assume they would be more safe considering they are made to handle increase pressure.

 dcampsorrell 

Any thoughts on why you have seen more infections with these devices?

 JanePasciuti 

Ports are very useful with the Cancer population. With short term antibiotic needs and ICU needs, other CVC's are easier to put in and less expensive. Mediports cost about $1000 to insert and again $1000 to take out.

 JanePasciuti 

It makes no sense to me that the positive pressure devices would experience more infections.

 dcampsorrell 

What population do you work with?

 lhmatey 

Hi Cathy, welcome! Ask your burning question!

 JanePasciuti 

Outpatient oncology - med onc

 dcampsorrell 

Without at doubt ports cost more to insert, yet have less cost with maintenance,

 nettie24 

We have looked into other factors such as flushing, dressing change, line change, practice issues relating to skill mix, education and credentialling of staff working with these devices,and the last resort is now to trial for two month the regular injection caps.

 dcampsorrell 

Are you in a position to do a study about it?

 JanePasciuti 

I have heard that , soon, Medicare is NOT going to pay for infection concerns with CVC's. Have any of you heard about this upcoming ruling with Medicare?

 dcampsorrell 

RE: infection issues:When having problems such as infections its best to start at the beginning. Perhaps alcohol wipe vs chlorohexidine wipes.

 nettie24 

We have an infection control team that collects our stats on catheter related blood stream infections and regular feeds data back.

 dcampsorrell 

RE: Medicare: You never know what Medicare may or may not do. As far as I know, this is not a regulation to date.

 dcampsorrell 

Great Nettie! I would suggest to look at the total picture. Patient's age, disease, tx, neutropenic, how many infusions per injection cap, when changed, etc. Can't wait to see this in the lit! We need the data to build on.

 JanePasciuti 

Recently, three hospitals near me have begun "gluing" the incision after mediport insertion (instead of stitching). Have any of you seen problems with this in any patients?

 dcampsorrell 

RE: gluing: To date, I haven't seen lit. Similar liquid bandage used for cuts. Sounds good, if not allergic to the solution.

 dcampsorrell 

I haven't seen data on this method?

 dcampsorrell 

Cathy and BC do you have problems or interesting cases about VADs?

 cathy 

Regarding the medicare question, I, too, have heard that they will not be paying for infections acquired while in the hospital. We have added masking the patient and the MD/ or RN and placing a surgical hat on both as well while placing lines. A full sterile gown is worn and body sterile drape placed on the patient.

 JanePasciuti 

The PI for Cathflo states that we can indwell a second dose of Cathflo if the first one did not declot the catheter. Have any of you seen ports or PICC's utilize a second dose of Cathflo and it regaining functionality of the CVC?

 dcampsorrell 

RE: restoring function: Yes, Jane. That's a great way to ensure the VAD is being restored

 dcampsorrell 

Cathy, that is great you are inserting with full sterile technique. I'm assuming your speaking of VADs and not peripheral.

 JanePasciuti 

It is almost 8:00. Thank you VERY MUCH for this chat room. I was delighted to ask my questions and hear from you others and MS Campsorrell. A wonderful offering from ONS !!!!!!

 dcampsorrell 

Thank you Jane!

 JanePasciuti 

Have a nice weekend. !!

 lhmatey 

It looks like we’ve answered most questions for today! If you have another question, please type it in now.

 nettie24 

Thank you very much for the opportunity to access expert advice. Please keep up with this great program and a range of times!! Have a wonderful day- evening

 dcampsorrell 

Thank you! Enjoyed the chat.

 lhmatey 

Thank you for your participation in this lively discussion! Please check the ONS website for the next chat session- if you didn’t get a chance to post your question, or if you have another, or if you’re just interested in hearing more from colleagues around the country, please join us at the next chat! Please note that each chat will be archived and viewable within a few days after the chat session and  check the ONS website for the archived transcripts. Thank you for attending! We hope to see you soon at another ONS Hot Topic Chat!

 lhmatey 

Hi Fatralph, tonight's chat has just ended - however, we will be back tomorrow for another chat on this topic at 11am ET. Please join us then!

 lhmatey 

Good night Dawn and participants! If you'd like to come tomorrow, please join us at 11am ET same place!

 dcampsorrell 

Good night! See you tomorrow.