Transcript causes of central venous access device (CVAD) occlusion

Is it Necessary to Verify Blood Return in Monthly Port Flushes?
Gloria B. Ascoli, RN, CRNI, Amy C. Brown, BSN, RN, Jessica L. Cooper, BSN, RN, Allison N. Crawford, BSN, RN, CRNI
Background
•Nurses in our outpatient infusion center see patients
with implanted ports requiring routine monthly
flushes for maintenance only
•Nurses were often encountering partial withdrawal
occlusions from implanted ports during routine monthly
port flushes
•Partial withdrawal occlusion – the ability to flush
easily but inability to aspirate blood
•Nurses questioned the necessity of a thrombolytic
agent to establish blood return when no therapy was
ordered
A literature search was conducted to
accomplish the research aims:
Keywords:
Monthly flush, blood
return, fibrin sheath,
implanted port,
withdrawal
occlusion
We had four overall research aims:
1. To determine the necessity of obtaining
blood return during monthly implanted port
flushes for patients with non-utilized ports
2. To determine appropriate assessment
criteria
3. To identify causes of central venous
access device (CVAD) occlusion.
4. To state complications caused by CVAD
occlusions
Results
Method
Data Bases:
Google Scholar,
CINHAL, and
PubMed
Conclusions
Research Aims
Inclusion Criteria:
Adult population,
implanted port,
malfunctioning port,
recommendations
for treatment
Infusion Nurses Society (INS) archives and
our internal policies (Sentara WaveNet) were
also searched
• Sixteen articles met inclusion criteria
•Fifteen articles were selected for review
•Articles provided evidence supporting
establishing blood return during monthly port
flush
•Search of WaveNet revealed an established
policy, providing an assessment tool and
subsequent interventions in the setting of an
occluded CVAD
1
• It is necessary to establish blood return
during a routine monthly port flush
2
• Assessment includes multiple pathways for
determining causes of occlusion
(see chart 1)
3
• Major causes of occlusion include
mechanical, non-thrombotic, and
thrombotic(see chart 2)
4
• Major complications include infection,
infiltration, etc. (see chart 3)
Implications For Practice
• Blood return must be verified prior to any therapy
via an implanted port, including monthly port flushes
•“Thorough assessment of the patient and the CVAD
for the potential cause of an occlusion will be
performed, and the appropriate intervention will be
performed to restore catheter patency (INS, 96)”
• Nurses should be educated about the importance
of the ability to aspirate blood from a CVAD prior to
use
Assessment of Central Line Catheter Occlusion
Chart 1
Complete
occlusion (unable
to flush or
aspirate blood)
Complete (unable
to flush or
aspirate blood)
Contact
Interventional
Radiology to
assess
Partial occlusion
(negative blood
aspiration)
Partial (negative
blood aspiration)
Assess for external
mechanical causes
Assess for
thrombotic causes
Assess for non
thrombotic causes
Per protocol, instill
catheter clearance
agent
Positive blood
return, proceed
with catheter use
Types of CVAD Occlusions
Chart 2
Types of central venous catheter occlusion
Mechanical
•External:
•Clamped or kinked IV tubing
•Tight suture at catheter exit site
•Non-coring needle dislodgement
and misplacement
•Internal:
•Improper catheter tip placement
•Catheter kinking or compression
Non-thrombotic
Thrombotic
•Drug precipitates
•Crystallization of total parenteral
nutrition admixtures
•Drug-to-drug incompatibilities
•Drug-to-solution incompatibilities
•Deposits of fibrin and blood components
•Intraluminal
•Fibrin Sheath
•Fibrin Tail
•Mural Thrombus
•Irritation from catheter rubbing against
the intima of the vessel wall
•Portal Reservoir Occlusion
42% non
thrombotic
58%
Thrombotic
Complications Associated with Central Line
Occlusions
Chart 3
Central line occlusions compromise patient care
Risk for Infection
•Formation of fibrin deposits and biofilm is a natural response that can start upon catheter placement
•Attracts, encloses, and protects bacteria and other microorganisms
•Microorganisms can be released into the bloodstream causing central line associated infection
Infiltration or Extravasation
•Infiltration causes pain, discoloration, and swelling
•Extravasation is more severe, and can result in pain, edema, and tissue necrosis
Thrombosis
•A thrombus between the catheter and the cell wall can lead to complete blockage of the vein
•This can be a life-threatening condition with potential complications, such as pulmonary embolism
Delay in treatment
•Canceled or delayed procedures
• Increased length of stay (LOS)
• Interruption in administration of medications and solutions, especially vesicants
References
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