Danielle has a double-lumen implanted port and is scheduled to receive rituximab for lymphoma. After accessing the lateral septum, the nurse is unable to get a blood return, even though saline flushes easily. Danielle comments that the “outside lumen hasn’t drawn well since it was placed a few months ago, and that the other nurses have been using the inside lumen.” The nurse accesses the inside lumen and is able to get a good blood return.

What Would You do?

Establishing patency prior to IV therapy is one of the basic foundations of parenteral medication administration. In addition to being able to easily flush a device, the presence of a brisk blood return has been recommended by both the Infusion Nurses Society and ONS

Extravasation, with potentially serious sequelae, is typically associated with the administration of vesicant chemotherapy. The risks are different for nonvesicants, where patient harm is more closely related to infiltrating significant volumes of fluid. In Danielle’s case, the nurse was concerned that one lumen of the nondrawing catheter may have a fibrin sheath. Although the incidence is unknown, extravasation and infiltration from a fibrin sheath is a possibility. However, studies have not been conducted to evaluate the risk of using a patent lumen in a double-lumen catheter where the opposing lumen does not draw. 

Ideally, both lumens would be functioning. However, Danielle stated that she needed to get her infusion started because she had to be home to pick up her children from school. Furthermore, an examination of Danielle’s chart showed that several instillations of alteplase had been used in the past without benefit.

Danielle’s nurse contacted her hospital’s clinical nurse specialist, who agreed with the physician that the patent lumen would be safe to use for the rituximab infusion. The infusion was completed without any complications, and a brisk blood return was again noted in the patent lumen at completion.

Comments

Posted by Patricia Reise… (not verified) 3 years 10 months ago

In this case I would have instilled Cathflo into the malfunctioning port. Started a peripheral Iv to accommodate the patient's need to finish treatment in reasonable time. Cathflo takes 45-60 minutes of dwelling time. If no blood flow after that time I would not have use the port or the 2nd port. The patient could come back at a later time to have small amount of dye to. Visualize the problem. This is a common occurrence and patient's should also plan for the treatment day to allow for delays that can occur. Adverse events could also cause a delay. Our patients do allow for the delay s that can occur

Posted by Kylie Starling… (not verified) 3 years 10 months ago

I have seen this happen with dual lumens several times and had wondered if one lumen actually is restricted by the vessel wall due to position. They flush well but give only some or difficult blood return on aspiration. On some instances we have had interventional radiology confirm patency.

Posted by Karin Leppanen… (not verified) 3 years 10 months ago

I share Kylie's experience and thoughts - waiting to see the "right answer"!

Posted by Jennifer (not … (not verified) 3 years 10 months ago

Based on the previous documentation that the TPA was not effective, it made sense not to instill again on this visit. If the opposite lumen was working without incident, and positioning, deep breathing and forceful sailing flushes still did not give a blood return, yet no pain, no leaking, nothing notable that would indicate malfunction, then the correct step was taken. The clinical decision was appropriate perhaps with just an extra eye during start of infusion. Left out of the story: access of the port. was the port newly accessed? size changed? the previous attempts to remove the thrombin sheath was the port used on those dates? Given the continued lack of blood return, did the patient have a chest X-ray to confirm placement? And most importantly..... After the infusion of Rituxan (usually large volume) the port did provide blood return. So it was most likely just a tough clot. The port should be given a good consistent heparin flush prior to taking it out. Also the double ports can position in a funny way and difficult blood return isn't so unusual.

Posted by Trish MacIsaac… (not verified) 3 years 10 months ago

In reply to by Jennifer (not … (not verified)

I agree with Jennifer if the TPA did not work I think an X-ray for placement is in order. The need to leave is solved easily by the peripheral IV.

Posted by Daphne (not ve… (not verified) 3 years 10 months ago

I agree with Kyle and Jennifer. This is a common problem on my pediatric unit. I notify the provider and use the lumen that is working, watching the infusion carefully and suggesting to the provider that IR look at the non-working lumen asap, if TPA attempts were not successful.

Posted by Melissa W. (no… (not verified) 3 years 10 months ago

My preference is to instill Cathflo in the port.... Access the Inner port and give the infusion (if good blood return). I would leave the indwelling cathflo and have her come the following day to see if it is working. If not; to avoid late appt with Rituxan and she has kids schedule a dye study prior to the following visit.
**Remember we put the wonderful devices in to prevent IV sticks** Unfortunately I am not very impressed with the double lumen Ports or Piccs. They all seem to have one side that fibrin sheaths, sticks to the side of the vessel, or completely quits working and becomes trouble some.

Posted by Erik Samarpan … (not verified) 3 years 10 months ago

I would tend to agree with the position that, as a vascular access/oncology nurse, I would not be comfortable with using that lumen. Without intending to offend, we are the experts in our field. I do not know the credentials or vascular access experience of the MD or CNS, but I would defer on the side of safe patient care.
A Rituximab infiltration potential for vessel damage would direct my actions to start a PIV, contact the provider and suggest a dye study to be scheduled on another day.

Posted by Lori Sammartin… (not verified) 3 years 10 months ago

In reply to by Erik Samarpan … (not verified)

I agree. In my institution it is policy to have a dye study done on the first incidence of absence of a blood return. Once the dye study is conclusive and the port is deemed intact, then it is okay to proceed with the use of the port. A peripheral line is adequate for rituxan infusions.

Posted by Cindy T. (not … (not verified) 3 years 10 months ago

In my area of practice, we do not come in contact with double lumen ports often. Recently when we did, we had a similar situation: lateral port flushed well, gave blood for the "discard" syringe, then gave a weak flow when trying to obtain actual sample for testing. We kept flushing and wasting, and were finally able to obtain the required amount required for the tests ordered. The area that concerns me, somewhat unrelated, is the picture at the beginning of the story. I believe it shows a pre-filled saline syringe placed on a sterile field. At my facility, pre-filled syringe wraps say that the outside of the syringe is not sterile and should not be placed on a sterile field. This has been a focus of observation and teaching when other nurses float into our area as this does not seem to be common knowledge outside of our department. I apologize, realizing this is not the focus of the presentation, however felt that I must address it since we are supposed to represent strong knowledge of correct technique when accessing ports. Are there pre-filled syringes out there that actually are sterile when the wrap is removed and safe to place on a sterile field?

Posted by fiona (not verified) (not verified) 3 years 10 months ago

In reply to by Cindy T. (not … (not verified)

the brand our hospital uses provides 'XP' and 'XS'...one is a sterile fluid path (ie, the syringe itself is clean on the outside, but the contents is sterile. the other is a completely sterile syringe and can be addd to a sterile field. The externally sterile one comes in a standard 'bubble pack' format.

At our facility we also have sterile syringes. They are in a paper wrapping just as any other sterile piece of equipment and the syringe inside is sterile. These are definitely more pricey, but we use them only for port initial port access.

Posted by Stacey Lucas (… (not verified) 3 years 10 months ago

At the hospital I work at there is a sterile saline packaging.

Posted by Stacey Lucas (… (not verified) 3 years 10 months ago

At the hospital I work at there is a sterile saline packaging.

Posted by Lisa Belote RN… (not verified) 3 years 10 months ago

Sometimes it seems that every double lumen port I run across there is a problem with one of the lumens. I think this must be a common problem. In my practice, we have typically attempted TPA in the non blood return lumen but that did not prevent us from continuing to use the fully functioning side of the port.
And to answer the saline question, we originally were getting pre- filled non-sterile saline syringes and were unaware that the sterile pre-filled were available.
Sterile pre-filled saline syringes are available, I am not sure of the brand, it could be Baxter.
We currently use them in my practice.

Posted by Marti L. (not … (not verified) 3 years 10 months ago

I have been a PICC nurse and IV access team RN. In my practice, especially on the oncology side, both lumens MUST flush easily and have a brisk blood return. A fibrin sheath is not meant to be on the catheter. This is a prime breeding ground for bacteria, not to mention that a piece of the sheath can break off and enter the blood stream. Alteplase can be used indwelling for 2hrs and then repeated again, for a total of 4hrs indwell time. I have also read about alteplase infusions (but never done one myself). If after 4hrs, there is no blood return pt should have a dye study. We need to advocate for our patients and keep them safe by NOT using a port that doesn't function properly.

Posted by Carol Knop (no… (not verified) 3 years 10 months ago

We had the same problem with dual lumen ports. We changed our protocol to require access of both lumens every time the port was accessed. In addition, we changed the sequence of steps before de-accessing. After all blood had been drawn and blood return had been checked for the last time on each lumen, each lumen was flushed with saline using the appropriate clamping technique (based on whether there was a positive pressure cap or hub to hub), and then they were both flushed with heparin. This prevented any further possibility that blood was being pulled into either lumen before de-accessing.

We also had a situation where the patient had a dual lumen that was repeatedly requiring Cath-flo. After several visits we decided to do a dye study and indeed the catheter had migrated to the left subclavian so the blood flow was actually into the lumen of the catheter! Interventional radiology was able to reposition the catheter and save the port but a lesson well learned that when in doubt, get a visualization of the device.

Posted by Kimberly (not … (not verified) 3 years 10 months ago

I think it is interesting that there are currently no studies evaluating the incidences/risk of extravasation or infiltration when one lumen of a double lumen port or picc is occluded AND the incidences of extravasation with fibrin sheath are unknown. Given that there is a lack of evidence out there, I think we need to ask the question: will exposing the patient to the risk of a dye study (not entirely sure if there are any major inherent risks, does anyone know if the dye is similar to radiocontrast dye?) and additional radiation (from the xray) improve safety for this patient? Given that she has had infusions before on the other lumen of the port without difficulty, is it a reasonable risk to infuse the rituxan in the functioning side of the port and spare her a peripheral IV poke? Is the peripheral IV more likely to infiltrate than a port lumen that has good blood return? Perhaps we can schedule her in at a later date to assess patency with a dye study?
My first reaction is to do the dye study, but I think with a lack of evidence out there, we need to assess the clinical picture, which suggests that infusing the Rituxan will be safe. Certainly not infusing the Rituxan through the port and performing a dye study is the most conservative approach, but there is really no data out there as to whether or not it will significantly improve safety for this patient (risk for extravasation). Most conservative, doesn't equate to most safe or least amount of risk. It is important to consider: does she have insurance? Will performing the dye study put an undue burden on the patient: pyschologically, physically, financially? Are we concerned with the amount of radiation we are exposing this person to? Cancer patients are exposed to many x-rays, CTs, MRIs and radiation treatment itself and increasingly we are seeing that the radiation from diagnostic testing is not an insignificant amount.

Posted by M.Sutton, RN, … (not verified) 3 years 10 months ago

In reply to by Kimberly (not … (not verified)

Yes, the dye used in the contrast study for port patency is the same radiocontrast dye used in CT scans, etc., but just a "squirt", under a C-arm for visualization. I have never seen a patient have any undue burdens put on them, other than being peeved because they have to make another appointment. They are usually happy to go, so the mystery can be solved.

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