What Would You Do: Would you use an implanted port that lacked a blood return to administer non-vesicant chemotherapy?

The “What Would You Do?” column answers clinical questions on topics for which evidence is lacking or controversial. Oncology nursing and vascular access leaders provide their expert opinions in answering these questions. Readers are invited to submit questions and comments to OncLive Nursing by sending them to Jason Broderick.

My short answer when asked questions like this is, “Never, ever, give chemotherapy without a blood return.” Even if an infiltrating medication causes no harm to the tissue (ie, non-vesicant), the device is not working as it was designed to function. I advise use of tissue plasminogen activator, with physician orders, to attempt restoration of blood return. If this does not work, I suggest a dye study be performed to evaluate the catheter function. If the dye study shows functioning is adequate with no backflow, it should be okay to administer non-vesicants via the line. However, I still recommend the “No blood return = No chemotherapy” approach. The reason is this is simple to remember for nurses. As nurses have varying knowledge sets and all nurses are susceptible to lapses of memory, I am concerned about the possibility of a vesicant being given inadvertently via a line that has no blood return. Therefore, “No blood return = No chemo.”

Michael Smart, RN, BSN, OCN®

Oncology Staff Nurse

Huntsville Hospital

Huntsville, Alabama

Presence of a good blood return (usually defined as the ability to draw back 3 mL of blood within 3 seconds) is an indicator that the implanted port is where it should be—in the venous system. Lack of a blood return from an implanted port can occur from a number of causes, and must be investigated before the port is used for any reason (including non-vesicant chemotherapy administration). I would attempt to get a blood return (eg, reposition the patient, gently use a “push-pull” technique using a saline filled syringe), and if a blood return was still not evident, further intervention is needed (eg, declotting or dye study, depending on the suspected cause of the lack of a blood return). There is a reason that the port lacks a blood return, and unless a blood return is obtained—or a dye study verifies correct placement and patency of the device—it should not be used for chemotherapy administration. Even if a non-vesicant is administered, if the catheter has fractured, migrated, eroded the vein, or if the catheter has disconnected from the portal body, the chemotherapy will be delivered into the tissue and not into the venous system as intended.

Lisa Schulmeister, MN, APRN-BC, OCN®, FAAN

Oncology Nursing Consultant

New Orleans, Louisiana

A blood return is important for administration of any medication. This is an important component of assessing catheter function. Lack of a blood return should result in further steps to assess catheter patency and potential causes, such as catheter malposition or a fibrin tail. If the cause is withdrawal occlusion, alteplase (tissue plasminogen activator), should be considered. Radiological studies may be needed to ascertain if there are catheter tip position and thrombotic problems.

Lisa A. Gorski, RN, MS, HHCNS-BC, CRNI, FAAN

Clinical Nurse Specialist

Wheaton Franciscan Home Health & Hospice Milwaukee, Wisconsin

If an implanted port lacks blood return, troubleshooting and declotting of the line must be performed. If declotting does not re-establish a blood return, a chest x-ray should be done to confirm proper tip location. A dye study may be used to determine whether or not there is a problem with the placement and/or patency of the catheter. In an ideal world, nonvesicant chemotherapy would never be given through any central line unless blood return is present. In the real world what sometimes happens is…a dye study is done to confirm proper functioning of the catheter, and then the prescriber will order for the line to be used (for non-vesicant chemotherapy only). The question that staff are then faced with is, how often should the dye study be repeated if an absence of blood return continues. If the line continues to lack blood return, the line should be replaced. Central lines should flush easily and have a brisk blood return.

MiKaela Olsen, RN, MS, OCN®

Oncology and Hematology Clinical Nurse Specialist

Sidney Kimmel Comprehensive Cancer Center Johns Hopkins Hospital Baltimore, Maryland

To date, no studies have been conducted to give a research-based answer to this question. In general, it is highly recommended that correct placement of the distal catheter tip is verified by chest x-ray, cathetergram (dye study), or ultrasound prior to making the decision to use or not to use a port that lacks a blood return. However, a chest x-ray will only verify the location of the distal tip of the catheter. A cathetergram will provide visualization of the integrity of the catheter and can be used to determine if an occlusion is present. An ultrasound will identify the location and the presence of an occlusion if an occlusion is causing the lack of blood return from the catheter. To proceed with administration of a non-vesicant should require a physician order; however, if an untoward event occurs, the nurse could be held negligent.

Dawn Camp-Sorrell, MSN, FNP, AOCN®

Nurse Practitioner

St. Vincent’s Adult Clinic Birmingham, Alabama