We have a trauma surgeon who is adamant that labs not be drawn from any central line, period. He cannot give a reason, just that he is uncomfortable with it and doesn't trust the resuts. We talked with him in an attempt to find out what the problem was and to provide staff teaching if it came down to the actual procedure of blood draws, ie... such as flushing with at least 20mls NS, etc.   Anybody else up against this? Anyone that could provide any expert opinions and hopefully research to back it up would be wonderful!!! Thanks, Cindy Hunchusky, RN  clhunchusky@yahoo.com

 

Blood sampling- pt teaching tool

Wendy, I don't see your patient teaching tool used to guide a patient in selection peripheral vs CVAD blood sampling. Can you kindly post in the resources (if not already done, although I didn't see it) or send to me?

Many thanks,

Daphne
dbroadhurst[at]oms[dot]ca

Daphne Broadhurst
Desjardins Pharmacy
Ottawa, Canada

HI .. I read your

HI .. I read your information and I do consulting work where I assist nurses with blood draw issues and I agree with the things you said.  Have you done any studies where you found that using your method described with the Luer Lok Access device actually decreases hemolysis or re draws? With the size of your institution I thought you may have.  Please email me at:

anitayanik@yahoo.com I appreciate your comments

Thanks Anita RN MSN

Gee, my apologies to all of

Gee, my apologies to all of you if I never sent the teaching sheet I referred to in my post from a year ago!  I was just going through these posts and found many requests that I may not have responded to. I have attached the sheet here.  Wendy

Wendy Erickson RN
Eau Claire WI

I would be very interested

I would be very interested in your teaching sheet as well. bj.emory@rivhs.com

Thanks in advance!

BJ Emory, RN, CRNI

Infusion Education Co

If someone has a competency

If someone has a competency for lab draws from a PICC or CVC, could you please email it to me?  CCAVRN@CFL.RR.COM

 

Thank you

Chris Cavanaugh, RN, BSN, CRNI, VA-BC

I drew a CBC and CMP from a

I drew a CBC and CMP from a groshong PICC once and  Lab techs questioned the values.  Within the same hour a peripheral sample from the other arm was obtained. The results?  Almost a complete IDENTICAL match. I haven't participated in any research on this subject, but in this one patient the PICC lab values were accurate. I would hesitate to say this should never be done. Saving patients from unneeded needle sticks is huge in the vascular access world.

   Our facility (lab) has

   Our facility (lab) has been doing a study on lab values from PICC's for over a year now, and they have come to the conclusion (not published yet) that the values, even compared to other central line draws, are VERY off from those drawn peripherally.  They tried last summer to ban lab draws from PICC's, but we came to a "meet in the middle" by agreeing to not place any PICC's for lab draws alone.  We also let the doc's know that they need to recheck the values if they seem abnormal when drawn from a PICC.  I do not know the specifics from the study, but I have been assured that it will be published when they are done.  I will keep you all posted.

 

Heather

Wendy, I forgot to include

Wendy, I forgot to include my email address: aowens3@clarian.org

Aileen Owens, BSN, RN

Clarian West Medical Center

Avon, In

If you have received the

If you have received the teaching tool could I receive it too. Thanks.

Aileen Owens, BSN, RN

Clarian West Medical Center

Avon, In

Here is the link to

Here is the link to PubMed:

http://www.ncbi.nlm.nih.gov/sites/entrez?db=PubMed

There is also CINAHL but you either have to be an ANA member or have a subscription since this is a private database

www.cinahl.com

Hope this helps, Lynn 

 

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Wendy, I had asked earlier

Wendy,

I had asked earlier if you could share the teaching tool, but never received.  If you wouldn't mind, could you please email to:

patricia.jean@mhbh.org

Thanks

Trish

Hi Lynn,   I am revisiting

Hi Lynn,

 

I am revisiting this issue and would like to know what is the best site to do a literature search that is most reliable? Thanks Cindy

Wendy, Could you please

Wendy,

Could you please email the patient decision tool to me at:

patricia.jean@mhbh.org

Thanks so much for sharing

Trish

Wendy I would appreciate a

Wendy

I would appreciate a copy of your teaching tool . oakl@sah.on.ca

Nadine: would you be willing to share your competency form with us? oakl@sah.on.ca

Thank you all

I wonder about the 5 minutes

I wonder about the 5 minutes being in policy.  Based on the blood flow rate in the SVC, 5 minutes seems to be a long time.  With multi-lumen catheters with infusions by the time you turn off everything and get ready to do the lab draw,  all of the medications infused should be gone.

With evidence based practice leading the way, what is his evidence? 

Gwen Irwin

A question has come up here

A question has come up here about flushing the line prior to the draw. 

Our policy calls for shutting off all running IVs x5 min prior to draw. 

Do you flush just the port you are drawing from or all ports?

I am so glad we are taliking

I am so glad we are taliking about the importance of blood draws. yes I agree that  not very many nurses are aware of these importance, including myself! We have now opened a very important topic! I have learn a lot just from the discussion from everyone in this listserve and here's an addition :

the order of the draw is very important for the accuracy of the the results ,afterall the lab result is only as good as the specimen sent to lab!

1. the vacuatainer tubes are now made of clear plastic and the additive coats the plastic that is why you realy don't see fluid in the bottom or white powder or white stuff at the bottom, and that is why  several inversion of tubes is also very important; to properly mix blood  & additive

2. Acoording to NCCLS ( lab guidelines) Blood cultures should be taken fiirst then the order of the tubes

3. BLUE top fFIRST because it contains the additive Sodium citrate. this additive does not really affect the other tubes additive, then RED (no additive) then YELLOW or tiger has clot activitor/separator gel at the bottom, then GREEN which has a lithium or sodium heparin additive. (remember that heparin lithium has different use from heparin sodium) then Gray has a postassium/na floride. then the LAST one is PURPLE because it has EDTA , this additive interacts with all the additive which will greatly affect result if the other tubes gets contaminated with it

Gina Ward R.N., C.P.A.N. I

Gina Ward R.N., C.P.A.N.

I am relatively new to the PICC world.  Could you explain to me the importance of having a sequence for the tubes filled when drawing blood from a central line?

I have also heard from the manufacturers and several others that it is o.k. to draw a "level" from a line that was used to give that med as along as med off, line flushed and blood wasted.  What is the reasoning of not using it?  Are we thinking it adheres to the catheter ?

I also would like to see the handout that someone has to help the pt make a decision regarding to have labs drawn from the central line or not. 

Thanks, in advance for your repsonses ,  Gina Ward R.N., C.P.A.N. 

Our phlebotomy supervisor

Our phlebotomy supervisor and I are working on our CVC blood drawing P&P.  this is the sequence he pulled from the NCCLS:

Blood cultures

Blue top

Red, yellow, tiger top

Green top

Lavendar/pink tops

 Gray tops need to fit in here somewhere, but they were not included in his initial response.

Nadine, Would you happen to

Nadine,

Would you happen to have literature regarding the order of draw for blood works? Thanks.

We allow lab work to be

We allow lab work to be drawn from any CVAD or PICC, but with several precautions.   1.  I prefer to use a luer lock vacutainer.  It makes a tighter connection between the vacutainer and the needlesless connector, decreasing the risk of hemolysis.  I prefer to flush with NS first, do a waste (we say to waste 5 mls, no matter what type of CVAD), then attach the vacutainer adaptor, then draw labs in the following order:   blue top, red/gold top, mint or green top, then lavendar top, followed by other less commonly used tubes (call your clinical lab for other labs).   

2.  We have a competency for lab drawing that we are trying to get all nurses in our institution to complete.   It goes over the order of the draw, something that not all nurses are aware of.
 
3.  Using a vacutainer adaptor decreases the risk of hemolysis, and prevents unnecessary blood exposure for the HCW.

4.  Of course, EVERY access should be done using a NEW alcohol wipe for severeal seconds with friction like "juicing an orange."   

5.  Make sure the nurses know to NEVER draw drug levels through a lumen in which that drug has been infused (eg, Vanco, Cyclosporine, Tacrolimus).

6.  Flush with at least 10, or 20 mls NS.

The reason the physician may not want labs drawn through any CVAD or PICC is because:  1)  higher occlusion rate due to poor flushing or technique, 2) higher infection rates because of poor technique, 3) skewed lab values because nurses don't know about the order of the draw, or draw drug levels through lumens that have had that drug infused (including PTTs from lumens that have been heparin locked), or 4) too many labs canceled because of hemolysis, again due to poor technique.  

All of these are solvable issues.  Like Kathy Kokotis has discussed, patients who get daily lab draws often end up with multiple bruises and it's very painful.  Accurate labs can be drawn safely from CVADs and PICCs, but the supplies and education should be in place before this is allowed.  Competency testing may reinforce the needed education.

Nadine Nakazawa, RN, BS, OCN, CRNI, VA-BC

§         Frey A.

§         Frey A. Drawing blood from vascular access devices: Evidence-based practice. Journal of Infusion Nursing. 2003;26(5):285-295.

Nancy Moureau, BSN, CRNI

PICC Excellence, Inc

nancy@piccexcellence.com

www.piccexcellence.com

Nancy L. Moureau, BSN, CRNI, CPUI, VA-BC

PICC Excellence, Inc

I believe there has been

I believe there has been several article in the past few years about blood  collection from diffrent VADs.   One article was by Linda Farjo, RN in the Nov/Dec issue of Jourlnal of Infusion Nursing.

I also believe a universal

I also believe a universal rule is not the answer. I would appreciate any info you would be able to send on the teaching tool you use. Thanks, Kaye

I agree it is a risk benefit

I agree it is a risk benefit analysis but I would draw labs from central lines.  Here are the reasons to do so:

Decreased multiple peripheral venipunctures with the risk of nerve injury, compartment syndrome, yes infection (we take peripheral puntures too non-seriously because we do not indeed know if they contribute to infection overall), patient comfort, better Press Ganey scores for venipunctures, Patient satisfaction, obtaining enough sample to be tested.  We take the usage of multiple peripheral venipunctures so lightly.  I for one do not like needlesticks as they are painful.  Call me a wimp but I am one of the future patients

 

Did you ever see a patient all bruised up and the venipuncture sites hurt worse than the major surgery they had?

 

Occlusion is primarily but not always a nursing error or complication as a result of poor education and never should be considered a reason not to draw labs from a central line

Blood loss should be consisdered.  Infection risk is also related to care (proper flushing and proper sample drawing).  I do not think it is acceptable to allow poor care issues to dictate whether a patient should have peripheral blood draws or central line blood draws

 

As for your doctor he probably read that taking blood samples from a central line increases infection (related to poor care once again) and results in inaccurate lab values (related to poor care i.e. blood draws)

Kathy Kokotis

Bard Access Systems

Hi Wendy, Thanks for

Hi Wendy, Thanks for responding. I would love to see your teaching sheet, as this could be very helpful. Thanks again, Cindy my e-mail is clhunchusky@yahoo.com

We do allow blood sampling

We do allow blood sampling from lines at our hospitals unless the physician orders otherwise.  Our patient population is primarily geriatric and it is often an advantage for them due to frequent testing.

It is also a challenge to educate nurses to do this properly, monitor technique and results, etc. 

Pretty much everything we do requires a risk-benefit analysis.  I believe it can be done safely and effectively, but there are definitely risks.

I agree with Lynn.  We had

I agree with Lynn.  We had a nurse refuse to draw labs from an implanted VAD in a patient who specifically requested it.(primarily due to lack of knowledge on how to do it).  The patient complained - rightfully so - and suddenly policies were changed to say that "ALL patients with a central line WILL HAVE lab work drawn from them".  As coordinato of the PICC service, I objected and was overruled but have seen a huge increase in clotted PICCs.  We are working to change this policy and I have developed a teaching tool for patients to read that gives the pros and cons of having their labwork drawn this way, and ask that the patient make an informed decision.

I have absolutely NO problem using the PICC for a blood draw if: 1) the patient requests it after reading the info, 2) there are no peripheral sites to get blood from, or 3) if the patient is needle-phobic, such as peds.  I would be happy to emai the teaching sheet we developed if that would be helpful to anyone.  Wendy

 

 

Wendy Erickson RN
Eau Claire WI

There are actually several

There are actually several issues with the use of all CVCs for drawing all blood samples on all patients as routine practice. In fact, my opinion is that this should be a patient-specific decision based on a risk-benefit analysis for each patient. Issues include 1) accuracy of the lab values, 2) increasing hub manipulation increases the risk of CRBSI, 3) nosocomial blood loss and iatrogenic anemia, a very real problem in critical patients. A literature search will lead you to several published articles on the accuracy of lab values. There is also a ton of literature on hub manipulation and BSIs and iatrogenic anemia. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861