Word: Blood Sampling From Central Venous Lines: Syringe …



Site ApplicabilityApplicable in all BC Children’s Hospital areas where patients with central venous lines (CVLs) are cared for. Practice Level/CompetenciesCentral line care, including blood sampling using syringe method from a CVL is considered a foundational nursing skill and is practiced once the nurse has:attended the Vascular Access Workshop, practiced the procedure in the lab setting, performed at least 3 blood sampling procedures on patients under supervision of a CVL competent RN, and has completed the CVL validation tool at the bedside with the appropriate clinical support person (i.e. clinical nurse educator, clinical resource nurse, CVL competent RN).Policy Statement(s) Blood sampling requires a prescriber’s order indicating blood samples to be drawn.Blood may be sampled using the syringe method from:External cuffed central venous lines Implanted PortsShort-term uncuffed central venous catheters Hemodialysis/Apheresis catheters (medcomps or powerlines)Single PICCs 2.6 French or larger, double PICCS 2.6 or larger – must use larger gauge lumenDouble PICCs 4 French power PICCs (either lumen)The push-pull method is the preferred method of blood sampling from a Hemodialysis CVC but other methods can be used. For renal patients outside of PICU with a hemodialysis CVC, a nephrologist’s order is required prior to all nursing care provided on that hemodialysis CVC. The renal nurse on call can be contacted through hospital paging at local 2161 for clarification of orders and care required.Although the vacutainer method is the preferred method for blood sampling from central venous lines, the syringe method is used:For all blood draws from PICCs 2.6 French or largerIf vacutainer method is unsuccessfulIf small volumes are required for microtubesFor drawing blood gas samplesFor drawing blood cultures to ensure accurate and optimal yieldEquipment & SuppliesRequisitions and computerized or addressograph labels for patientHospital grade surface disinfectant wipe (e.g. CaviWipes?)10mL empty sterile syringe for discard blood (1 per lumen)10mL empty sterile syringe for blood sample (refer to eLab handbook to determine total volume of blood to be collected – this will determine how many syringes you need) Chlorhexidine 2% in 70% alcohol swabs (2-3 per lumen)Appropriate blood collection tubes (ensure to check expiry on tubes)Blood transfer device vacutainer (1 per lumen)Gloves, non-sterile10 mL syringes filled with normal saline Sterile dead-end cap if interrupting infusion (1 per lumen)If heparin locking, add:10 mL syringe filled with heparin 10units/mL (1 per lumen)Swabcap? if appropriate (1 per lumen)If drawing blood cultures, add:Chlorhexidine 2% in 70% alcohol swabs x 3Blood culture bottles as required**NOTE: If drawing blood cultures please refer to Pediatric Blood Culture GuideProcedureSTEPSRATIONALE1. REVIEW physician orders for bloodwork and determine appropriate blood tubes and volumes required to be collected by REFERRING to the eLab Handbook and Order of Draw reference tool. If drawing blood cultures, REFER to the Pediatric Blood Culture Procedure.Ensures correct amount of blood collected, sample placed in correct tube and handled correctly. Reduces need to recollect samples.2. PERFORM a Point of Care Risk Assessment (PCRA) of the patient and select appropriate PPE. Confirm if the patient is on any additional precautions and DON appropriate PPE and PERFOM hand hygiene prior to entering patient environment.Routine practices prior to entering patient environment. Please refer to: Routine Practices – Hand Hygiene IC.03.03Donning (Putting On) Personal Protective Equipment3. IDENTIFY patient by comparing name on requisition and labels to patient ID band or hospital approved photo ID. Please refer to Patient identification Policy.Failure to correctly identify patients prior to procedures may result in errors and/or recollection.4. EXPLAIN procedure to the patient and caregiver.Evaluates and reinforces understanding of previously taught information and confirms consent for procedure.5. CLEAN non- porous work surface with hospital grade surface disinfectant wipe (e.g. CaviWipes?) and let dry for recommended contact time.Routine practices. Reduces transmission of microorganisms.6. PERFORM hand hygiene as per infection control standards. Routine practices prior to CVL care.7. PREPARE equipment using aseptic technique at the bedside of the patient.NOTE: If drawing blood cultures, REMOVE the protective cover on the blood culture collection bottle and SCRUB the top of the culture bottle with Chlorhexidine 2% in 70% alcohol swabs for 30-60 seconds using good friction. Allow to dry for 1 minute. Refer to Pediatric Blood Culture Guide. To reduce risk of contaminating sample.8. CLAMP CVL catheter. If second lumen infusing, CLAMP second lumen. NOTE: If high risk infusion running in second lumen, it may not be appropriate to clamp second lumen or draw blood from this lumen. In these scenarios, please consult with physician prior to clamping second lumen. It may not be clinically appropriate for patients dependent on a high risk infusion to clamp second lumen (i.e. inotropes, insulin infusion etc.)9. PAUSE or DELAY infusion on IV pump. If CVL is heparin locked, disregard this step.10. PERFORM hand hygiene as per infection control standards. Routine practices prior to CVL care.11. REMOVE IV tubing and attach sterile dead-end cap to open end to keep covered. If CV is heparin locked, disregard this step. 12. SCRUB the needleless connector (cap) for 30 second with Chlorhexidine 2% in 70% alcohol swab and allow to dry for one minute. Repeat with a second swab and clean up the line from the cap towards the clamp, including the clamp. Allow to dry for one minute.NOTE: If CVL has had a SwabcapTM on the needleless connector for >5minutes you may remove the SwabcapTM and proceed to the next step without cleaning if the SwabcapTM has not been compromised.Routine practices. Decreases risk of contamination. Chlorhexidine is active against?Gram-positive?and?Gram-negative?organisms,?facultative anaerobes,?aerobes, and yeast. Must allow for full dry time to be effective.13. ATTACH empty syringe sample syringe to the needleless connector to withdraw discard sample*. If experiencing difficulty with blood sampling refer to Management of an occluded Central Venous Lines – Policy and/or contact the IV team.Removes solution from catheter to ensure uncontaminated blood specimen.14. UNCLAMP catheter and WITHDRAW appropriate amount of blood for discard*:Type of CVLAmount of discardExternal Cuffed CVC < 10 kg1.5 mLExternal Cuffed CVC > 10 kg3 mLUn-cuffed Short-term CVC1.5 mLImplanted Port3 mLPICC < 2.6 FrenchDo not draw blood workPICC 2.6 Fr 1 mLCuffed/Uncuffed PICC >2.6 Fr and < 10kg1.5mLCuffed/Uncuffed >2.6Fr and >10 kg3 mLHemodialysis/Apheresis3 mL*NOTE: Discard blood can be used in blood culture collection sample if CVL is not antibiotic “locked”. Refer to Pediatric blood culture procedure. Opposite lumen must remain clamped during blood sampling to ensure no contamination or dilution of blood samples. 15. CLAMP catheter. REMOVE syringe andDISCARD into appropriate biohazard bin.16. ATTACH empty sterile sample syringe to needleless connector using aseptic technique. UNCLAMP catheter and WITHDRAW appropriate amount of blood required by gently pulling back on the plunger of syringe.. Refer to the eLab Handbook to ensure appropriate volume of sample is collected. To obtain total amount for transferring to appropriate tubes.If you pull back to quickly, the blood may rush into the syringe too quickly causing lysis or hemolysis of the cells. 17. CLAMP catheter, REMOVE syringe from needless connector and IMMEDIATELY TRANSFER blood from sterile sample syringe to appropriate blood culture collection bottles and/or blood tubes using the blood transfer vacutainer device. 089217500REFER to Order of Draw reference tool to ensure appropriate transfer order and appropriate number of inversions per blood tube.DO NOT invert blood while in sterile sample syringes.If putting blood into micro-tubes, remove top of micro-tube and gently depress blood filled syringe to add appropriate amount of blood to micro-tube. Note: If you do not have a buddy RN to assist in this process, to keep end of CVL clean while you are transferring the blood, you may ATTACH the next empty sterile sample syringe to needless connector (if further blood sampling is required) or, if no further bloodwork required, ATTACH sterile NS pre-filled syringe and allow line to rest, clamped, with syringe attached until you have completed transferring all the blood. Once in tubes, inverting ensures blood cells are all mixed with additives in tubes. DO NOT SHAKE or will cause cell lysis.Inverting or mixing blood in sample syringe will cause hemolysis and dramatically impact accuracy of results. Blood must be immediately transferred to appropriate tube or collection bottle with the least amount of manipulation as possible.18. If further blood sampling required, if you have not done so already, ATTACH un-used sterile sample syringe or vacutainer, UNCLAMP catheter and WITHDRAW required amount of blood until full volume of blood has been collected from lumen and all blood transferred into appropriate collection tubes. If no further blood sampling required, using sterile pre-filled normal saline syringe, UNCLAMP catheter and with thumb on the plunger of the syringe, give two-three quick pushes of the normal saline into the catheter. Then with a continuous fast motion, FLUSH into the needleless connector and catheter with remaining normal saline required: Type of CVLMinimum NS Flush RequiredExternal Cuffed CVC< 10 kg3 mLExternal Cuffed CVC> 10 kg9 mLUn-cuffed Short-term CVC3 mLImplanted Port <10kg9mLImplanted Port > 10kg18 mL (use x2 pre-filled 10 mL syringes)PICC 2.6 Fr1mLCuffed/Uncuffed PICC > 2.6Fr and < 10kg 3 mLCuffed/Uncuffed PICC >2.6Fr and >10kg9 mLHemodialysis/Apheresis 9 mLCreates turbulent flow to clear catheter of blood and help maintain patency of the line. Flush must always be done. Do not connect back to line and use IV fluids to flush the line.19. RECONNECT infusion set and commence infusion or heparin lock line as ordered.- If second lumen is in use, UNCLAMP second lumen and RECOMMENCE infusion.Resumes therapy as ordered.20. COMPLETE site to source safety check of IV infusion system:Site assessment (“TLC”)Trace tubing from bag/bottle/syringe to site to ensure right solution/medication is infusing via right channel and at right rateCheck tubing for leaks, kinks, air bubbles, loose connections, breaks in system, etc.Check that clamps are opened/closed as appropriateCheck that needless connector attached to end of central line and at top of syringe line (except in PICU) to maintain a closed system. Decrease risk of infiltration or extravasation. Ensure line remains patent.21. LABEL specimen tubes at the patient's bedside. Label must include MRN, first and last name, date of birth, date and time sample drawn and RN initials. May use computerized or addressograph labels if available, except for Group & Screen and Crossmatch.*NOTE *Group & Screen and Crossmatch collection procedure: National Standards for safe transfusion practice require specimen labeling at the bedsideConfirm patient identification - name, DOB, MRN on patient ID band matches with the requisition. Resolve any discrepancies prior to collectionWhen possible, ask patient his/her name and DOBSpecimen MUST be hand labeled at bedside only by the person who collected the specimenComputer generated labels are not to be usedLabel must contain patient name, DOB, MRN, date and time of collection and RN initialsSign requisition and record date and time of collection. Signing requisition confirms you have correctly identified the patient.Safe blood sampling and transfusion practices. Refer to Transfusion medicine manual.PLACE specimens in transport bags.Ensures sample is delivered in approved validated sate of delivery to the lab. REMOVE gloves and PERFORM hand hygiene. If patient is on any additional precautions, please follow proper hand hygiene and PPE DOFFING procedures.Refer to DOFFING (TAKING OFF) PERSONAL PROTECTIVE EQUIPMENT:DROPLET & CONTACT AND AIRBORNE PRECAUTIONS (INCLUDES AEROSOL-GENERATING MEDICAL PROCEDURES) Routine practices. 24. COMPLETE appropriate laboratory requisitions indicating the site where blood sample was obtained, RN initials, and date and time. On the transfusion medicine requisition: sign, date and time the requisition in the appropriate space. Your signature MUST include full last name, and first name or first initial. Person who collects sample MUST be the person who signs the requisition.NOTE: For blood culture requisitions, location and ‘site’ requited. Refer to Pediatric Blood Culture Guide. ARRANGE for transport to the lab. Glass tubes/bottles must be transported via porter. Please refer to elab handbook for any special specimen transport considerations. NOTE: all samples being sent via pneumatic tube system in the Teck ACC building must be put inside appropriate zip and fold bag. If unable to locate zip and fold bag, a porter must be called to deliver specimens.Routine practices.DocumentationDOCUMENT on appropriate record(s) – Nurses Notes, PIV initiation flowsheet and/or CVL flowsheet if appropriateProcedure and timeAny difficulties with blood return from the CVLPatient’s response to procedure if unusualReferencesBoyce, J.M. and Pittet, D.?Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for hand hygiene in health-care settings.?MMWR Morbid Mortal Wkly Rep.?2002;?51:?1–45Clinical and Laboratory Standards Institute (formerly NCCLS) Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture: Approved Standard – Fifth Edition Hs-A5.Farjo, L. (2003). Blood Collection from Peripherally Inserted Central Venous Catheters. Journal of Infusion Nursing.26(6):374-379.Infusion Nurses Society (INS) (2016) Infusion therapy standards of practice. Standard 33: Vascular access site preparation and device placement. Journal of Nursing, 39(Suppl. 1) S64-S67 (Level VII) Knue, M., Doellman, D., Rabin, K. and Jacobes, B.R. (2005). The Efficacy and Safety of Blood Sampling Through Peripherally Inserted Central Catheter Devices in Children. Journal of Infusion Nursing. 28(1):30-35.Larwood, KA, Anstey, CM and Dunn, SV. (2000). Managing Central Venous Catheters: a Prospective Randomised Trial of Two Methods. Australian Critical Care. 13(2):44-50.Newman, CD. (2006). Catheter-Related Blood Stream Infections in the Pediatric Intensive Care Unit.Seminars in Pediatric Infectious Diseases. 17(1):20-24.O’Grady, N.P., Alexander, M., Burns, L.A., Dellinger E.P., Garland, J., Heard, S.O., Lipsett, P.A., Masur, H., Mermel, L.A., Pearson, M.L., Raad, I.I., Randolph, A., Rupp, M.E., Saint, S. and the Healthcare Infection Control Practices Advisory Committee (HICPAC).? (2011). Guidelines for the prevention of intravascular catheter-related infections, 2011.? Centers of Disease Control and Prevention.? Retrieved Dec 19 2019 from , Christine & Sriram, Sudhir & White, Melissa & Polinski, Carol & Seng, Carolyn & Schreiber, Michael. (2018). Feasibility and Outcomes Associated With the Use of 2.6-Fr Double-Lumen PICCs in Neonates. Advances in Neonatal Care. 19. 1. 10.1097/ANC.0000000000000570.Ogston-Tuck, S. (2012). Intravenous therapy: guidance on devices, management and care. British Journal of Community Nursing, 17(10):474-484.Registered Nurses’ Association of Ontario. (2008). Best Practice Guideline: Care and Maintenance to Reduce Vascular Access Complications. Retrieved December 19, 2019 from ByBCCH Oncology/Hematology/BMT Program – Clinical Nurse EducatorVersion HistoryDATEDOCUMENT NUMBER and TITLEACTION TAKEN03-Oct-2018CV.03.06 Blood Sampling From Central Venous Lines: Syringe MethodApproved at: BCCH Best Practice Committee06-Feb-2019C-05-12-60030 Blood Sampling From Central Venous Lines: Syringe MethodApproved at: BCCH Best Practice Committee01-Jun-2021“Approved at: C&W Best Practice CommitteeDisclaimerThis document is intended for use?within?BC Children’s and BC Women’s Hospitals only. Any other use or reliance is at your sole risk. The content does not constitute and is not in substitution of professional medical advice. Provincial Health Services Authority (PHSA) assumes no liability arising from use or reliance on this document.?This document is protected by copyright and may only be reprinted in whole or in part with the prior written approval of PHSA.? ................
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