introduction continuous heparin infusions require monitoring of aptt values and appropriate...
TRANSCRIPT
IntroductionContinuous heparin infusions
require monitoring of aPTT values and appropriate adjustments in the
infusion rate.
If the heparin is infusing through the central venous access devices (CVAD), how should aPTTs
be collected? Peripheral required/desired? From CVAD acceptable?
Turn off infusion?Flush first?Waste amount?Desired port?
For patients with central venous access devices (CVAD), blood samples may be collected from the CVAD or from a peripheral vein.
Comparison of aPTT values from venipuncture and central venous access device specimens in hospitalized adult patients receiving
continuous heparin infusionsMary Sue Dailey, APN- CNS, Fortunata Dabu, RN, BSN, Sue Durkin, APN- CNS, Barbara Gulczynski, APN- CNS, NP,
Colleen O’Leary, APN-CNS, Carrie Bauman, RN, BSN, Karen Calimlim, RN, BSN, Karen Hagemaster, RN, BSN, Joy Kennedy, RN, BSN, Barbara Kohn, MTRN, BSN,
Comparison of aPTT values from venipuncture and central venous access device specimens in hospitalized adult patients receiving
continuous heparin infusionsMary Sue Dailey, APN- CNS, Fortunata Dabu, RN, BSN, Sue Durkin, APN- CNS, Barbara Gulczynski, APN- CNS, NP,
Colleen O’Leary, APN-CNS, Carrie Bauman, RN, BSN, Karen Calimlim, RN, BSN, Karen Hagemaster, RN, BSN, Joy Kennedy, RN, BSN, Barbara Kohn, MTRN, BSN,
Selected References
Preliminary ResultsPaired blood specimen results compared
62% of specimens correlate within 10%
Further data analysis concerning type of line, concurrent infusions, and other clinical variables will be performed
Previous StudiesVenipuncture vs Peripheral VAD•Powers (1999) n=32•Prue-Owens (2006) n=23
Venipuncture vs Arterial Line•Alzetani (2004) n=49•Heap (1997) n=79
Venipuncture vs CVAD•Bellmunt. P, et al. (2000) n=74•Humphries and Baldwin (2009) n=30
.
Discrepancies
PoliciesLab•Turn off infusion•Waste depends on dead spaces : 5-12mL•Coags first
Nursing•Does not mention stopping infusion first•No mention of “desired port”•Waste first 6 mL•No guidelines regarding order of tube fillProfessional
StandardsInfusion Nursing Society (2006)•Stop infusion•Flush with 3-5 mL•Distal lumen preferred•Discard volume equal to 1.5-2 times the fill volume of the CVAD
Manufacturer’s Guidelines Arrow (TLC)
Use proximal port Turn off distal infusions for at least
one minuteDiscard volume varies from priming
volume (dead space) to 3-10mL
Bard (PICC)Flush per hospital protocolWaste 2-6 X the priming volume 5mL = 6x the priming volume of all non-
tunneled PICC
Study DesignPaired blood samples from 80 patients receiving a continuous heparin infusion through a CVAD will be collected by a research RN and a lab phlebotomist•CVAD specimen•Peripheral Venous specimen•Need 74 subjects (37 in each group) to detect a 2 second difference between specimens (SD 3 seconds) Power of .80 and alpha=.05
Clinical environment and demographic data collected
Further Data AnalysisComparison of paired blood specimen results, screening for outliers, and unexpected variations
Further review of Clinical Environment and Demographic data to be done, including analysis of trends per individual research RN
Following data verification, descriptive statistics
will be generated
Obstacles and Solutions
Actual RN practice 134 respondents completed
online survey•82% flush prior to obtaining sample•50% waste 10 mL•56% collected coag specimen first•94% stop infusion
Range of % Difference of Lab Draw aPTT and RN aPTT
Purpose of StudyIs there a clinically significant difference between
the aPTT results from a specimen collected fromCVAD and a specimen collected from a peripheralvein? Patient Consent- Many critically ill
Patient/ Family reluctant/unwilling to be “stuck”Concurrent focus on central line
necessityReports generated early AM- patient
condition changes Research RN coverage
• Bellmunt. P., et al. (2000). Sample extraction through central venous catheters to control partial thromboplastin time in patients undergoing heparin sodium perfusion. Enfermeria Intensiva 11(4), 155-60.
• Humphries, L., & Baldwin, K. (2009). A study comparing test results from PICCs and veinipunctures. Poster presentation at National Association of Clinical Nurse Specialists Annual Conference.