65: Blood Sampling from a Central Venous Catheter

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Blood Sampling from a Central Venous Catheter

Teresa Preuss and Debra Lynn-McHale Wiegand

To obtain blood from the central venous catheter for laboratory analysis.

PREREQUISITE NURSING KNOWLEDGE

• Knowledge of anatomy and physiology of the cardiovascular system is needed.

• Understanding of principles of sterile and aseptic technique and infection control is necessary.

• The technique for specimen collection and labeling should be understood.

• Signs and symptoms of catheter-related infection and sepsis should be known.

• Infection has been identified as a potentially life-threatening complication of central venous catheterization, with an associated estimated mortality rate of 10% to 25% for each infection.4,6,10,12

• Knowledge of strategies to prevent catheter-related infections is essential.7,8,11

• Knowledge regarding the care of patients with central venous catheters (CVCs) is needed (see Procedure 82).

• Understanding of the principles of hemodynamic monitoring is necessary.

• The effect of heparin and hemolysis on various blood tests and appropriate discard volumes should be understood.

• Although blood can be withdrawn from CVCs, alternate routes of blood withdrawal (e.g., venipuncture, arterial catheters) should be considered first to minimize the risk of central venous catheter-related bloodstream infections.

• A needleless system should be used for capping and accessing CVC ports. Study results show that needleless systems not only reduce needle-stick injuries and the resultant risk for transmission of blood-borne infection to healthcare workers ⁸ but also may reduce central venous catheter-related bloodstream infections.^1,3

EQUIPMENT

• Nonsterile gloves

• Goggles or fluid shield face mask

• Antiseptic solution (e.g., 2% chlorexidine-based solution)

• Needleless blood sampling access device

• Blood specimen tubes

• 10-mL syringe

• Sterile normal saline solution for injection

• Extra blood specimen tube for discard

• Laboratory form and patient identification specimen labels

Additional equipment to have available as needed includes the following:

• 4 × 4 gauze pad

• Needleless caps

PATIENT AND FAMILY EDUCATION

• Explain the purpose for blood sampling to the patient and family. Rationale: Teaching provides information and decreases anxiety and fear.

• Explain the patient’s expected participation during the procedure. Rationale: This explanation increases patient cooperation and assistance.

PATIENT ASSESSMENT AND PREPARATION

Patient Assessment

• Assess the patency of the CVC. Rationale: This ensures a functional CVC catheter. If the CVC is clotted, blood sampling cannot be performed.

• Assess previous laboratory results. Rationale: These results provide baseline data andv data for comparison.

• Assess whether intravenous solutions or medications are infusing through the CVC. Rationale: Intravenous solutions and medication need to be stopped temporarily before blood sampling.

Patient Preparation

• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the correct identification of the patient for the intended intervention.

• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.

• Position the patient so that the blood sampling port is exposed. Rationale: This positioning improves the ease of obtaining the blood sample and minimizes the contamination of the stopcock.

Procedure for Blood Sampling from Central Venous Catheters

Figure 65-1 Needleless blood sampling device attached to the needleless capped stopcock of the hemodynamic monitoring system. The stopcock is open to the transducer system. (Drawing by Paul W. Schiffmacher, Thomas Jefferson University, Philadelphia, PA.)

Figure 65-2 Needleless blood sampling device attached to the needleless capped stopcock of the hemodynamic monitoring system. The stopcock is turned “off” to the monitoring system and flush solution. (Drawing by Paul W. Schiffmacher, Thomas Jefferson University, Philadelphia, PA.)

Figure 65-3 A syringe attached to the port of the three-way stopcock. The stopcock is turned “off” to the patient. The system is open between the flush solution and the syringe attached to the needleless cap. (Drawing by Paul W. Schiffmacher, Thomas Jefferson University, Philadelphia, PA.)

Figure 65-4 A syringe attached to the port of the three-way stopcock. The stopcock is turned “off” to the monitoring system and flush solution. The system is open between the patient and the syringe attached to the needless cap. (Drawing by Paul W. Schiffmacher, Thomas Jefferson University, Philadelphia, PA.)

Figure 65-5 The needleless blood sampling device attached to the needleless cap of the CVC port. (Drawing by Paul W. Schiffmacher, Thomas Jefferson University, Philadelphia, PA.)

References

1. Bouza, E, et al, A needleless closed system device (CLAVE) protects from intravascular catheter tip and hub colonization. a prospective randomized study. J Hosp -Infection 2003; 54:279–287.

2. Carlson, KK, et al. Obtaining reliable plasma sodium and glucose determinations from pulmonary artery catheters. Heart Lung. 1990; 19:613–619.

3. Casey, AL, et al. A randomized, prospective clinical trial to assess the potential infection risk associated with the PosiFlow needleless connector. J Hosp Infection. 2003; 54:288–293.

4. Kluger, DM, Maki, DG. The relative risk of intravascular device related bloodstream infections in adults [abstract]. In: In Abstracts of the 39th Interscience Conference on Antimicrobial Agents and Chemotherapy. San Francisco, CA: American Society for Microbiology; 1999:514.

5. Krueger, KE, et al. The reliability of laboratory data from blood samples collected through pulmonary artery catheters. Arch Pathol Lab Med. 1981; 105:343–344.

6. Maki, DG. Pathogenesis, prevention and management of infections due to intravascular devices used for infusion therapy. In: Bison AL, Waldvogel F, eds. Infections -associated with indwelling medical devices. Washington, DC: American Society for Microbiology; 1989:161–177.

7. Mermel, LA, Prevention of central venous catheter–related infections. what works other than impregnated or coated catheters. J Hosp Infection. 2007; 65(Supp 2):30–33.

8. O’Grady, NP, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control. 2002; 30:476–489.

9. Palermo, LM, Andrews, RW, Ellison, N. Avoidance of heparin contamination in coagulation studies drawn from indwelling lines. Anesth Analg. 1980; 59:222–224.

10. Pittet, D, Tarara, D, Wenzel, RP, Noscomial bloodstream infection in critically ill patients. excess length of stay, extra costs and attributable mortality. JAMA 1994; 271:1598–1601.

11. Safdar, N, Kluger, DM, Maki, DG. A review of risk factors for catheter-related bloodstream infection caused by percutaneously inserted, noncuffed central venous catheters. Medicine. 2002; 81:466–479.

12. Smith, RL, Meixler, SM, Simberkoff, MS. Excess mortality in critically ill patients with nosocomial bloodstream infections. Chest. 1991; 100:164–167.

Additional Readings

Beutz, M, et al. Clinical utility of blood cultures drawn from central vein catheters and peripheral venipuncture in critically ill medical patients. Chest. 2003; 123:854–861.

Maki, DG, et al, The risk of bloodstream infection in adults with different intravascular devices. a systematic review of 200 published prospective studies. Mayo Clin Proc 2006; 81:1159–1171.

Shapey, IM, et al, Central venous catheter-related bloodstream infections. improving post-insertion catheter care. J Hosp Infection 2009; 71:117–122.

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Aacn Procedure Manual for Critical Care