Blood Sampling & Interventional Radiology

Common language facilitates communication between professional and organisations, the translation of evidence into clinical practice, data sharing, and research. CNSA, eviQ and eviQ Education are leading vascular access management and education in cancer care in Australia utilizing common, contemporary terminology (Table 1).

Table 1: CVAD terminology

CNSA recommends that:

1. Blood Sampling:

Central venous access devices (CVADs) for adult and paediatric patients with cancer can be used for blood sampling procedures (1-20).

Peripheral intravenous cannulas (PIVCs) for adult and paediatric patients with cancer can be used for blood sampling at the time of insertion of the cannula (21). Consider the risks and benefits (22,23).

If SACTs, irritants, and vesicants are to be administered via a PIVC, take blood samples at the time of PIVC insertion only, and do not use the PIVC for blood sampling during the dwell time. This is to prevent patency complications related to blood sampling that may impact the administration of SACTs, vesicants and irritants, and potential venous injury that may increase the risk of infiltration or extravasation of these medications.

And incorporating the following practices:

• Order and blood conservation. Obtain blood samples using the recommended order of draw and blood conservation strategies to reduce anaemia from regular draws e.g. eradicate routine or non essential blood sampling, consolidate or combine tests which use the same type of tube where possible or use smaller volume tubes where appropriate (24)
• Flushing pre and post blood sampling:
  • CVAD: flush with 10mL 0.9% sodium chloride for injection (3,9) pre blood sampling and 20mL (1,10,13) post blood sampling. Reduce the volume if clinically appropriate or for paediatric patients.
  • PIVC: flush with 3mL 0.9% sodium chloride for injection (8) pre and post blood sampling.

Refer to flushing and locking question for more detail.

• Technique:
  • CVAD: use a pulsatile flushing technique (3,8,25) with a 10mL luer lock syringe and complete with the appropriate clamp disconnection sequence (3,8) according to the type of needleless connector to maintain a positive pressure and reduce the risk of blood reflux into the catheter tip.
  • PIVC: flush with a slow and steady technique.

Refer to flushing and locking question for more detail.

• Equipment:
  • CVAD and PIVC – prepare equipment for flushing prior to commencement to avoid delays post blood sampling to ensure blood is efficiently, effectively and promptly removed from the internal lumen surface of the catheter (8).
• Special Considerations:
  Some blood samples require special consideration including:
  • Blood cultures:
    • Peripheral: take via peripheral venepuncture to reduce the risk of contamination when taking from PIVC during insertion. Do not take from indwelling PIVC (22).
    • Peripheral blood cultures and simultaneous CVAD cultures are collected for investigation of suspected CVAD related infection (22).
    • CVAD: replace the needleless connector prior to obtaining the sample, first blood specimen, commonly used as the discard, is instilled into the blood culture bottles (21,22).
  • Coagulation testing, medication serum levels, serum electrolyte during parenteral nutrition e.g.
    • CVAD: use a different lumen for blood sampling to the lumen used for anticoagulant or medication administration (22,24).
    • Strategies to reduce the risk of incorrect elevated levels include: (a) flush the lumen with 0.9% sodium chloride prior to serum, (b) take adequate blood discard prior to blood sampling for adults and appropriate amount for paediatric patients according to age and type of device e.g. 6mLs for adult, 3mLs for paediatric patients and (c) ensure all infusions are turned off during blood sample (if clinically safe to do so) (24).
    • Peripheral venepuncture: when a patient has a single lumen CVAD or PIVC only (24).
    • Cyclosporin levels may require a peripheral sample if serum levels are increased or abnormal (26).

2. Interventional Radiology:

CNSA recommends central venous access cevices (CVADs) that have been manufactured and documented to tolerate the pressures exerted by power injectable technology, should be considered for interventional radiological investigations for adult and paediatric patients with cancer (27) and

• Performed by educated and competent clinicians
• After confirmation of
  • Assessment of the power-injectability capacity to detect any system abnormalities of the:
    • CVAD
    • Non coring needle for totally implantable venous access devices (TIVADs)
    • All add-on equipment
  • CVAD patency refer to Patency Assessment
    • All practices align with recommendations for infection prevention
    • CVADs are flushed post procedure with at least 20mL 0.9% sodium chloride for injection in adults and an appropriate increased volume for paediatric patients, using a pulsatile technique and completed with the appropriate clamp disconnection sequence according to the type of needleless connector to maintain a positive pressure and reduce the risk of blood reflux into the catheter tip.

An alternative practice to using a CVAD, is to use a newly inserted, appropriate gauge PIVC in a large, healthy vein for rapid infusion of the contrast medium and improved image quality (27). A CVAD is preferred to reduce the pain, anxiety and cost of insertion of a new PIVC (27).

CNSA recommends any complications encountered during interventional radiology procedures are entered into the CVAD database/registry/clinical incident management system at the individual health care organisation.

Refer to the individual product Instructions For Use (IFU).

1.1 Summary of Evidence

CVADs

Numerous studies identify blood sampling as one of the essential functions of CVADs including:

Adult literature review and international vascular access expert consensus (5). Frequent blood sampling is an indication for insertion of

• Centrally inserted central catheters (CICCs) for short term use (e.g. up to 14 days) in critically ill patients are preferred, compared to peripherally inserted central catheters (PICCs) for this timeframe
• PICCs: for use greater than or equal to 6 days. PICCs are preferred to tunnelled CVADs (if use 15-30 days
• Tunnelled CVADs - neutral / lack of consensus for a recommendation for insertion for frequent blood sampling greater than or equal to 15 days
• Frequent blood sampling is not an indication for TIVAD insertion

TIVADs

Adult:

• Prospective observational study involving 150 standard blood sampling procedures by 111 oncology nurses stated standard procedure was to flush with 10mL prior and 10mL post with 0.9% sodium chloride for injection (9)
• Prospective, observational, cohort study stated 20mL 0.9% sodium chloride for injection was required post blood sampling (13)
• Prospective study stated patients and medical staff “often decide to keep the port in place after chemotherapy has been completed because of the frequent need for blood sampling” (7)
• Retrospective comparative study comparing TIVADs with valved catheters versus non-valved/open catheters stated TIVADs are used for routine collection of blood samples (18)

Adult and Paediatric:

• Randomised control study (RCT) with 802 participants stated blood sampling must be completed by using standardised practices of flushing the TIVAD with 10mL of 0.9% sodium chloride for injection before and 20mL after blood sampling using a pulsatile flushing technique and completing the procedure with a positive pressure clamping technique (10)
• Questionnaire including 44 hospitals identified the main reason for TIVAD insertion was for chemotherapy but in 14% of hospitals, TIVADs were inserted for chemotherapy and blood sampling. Also flushing practices were essential post blood sampling: pulsatile technique and completed using a positive pressure clamping technique (6)
• Descriptive, retrospective study stated TIVADs were primarily used for chemotherapy and blood sampling (11)

Paediatric:

• Small retrospective study of patients with mainly haematological malignancies had their TIVADs used for blood sampling (16)
• TIVADs and tunnelled cuffed-centrally inserted central catheters – a large, paediatric, prospective, longitudinal surveillance study stated these devices were used for daily blood sampling (4)

PICCs

Adult

• RCT comparing PICCs inserted on the left compared to the right side, stated PICCs were widely used for administration of medication as well as blood sampling (15)
• Retrospective study with 57 participants with haematological malignancies undergoing stem cell transplants used PICCs for blood sampling by flushing with 10mL 0.9% sodium chloride for injection prior and 20 mL post (1)
• Large observational study also used PICCs for blood sampling (12)
• Small cohort study (n=22) of male patients with head and neck cancer found haemolysis rates were lower when sampling from the PICC in comparison to venepuncture, with no cases of occlusion (20)

Paediatric

• PICCs and tc-CICCs: a Cochrane review identified the purpose of inserting these devices is for the administration of medication and fluids and collection of blood specimens to avoid unnecessary venepunctures (3) – flush before and after blood collection, positive pressure lock technique

Centrally Inserted Central Catheters (CICCs) – tunnelled and non-tunnelled, and tc-CICCs

Adult

• Survey of 23 Dutch and Belgian haematology oncology centres identified tunnelled and non-tunnelled CICCs were frequently used for blood sampling (2)

Paediatric

• Observational study identified blood sampling via a CICC improved quality of life (14)

Adult and paediatric

• A Cochrane review discussing the restoration of patency for occluded CICCs identified blood sampling was one of the functions of a CICC (17)
• Expert opinion states CICCs can be used for obtaining blood samples (19)

One study did not support blood sampling from CVADs: an adult, prospective observational study of TIVADs stated these devices were not intended for routine blood sampling, however blood cultures were acceptable (28).

PIVCs

A literature review of adult studies by an international, multispecialty expert panel stated frequent blood sampling was one of the indications for insertion of PIVCs of 5 or less days (5).

Expert opinion in two articles state all vascular access devices, peripheral and central can be used for blood sampling (8,25).

No studies in patients with cancer were identified in this search.

The Infusion Therapy Standards of Practice state to consider the risks and benefits (22). Risks include haemolysis, contamination from infusates, and local complications including accidental removal. Potential benefits include reduced number of venepunctures, potential vein damage, reduced stress or anxiety for the patient.

1.2 Practice Recommendation

CNSA recommends that central venous access devices for adult and paediatric patients with cancer can be used for blood sampling procedures (1-20).

GRADE Ib

CNSA recommends that peripheral intravenous cannulas for adult and paediatric patients with cancer can be used for blood sampling at the time of insertion of the cannula (21). Consider the risks and benefits (22,23).

GRADE IV

If antineoplastic medications, irritants, and vesicants are to be administered via a PIVC, take blood samples during PIVC insertion only, and do not use the PIVC for blood sampling post insertion. This is to prevent patency complications related to blood sampling that may impact the administration of antineoplastic medications, irritants, and vesicants and potential venous damage that may increase the risk of infiltration or extravasation of these medications.

2.1 Summary of Evidence

Studies that support blood sampling from CVADs and PIVC practices also recommend the following essential practices:

CVADs:

• Flushing pre and post blood sampling: flush with 10mL 0.9% sodium chloride for injection (3,8,9) pre and post blood sampling and several studies state to increase the volume to 20mL post blood sampling (1,10,13). Reduce the volume as clinically appropriate for adult patients with cardiac or renal impairment and paediatric patients.
• Technique – use a pulsatile flushing technique pre and post blood sampling (3,8,25) to remove blood components from the internal surface of the catheter and complete it with a positive pressure clamping technique (3,8)
• Equipment – prepare equipment for flushing to avoid delays post blood sampling to ensure blood is efficiently and effectively removed from the internal lumen surface of the catheter (8)

A small prospective observational study with 52 participants showed increased serum cyclosporin levels in samples obtained from a double lumen PICC compared to samples via venepuncture, despite using a dedicated lumen for sampling which was not used for the infusion, pausing the infusion for 5 minutes and peforming a 5mL blood discard (26).

PIVCs:

One expert opinion article (8) stated:

• Flushing post blood sampling: flush with 0.9% sodium chloride for injection post blood sampling
• Technique – pulsatile flush technique can also be used for Peripheral Intravenous Cannulas
• Equipment – ensure all flushing equipment is ready so there is no delay in flushing post blood sampling to ensure blood is efficiently and effectively removed from the internal lumen surface of the cannula

2.2 Practice Recommendation

CNSA recommends that practices associated with blood sampling should include the following for adult and paediatric patients with cancer:

1. Order and blood conservation:

• Obtain blood samples using the recommended order of draw and blood conservation strategies to reduce anaemia from regular draws e.g. eradicate routine or non essential blood sampling, consolidate or combine tests which use the same type of tube where possible or use smaller volume tubes where appropriate (24)

2. Flushing pre and post blood sampling:

• CVAD: flush with 10mL 0.9% sodium chloride for injection (3,9) pre blood sampling and 20mL (1,10,13) post blood sampling. Reduce the volume as clinically appropriate for adult patients with cardiac or renal impairment or for paediatric patients.
• PIVC: flush with 3mL 0.9% sodium chloride for injection (8) pre and post blood sampling.

Refer to flushing and lock question for more detail

3. Technique:

• CVAD: use a pulsatile flushing technique (3,8,25) with a 10mL syringe and complete with the appropriate clamp disconnection sequence (3,8) according to the type of needleless connector to maintain a positive pressure and reduce the risk of blood reflux into the catheter tip.
• PIVC: flush with a slow and steady technique.

Refer to flushing and lock question for more detail

4. Equipment

• CVAD and PIVC – ensure all flushing equipment is ready so there is no delay in flushing post blood sampling to ensure blood is efficiently and effectively removed from the internal lumen surface of the catheter (8)

5. Special Considerations:

Some blood samples require special consideration including:

• Blood cultures:
  • Peripheral: take via peripheral venepuncture to reduce the risk of contamination when taking from PIVC during insertion. Do not take from indwelling PIVC (22).
  • Peripheral blood cultures and simultaneous CVAD cultures are collected for investigation of suspected CVAD related infection (22).
  • CVAD: replace the needleless connector prior to obtaining the sample, first blood specimen, commonly used as the discard, is instilled into the blood culture bottles (21,22).
• Coagulation testing, medication serum levels, serum electrolyte during parenteral nutrition e.g
  • CVAD: use a different lumen for blood sampling to the lumen used for anticoagulant or medication administration (22,24).
  • Strategies to reduce the risk of incorrect elevated levels include: (a) flush the lumen with 0.9% sodium chloride prior to serum, (b) take adequate blood discard prior to blood sampling for adults and appropriate amount for paediatric patients according to age and type of device e.g. 6mLs for adult, 3mLs for paediatric patients and (c) ensure all infusions are turned off during blood sample (if clinically safe to do so) (24).
  • Peripheral venepuncture: when a patient has a single lumen CVAD or PIVC only (24).
  • Cyclosporin levels may require a peripheral sample if serum levels are increased or abnormal (26).

GRADE: V

3.1 Summary of Evidence

An international expert consensus document by medical oncologists, surgeons, interventional radiologists, nurses, infection control and vascular access experts discussed the use of power-injectable TIVADs for investigations in interventional radiology (27). Possible risks of infection, infiltration or extravasation, blockage, damage or rupture of the body or catheter of the TIVAD were identified as well as the potential advantages, for example improved image quality and improved patient comfort. Finally, recommendations supported by the best currently available evidence for the safe use of TIVADs for investigations in interventional radiology were discussed including:

1. Education and competency assessment: are essential for all clinicians involved with insertion, access and maintenance of a TIVAD
2. Identification of power-injectability: prior to use, all components of the system including huber needle, attachments and the device must be verified for power injectability
3. Scout view: a preliminary scan of the system is ‘mandatory’ (27) to assess for kinks, malposition and abnormalities
4. Patency: must be assessed and confirmed prior to use for interventional radiology procedures
5. Prevention of infiltration or extravasation: access of the TIVAD by educated and competent clinicians, patency is verified (free aspiration of blood and easy injection of fluid), huber needle is secured and covered by a transparent semipermeable polyurethane dressing and the device is monitored during the procedure.
6. Infection prevention: all infection prevention measures are taken as per current vascular access guidelines
7. Flushing: TIVAD is flushed with at least 20mL 0.9% sodium chloride for injection using a pulsatile technique and completed with the appropriate clamp disconnection sequence according to the type of needleless connector to maintain a positive pressure and reduce the risk of blood reflux into the catheter tip

3.2 Practice Recommendation

1. CNSA recommends a central venous access device that has been evaluated to tolerate the pressures exerted by power injectable technology should be considered for interventional radiological procedures for adult and paediatric patients with cancer (27) and:

Performed by educated and competent clinicians

• After confirmation of
  • Assessment of the power-injectability capacity to detect any system abnormalities of the:
    • CVAD
    • Huber needle for Totally Implanted Venous Access Devices
    • All add-on equipment
  • CVAD patency refer to Patency Assessment
• All practices align with recommendations for infection prevention
• CVADs are flushed post procedure with at least 20mL 0.9% sodium chloride for injection using a pulsatile technique and completed with the appropriate clamp disconnection sequence according to the type of needleless connector to maintain a positive pressure and reduce the risk of blood reflux into the catheter tip

An alternative practice to using a CVAD is to use a newly inserted, appropriate gauge peripheral intravenous cannula with a corresponding large, healthy vein for rapid infusion of the contrast medium (27). A CVAD is preferred to reduce the pain, anxiety and cost of insertion of a new PIVC (27).

2. CNSA recommends any complications encountered during interventional radiology procedures are entered into the CVAD database/registry/clinical incident management system at the individual health care organisation.

Refer to eviQ for more information on www.eviq.org.au/clinical-resources/extravasation

GRADE: V

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18. Zottele Bomfim GA, Wolosker N, Yazbek G, Bernardi CV, Valentim LA, De Castro TM, et al. Comparative study of valved and nonvalved fully implantable catheters inserted via ultrasound-guided puncture for chemotherapy. Ann Vasc Surg. 2014;28(2):351-7.

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