Fibrin sheath and port occlusion

[StephN]

Since a few of us here have had port problems, thought I would add a little more information on the causes of clogging.

I posted and then the server problems here "ate" a few threads including mine on the port problem, which had some good replies and perhaps some I did not see.

My catheter line had a small loop in it a little ways past my port and this must have happened at the initial placement according to my experts at the cancer center. This was discovered during a DYE STUDY done under a Flouroscope, which is also what they use to follow the insertion of the catheter in a new placement. The loop was not obstructing. The problem was a fibrin sheath that had thickened where the catheter enters the vein.

Here is some info on how this happens. Another site I read said that fibrin buildup starts only a few minutes after the catheter is placed in the vein. This is from the platelets and clotting factors that come rushing to the incision site.

Central Line Complications

Partial Catheter Occlusion

Causes:

* Common occurrence in long-term catheters secondary to long dwell-time of these catheters.

* Encasement of the catheter by a fibrin sheath. The fibrin sheath may also become seeded with microorganisms which may disseminate into the bloodstream.

*Residue of blood products deposited within some central venous access devices each time blood is aspirated or infused.

*Small clots adhering to the catheter tip.

*Drug precipitation adhering to the wall of the catheter.

Signs and Symptoms:
* Withdrawl occlusion - the inability to withdraw blood from the catheter but are able to infuse fluid. The fibrin sheath or blood/drug precipitates acts as a flap over the tip of the catheter when blood is withdrawn but opens when fluid is injected.

Interventions:

* Do not infuse any product through a central line that does not have a blood return.

*Notify the physician.
* May need chest x-ray for verification of tip placement.

Prevention:
* Strict adherence to the flushing protocol before and after drug infused and after blood drawn.

*With persistent withdrawl occlusion, may need to follow the fibrinolytic agent protocol to lyse the fibrin sheath or cleanse the catheter of residual blood products.


http://www.rncentral.com

Steph - thanks for this info. Have been unable to draw from port last two infusions and nurses did not seem concerned - I will point this info out to my onc this week. Again thanks!

[mamacze]

Dear Steph,
Thank you once again for providing helpful info, this time for your sisters with ports. I am grateful to catalogue this in the dusty annals of my mind for future reference should I need it.
Love Kim from CT

[Lolly]

Steph, I can completely symphathize with your ordeal as I am on my third port since 2001. My problems were caused by "pinch-off" syndrome, and I've copied a PubMed article and included the link so others can be aware of this rare complication. The symptoms are very similar to those caused by a fibrin sheath, but my ports would also be difficult to infuse, a give-away for this complication. My surgeon finally got around this problem by by-passing the clavicular junction and accessing the vein in my shoulder.
Even though I've had a few problems with my port(s), I would not consider doing without it as I only have one good vein in my one good arm (lymphedema in the other).

Pinch-Off Syndrome/PubMed
http://www.ncbi.nlm.nih.gov/entrez/q...&dopt=Abstract

Pinch-off syndrome: a rare etiology for central venous catheter occlusion.

Andris DA, Krzywda EA, Schulte W, Ausman R, Quebbeman EJ.

MedicalCollege of Wisconsin, Department of Surgery, Milwaukee53226, USA.

BACKGROUND: Catheter pinch-off syndrome is a rare and often misdiagnosed complication of tunneled Silastic central venous catheters. Pinch-off syndrome occurs when the catheter is compressed between the first rib and the clavicle, causing an intermittent mechanical occlusion for both infusion and withdrawal. We report its incidence in a large series of catheter insertions and describe the clinical presentation, radiographic findings, and recommended treatment. METHODS: A total of 1457 tunneled Silastic central venous catheters that were inserted using the percutaneous subclavian approach were prospectively studied. Indications for catheter placement included bone marrow transplant, continuous or intermittent chemotherapy, long-term antibiotics, and parenteral nutrition. Catheters were evaluated for clinical presentation of an occlusion relieved by postural changes and radiographic findings of luminal narrowing. RESULTS: Pinch-off syndrome was identified in 16 (1.1%) catheters. Radiographic findings were present in all catheters; clinical findings were present in 15 catheters. Clinical symptoms presented within a median of 2 days after placement (range, 0 to 167 days). Partial or complete catheter transection, a serious sequela of catheter pinch-off syndrome, occurred in 19% of the identified catheters. CONCLUSIONS: (1) Catheter pinch-off syndrome presents clinically as a catheter occlusion related to postural changes; (2) clinical symptomatology should be confirmed radiographically; and (3) catheter removal with a more lateral replacement in the subclavian vein or in the internal jugular vein will avoid a recurrent complication.

[sarah]

Sorry to hear so many of you have had port problems.

Steph,
the article stated:
Interventions:

* Do not infuse any product through a central line that does not have a blood return.

does that mean they should do a blood withdrawal before infusion or is it just a check afterwards? I think they just flush fluid through it first before infusion and only after the infusion at the end do they withdraw blood which they throw away.
thanks
sarah

[StephN]

Hi Sarah -
I know when my port is accessed the nurse will get ready to flush, but also checks for blood return. They sort of tease the syringe back and forth till they see a little blood entering the short line. You may not be aware of this as you would have to be looking down and watching.

The first time there was no blood return, the nurse was not worried as it flushed so normally/easily. The fear is that if there is no blood return there could be some leakage of the drug outside the catheter where it enters the vein. Some drugs should not reach tissue in this way. Since I was only getting Herceptin and not the harsh, really toxic stuff, the concern was minimal until it became the norm to where was NEVER a blood return any more.

[Barbara H.]

My nurse continuously checks for a blood return as she gives me Navelbine. Navelbine can really damage the tissues if it leaks out.
Barbara H.

[sadie]

Oh my gosh! I have not had a blood return since starting my Herceptin-only treatments.
The nurses do not seem concerned at all.
My concern is that the "no blood return" started after a little accident: The IV monitor fell off of the pole and it pulled the iv part way out of the port. They had to pull the iv out and start all over again.
The nurses tell me that as long as it flushes okay, there is no problem with no blood return. Should I be worried? I've never mentioned this to the onc.

[StephN]

Hi -
If you read the phamphlet that should have been given to you when your port was installed, it should tell you warning signs and what to do.

Generally, your med onc should be brought into the loop and let know that there has been no blood return. It is the doc who will order any kind of x-ray, dye study or TPA to try to "unplug" the tip or if there is a clot in the port disc itself.

Call your doc's nurse and let her know. If she is not concerned, ask to see the doc ASAP and see what he has to say. He SHOULD be concerned.
Good luck.

[sadie]

Thanks StephN for your quick reply.
I asked the nurse about it and she said as long as the port flushes with no resistance, it's fine.
I didn't receive any pamphlet regarding the port.
I'll be seeing the onc this week, so I'll mention it to her.
Thanks!

[StephN]

Was wondering if you got the plastic card with the information that you have such a device implanted that you carry in your wallet. They are supposed to give you that immediately to put in your wallet before you leave the facility that put in the port. Can't imagine that you did not get the pamphlet.

You can look on the plastic card or your records to see what kind of port you have and then maybe look it up on line.

Ports NEED to show a blood return. Good luck with the oncologist visit.

[sadie]

I received no card to put in my wallet.
Before all of my chemo, I had a "chemo-teach" class at the onc's office. The nurse showed me the type of port I would be getting. I also received an information packet that told me all about chemo; but nothing more about the port.
When I saw the surgeon, he described the port to me and how it would be surgically implanted. I was told that if I ever had an mri that I would need to tell them that I have a port in me.
Other than that, I was given/told nothing.
I think I'm going to have a loooong talk with my onc this week.
Thanks for all you info!

[cherylynnie]

Because I am not a nurse I don't know the name of the drug, but when I have had problems with blood return more than once in a row they infuse me with something to remove the sheath that could be causing the lack of blood return. During chemo, I had this done twice. But since I finished chemo , when they don't need my blood all the time they are able to get a blood return, go figure.

After they infused me with the drug to clear the sheath away. They were able to get blood both times. This process took any where from 1-2 hours.

[sadie]

I saw my onc today. I told her that I've been having a problem with "no blood return".
She said it could just be that the flap could actually be pulled/suctioned closed when they are trying to get a blood return or sometimes there could be little particles that block it. She said as long as it flushes ok, there is no problem.
I'm going to ask the nurses each and every time if there is a blood return and I'll track it more seriously from now on. I will mention the drug that Cherylynnie mentioned and see what they say. I believe this started when I was getting Herceptin-only treatments (when the iv monitor dropped off the pole and pulled the iv partway out of the port. I remember asking the nurse if that had anything to do with it and she said she doubts it. She said it happens sometimes and it's nothing to worry about right now.
Thank you all for your info!
By the way, the onc said she expects me to make a full recovery and she does not expect me to have any recurrence!