N=74

Comparison of aPTT values from venipuncture and central venous access device specimens in hospitalized adult patients receiving continuous heparin infusions
Mary Sue Dailey APN-CNS, Fortunata Dabu, RN, BSN, Sue Durkin, APN- CNS, Barbara Kohn, MTRN, BSN, Barbara Berger, PhD, RN

Introduction
CONTINOUS HEPARIN INFUSIONS require monitoring aPTT values. Blood samples can be collected from a central venous access device (CVAD) if present or from a peripheral vein (PV). If heparin is infusing through a CVAD, how should aPTTs be collected? Peripheral specimen required/desired? From CVAD acceptable? Desired port? Turn off infusion? How long? Flush first? Waste amount?

Discrepancies at Start of Study

Policies Lab: Turn off infusion Waste depends on dead space 5-12mL Nursing: No mention of stopping infusion first No mention of desired port Waste first 6 mL Professional Standards -- Infusion Nursing Society (INS) (2006) Stop infusion Flush with 3-5 mL saline Distal lumen preferred Discard volume = to 1.5-2 times the fill volume of the CVAD Manufacturers Guidelines . Arrow ( TLC)
Use proximal port Turn off distal infusions for at least one minute Discard volume varies from priming volume (dead space) to 3-10mL

Sample Characteristics
Age: mean = 67.5 yrs (SD 13.8), median = 70, range 26 to 94 Sex: 36 females (49%), 38 males (51%) Race: 63 white (85%), 11 other (15%)

PTT difference (seconds) By line type By indication

Results
variable PTT (seconds) PTT difference (seconds) From central line From venipuncture (CVAD venipuncture) n 74 74 74 mean (SD) 82.1 (47.2) 74.0 (42.0) 8.1 (34.6) t73 = -2.017 .047 Test statistic p-value

Additional infusions

By collection method By additional specimens By time infusion off

PICC Other central line DVT / PE Cardiac Other Heparin only Heparin + fluids Heparin + meds Syringe Vacutainer Yes No 1 minute >1 minute

n 55 19 34 32 8 24 19 25 53 21 7 67 55 19

mean (SD) Test statistic p-value -16.7 (55.0) t20.4= -0.881 .389 -5.2 (24.1) -2.0 (29.6) -11.9 (35.0) F2,71 = 1.099 .339 -18.8 (50.7) -5.1 (29.4) 2.7 (25.5) F2,65=2.534 .087 -20.4 (44.7) -7.6 (32.6) t72 = 0.205 .838 -9.4 (40.2) -27.1 (52.0) t72 = 1.538 .128 -6.1 (32.3) -11.2 (38.8) t72 = -1.307 .196 0.8 (15.2)

Purpose
Is there a clinically significant difference between the aPTT results from a CVAD specimen and a peripheral venipuncture (VP) when the patient is receiving continuous heparin through the CVAD?
.

PTT difference by relative position of sampling port

Discussion
PTT values between CVAD & peripheral specimens were significantly different if sample was drawn from heparin infusion port; there was no difference between peripheral & CVAD specimens if sample was drawn from port either proximal or distal to heparin infusion port. For nurses, compatibility of infusates was of greater concern than which port of the CVAD was used for the infusion, resulting in no standard approach to which drug should be infused where. After study began, the INS (2011) issued standards recommending coagulation studies not be drawn from lines with any exposure to heparin. Institution policies were recently revised to recommend peripheral specimens for coagulation studies.

Bard ( PICC)
Flush per hospital protocol Waste 2-6 X the priming volume 5mL = 6x the priming volume of all nontunneled PICC

Relevant Literature
Venipuncture vs Heparinized Arterial Line
Alzetani (2004)( n=49) Arterial aPTT unreliable Heap ( 1997) (n=79) Arterial aPTT valid 96% of time

Venipuncture vs Heparinized CVAD without continuous heparin infusion

Humphries and Baldwin (2012)( n=30) Power =.71 0.99 correlation between PICC and VP specimens Rondina (2007) (n= 41) No significant difference between CVAD and VP specimen Hinds (2002) (n=53 pediatric patients with tunneled CVAD ) Tunneled CVAD results inaccurate but as discard volume increased paired results closer ( tested 6,9,12mL discards)

Actual RN practice at Good Samaritan Hospital 134 respondents completed an online survey in 2009 82% flushed prior to obtaining sample 50% wasted 10 mL 56% collected the coagulation specimen first 94% stopped the infusion

Recommendations
PTT difference (seconds) by relative position of specimen port to heparin infusion port Specimen from heparin port Specimen from a port proximal to heparin port Specimen from a port distal to heparin port n mean (SD) Kruskall Wallis test pvalue

Study Design & Methods

Paired blood specimens (CVAD & peripheral venipuncture) from 74 patients receiving a continuous heparin infusion through a CVAD. Specimens were collected simultaneously by a research RN and a phlebotomist Protocol: turn off infusions for at least 1 minutes, flush line with 10 ml., wait 1 minute, draw and discard 10ml, then draw aPTT specimen. Power = .80 with alpha=.05

Venipuncture vs CVAD-with continuous heparin infusion

Bellmunt. P, et al. (2000) (n=74) Significant difference in aPTT between CVAD and venipuncture specimens with either a 10 or 20mL discard -- the difference was slightly lower with 20mL discard (10.6 sec aPTT difference with 20mL discard vs. 12.7 sec with 10mL discard)

15 27

-31.0 (43.8) -3.0 (24.7) X22=13.007

Collect aPTT specimen from peripheral venipuncture if possible If CVAD specimen necessary: Collect from port without a heparin infusion Follow INS guidelines-turn heparin off 5 minutes prior to specimen collection Designate port for heparin infusion- proximal port is preferred as blood flow diffuses drug into circulation.
Thanks to data collectors:
Colleen OLeary, APN, Karen Calimlim, RN, Carrie Bauman, RN, Barbara Gulczynski,APN, Karen Hagemaster, RN, Joy Kennedy, RN, Cindy Zaletel, APN

.001

25

-1.4 (37.3)