Central Lines: All you ever wanted to know Allison Ballantine, MD Assistant Professor of Pediatrics Medical Director, Integrated Care Service Director of Education Division of General Pediatrics The Children’s Hospital of Philadelphia
Part 1: The Devices
PICC
Alternative PICC sites
Tunneled CVC’s (Broviac or Hickman) Cuff Tunnel entrance Vessel entrance
Subcutaneou s Port Oreilly.com Tunnel Port
Centrally Inserted, Non- Tunneled Devices (Arrow or Cook)
Other Devices “Statlock” securement device “Biopatch” chlorhexidine sponge
Arm PICC Tunneled Femoral PICC Femoral PICC Tunneled IJ Broviac/Port Tunneled IJ Broviac (posterior)
pH and osmolarity What can you give peripherally? –pH between 5 and 9 (What works? 9 to 5) –Osmolarity < 600 mOsm/L –Samples of agents that are not in these ranges: Acyclovir: pH = 10 – 11 –Acyclovir = ammonia Vancomycin pH = –Vanco = vinegar Phenytoin: pH = 12 –Dilantin = Draino
Part II: Catheter-Related Complications Catheter Insertion - pneumothorax - vascular injury - air embolism - arrhythmias Catheter Removal -bleeding -air embolism Catheter Use - fibrin and thrombosis formation - dysfunction - infection
CDC Public Health Image Library Fibrin and Thrombosis
“Saran-wrap” layer of thin fibrin and thrombus
Intraluminal thrombus
Occlusive Thrombus
Thrombus causing valve effect when aspirating back
Occulsion CauseTreatment ThrombusUrokinase LipidEthanol CaPhos Precipitate HCl Basic DrugSodium Bicarbonate Acidic DrugHCl
Pinch-Off Syndrome - compression of the catheter between the clavicle and the 1 st rib clavicle compression of the subclavian vein
Pinch-Off Syndrome port catheter fracture by Pinch-Off syndrome
kink Occlusion due to kinking
Non-Aspirating Implanted Device
Non Functioning Device History Examine (site, variablity with positioning?) Diagnostics (X-ray, veinogram) Pharamco-theraputics Replacement
Part 3: Infection
Points of Entry Insertion site Catheter hubs Hematogenous Contaminated infusate Skin Vein Filter Catheter hub
Tunnel infection Insertion site
Exit site infection
Device
Intraluminal
Common Pathogens Staph Aureus Enterobacter spp Enterococcus Coag Negative Staph 38% 6% 11% 9%
Common Pathogens (con’t) Pseudomona s Aeruginosa E. coli Klebsiella pneumoniae Candida Albicans 5% 3% 4% 5%
Diagnosis Line cultures Peripheral cultures Routine diagnostics Differential time to positivity Tip culture
Treatment Empiric Antibiosis: –CoNS and Staph Aureus coverage (Vanc) –Gram negative (Gent) –Resistent pseudomonas or E. coli (Ceftazidime) Line Salvage Duration –10-14 days without removal –Less (t/c PO) if removed
Prevention
“Bundle” Minimize line entrances Modified barrier for line entrances Hub scrub Optimize environment/care team
Infection Rate per 1000 Line Days CLABSI per 1000 line days Month