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