1. 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

2. Part 1: The Devices

3. PICC

4. Alternative PICC sites

5. Tunneled CVC’s (Broviac or Hickman) Cuff Tunnel entrance Vessel entrance

6. Subcutaneou s Port Oreilly.com Tunnel Port

7. Centrally Inserted, Non- Tunneled Devices (Arrow or Cook)

8. Other Devices “Statlock” securement device “Biopatch” chlorhexidine sponge

9. Arm PICC Tunneled Femoral PICC Femoral PICC Tunneled IJ Broviac/Port Tunneled IJ Broviac (posterior)

11. 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 = 2.5 - 4.5 –Vanco = vinegar Phenytoin: pH = 12 –Dilantin = Draino

13. 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

14. CDC Public Health Image Library Fibrin and Thrombosis

15. “Saran-wrap” layer of thin fibrin and thrombus

16. Intraluminal thrombus

17. Occlusive Thrombus

19. Thrombus causing valve effect when aspirating back

21. Occulsion CauseTreatment ThrombusUrokinase LipidEthanol CaPhos Precipitate HCl Basic DrugSodium Bicarbonate Acidic DrugHCl

22. Pinch-Off Syndrome - compression of the catheter between the clavicle and the 1 st rib clavicle compression of the subclavian vein

23. Pinch-Off Syndrome port catheter fracture by Pinch-Off syndrome

24. kink Occlusion due to kinking

25. Non-Aspirating Implanted Device

26. Non Functioning Device History Examine (site, variablity with positioning?) Diagnostics (X-ray, veinogram) Pharamco-theraputics Replacement

27. Part 3: Infection

28. Points of Entry Insertion site Catheter hubs Hematogenous Contaminated infusate Skin Vein Filter Catheter hub

29. Tunnel infection Insertion site

30. Exit site infection

31. Device

32. Intraluminal

33. Common Pathogens Staph Aureus Enterobacter spp Enterococcus Coag Negative Staph 38% 6% 11% 9%

34. Common Pathogens (con’t) Pseudomona s Aeruginosa E. coli Klebsiella pneumoniae Candida Albicans 5% 3% 4% 5%

35. Diagnosis Line cultures Peripheral cultures Routine diagnostics Differential time to positivity Tip culture

36. 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

37. Prevention

39. “Bundle” Minimize line entrances Modified barrier for line entrances Hub scrub Optimize environment/care team

40. Infection Rate per 1000 Line Days CLABSI per 1000 line days Month