Venous Vexation: A Central Line Conundrum

So he's going to present a case that we saw at Akron recently. Um so this is a three-month old male in the you. He's got intestinal failure um and has a femoral Broviac in place for a long-term IV access for TPN. Um and he's preparing for discharge in the next few weeks but still needs that IV. Um and at the time of uh rounds one day, um we notice uh this. So the um outer sheath there is is now broken. So there's some debate amongst the group about uh what the next best step would be and thought it'd be great to bring to the update course. So um. So damaged Broviac. And patient broken sheath on the Broviac is going to need central access at their upcoming discharge. What would you do? So my question is, why did you put it in the femoral in the first place? Cuz like if that that might influence what you would do if there was a reason that drove you to put it in the femoral in the first place. He had also had uh um hemodialysis uh access site previously. So the femoral uh was the one that was selected for his I I think he had the um hemodialysis line and the um Broviac placed at the same time pretty much. Good question. I don't know the answer. Why does he still need the line? He still is intestinal failure patient and needs it for a TPN. Yeah. I don't know if you all can see the variability but um. A lot of variability, but about half will repair it with a kit. some people talk about exchanging it over a wire or placing a new one over the new site. So the debate that the reason I asked Alex to present is, so I came on as Sa and I'm a repair kit person. Uh one of the other surgeons said that, you know, if this patient is going to need very long-term TPN, they would rather replace the line. Um my argument was, that's exactly the reason why but then the question is, well how many repairs can you do? So we debated it. Eventually was repaired with a kit but the question was, would you ever not do that? So it sounds like most people here. But it is impressive how many other people would not do that. So. And we saw um one study that was looking at um complication or infection rates comparing the repair versus uh ex um placing it at a a new site. Um and uh they had like 36 patients um who um had a Broviac in place and looked at how many ended up getting a repair and I think there was like 96 repairs and only one of them ended up getting a central line associated bloodstream infection. So got 1% risk for infection uh with the repair. And most of them had multiple repairs. Um the median was 1.5 repairs per patient and um some of them even had like 10 repairs on the same line. Yeah you can keep preparing them. So you have a a six-year-old with AML who has positive cultures for staff Arius through a central Venus port. So, what is the single most important way to prevent central Venus catheter infections? because I figured that we can't talk about central line complications without talking about the most common central line complication, which is central line infections. All of these things have been shown to impact central line infections. Um including dental care, especially in your Hemonk patients. So we actually have dentists who sold their there to prevent central line infections in our Hemonk patients. Preventing mucusal barrier infections and things like that. We talk about MBI collapsees and non MBI collapsees. But it really is all the above. There is a lot of data to support this. Um and it's really hard to pick out if it's any one of these things that does the most in this patient or whatever it is. So these are this is just a pitch for the central line bundles that we all have and to follow them. And this is the kind of thing that for those of us in leadership positions, we're constantly harping on this and you know, making sure that people don't forget. It always amazes me when I start to see hand hygiene fall off. And uh, you know, then we have to have a little new foam up foam, you know, foam in foam out campaign and those sorts of things, but you it's a never ending, it's a never ending battle and it's really something that should be on the forefront of our minds because to remember, the most common complication of central lines is a central line infection. When you get an infection, what's your initial treatment? So that's so I so I didn't go into that here because then um but if it's if it's staff or something that's treatable, we'll treat it through the line. Um Antibiotic. Antibiotic. Well, so in high risk patients, actually in our high risk patients, we're doing antibiotic locks. So in patients that are short gut and some of our Hemonk patients, we do uh we we're doing ethanol locks for uh to to help, there's some evidence that those help. Uh I don't know if everybody's doing that or not. Are you guys doing that as well? Yeah, we're doing that. looks like I've seen lots of nods about people doing that in we don't do that in every patient though. Just high risk patients. Fair enough. When I was telling, I think Alex was on rounds with me yesterday or two days ago and I was telling the team that when I was a resident or fellow, we were taking out lines a lot and I don't think I can remember the last time I take out in fact, I mean it's very rare we take out infected lines now because we can treat through almost all of them. almost all of them. So so gram positives, you have about a 90% chance of clearing them. Gram negatives, it's closer to 50%. Fungal, it's it's it's really hard. So if you know, so that's sort of, you know, depending on the risk of the patient and which you need and which you need to do it. But usually gram positives, we can clear the others, you a lot of times have to take it out. I just want to make a comment about a standardized dressing. Mhm. What the surgeon thinks is the right dressing is not what nursing thinks is the right dressing. That is true. And so what happens is you put on the dressing in the OR that you think is the right dressing for that line. And as soon as they get to the floor, that's not the hospital approved standardized dressing and it gets taken off. Uh-huh. That's how the line gets pulled out, that's how the line gets infected. So I'm encouraging everyone to work with their nursing leadership to come up with a standardized line. Yes, so so Megan Durham, one of uh, one of one of my partners uh has uh spearheaded this and and she uh, and some of the other folks, they they actually took pictures of what the standardized dressings are and put them up in the operating room. So that we can see what we're supposed to do. But it and it and if a lot in in our case, we found that the recovery room nurses or the pack nurses were cha were like you do all this stuff and it'll be all look nice and pretty and then you go in, they'd be changing it just because it wasn't the standard dressing. We had the same problem and we all the other problem we had that we had to address is that the standard dressing changed every three weeks and nobody you know, communicating that to everybody was a challenge. So we've done the same thing on our central line cart, we have pictures of what the dressing's supposed to look like and that is the dressing. And unless there's there's evidence to change it to something else, that's the dressing.