Central Lines:All you ever wanted to

knowAllison Ballantine, MD

Assistant Professor of PediatricsMedical Director, Integrated Care Service

Director of EducationDivision of General Pediatrics

The Children’s Hospital of Philadelphia

Part 1:The Devices

PICC

Alternative PICC sites

Tunneled CVC’s(Broviac or Hickman)

Cuff

Cuff

Tunnel entrance

Vessel entrance

Subcutaneous 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

FemoralPICC

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 = 2.5 - 4.5– 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 Fibrin and ThrombosisThrombosis

“Saran-wrap” layer of thin fibrin and thrombus

Intraluminal

thrombus

Occlusive Thrombus

Thrombus causing valve effect when aspirating back

Occulsion

Cause Treatment

Thrombus Urokinase

Lipid Ethanol

CaPhos Precipitate

HCl

Basic Drug Sodium Bicarbonate

Acidic Drug HCl

Pinch-Off Syndrome

- compression of the catheter between the clavicle and the 1st rib

claviclecompression of

the subclavian vein

Pinch-Off Syndrome

port catheter fractureby 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 infectionInsertion site

Exit site infection

Device

IntraluminalIntraluminal

Common Pathogens

Staph Staph AureusAureus

Enterobacter Enterobacter sppspp

EnterococcEnterococcusus

Coag Coag Negative Negative StaphStaph

3838%%

6%6%

1111%%

99%%

Common Pathogens (con’t)

PseudomonPseudomonas as AeruginosaAeruginosa

E. coliE. coli

Klebsiella Klebsiella pneumoniapneumoniaee

Candida Candida AlbicansAlbicans

5%5%

3%3%

4%4%

55%%

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

Prevention

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

Infection Rate per 1000 Line Days

CLA

BS

I per

100

0 lin

e da

ys

Month

0

20

40

60

80

100

120

140

4/1/

2005

5/1/

2005

6/1/

2005

7/1/

2005

8/1/

2005

9/1/

2005

10/1

/200

5

11/1

/200

5

12/1

/200

5

1/1/

2006

2/1/

2006

3/1/

2006

4/1/

2006

5/1/

2006

6/1/

2006

7/1/

2006

8/1/

2006

9/1/

2006

10/1

/200

6

11/1

/200

6

12/1

/200

6

1/1/

2007

2/1/

2007

3/1/

2007

4/1/

2007

5/1/

2007

ICS CLABSI Rate

Annual Median