Advice on Caring for a Central Line

Many preemies in the NICU have a central line or umbilical line through which they receive TPN (liquid nutrition), IV medication and blood transfusions. These lines can also be used to obtain blood for analysis. Although these lines are often necessary and valuable for these procedures, they do increase the risk of infection to the infant. Most preemies do not go home with a central line because they central access to the bloodstream is no longer needed.

When Sammy was about five months old, he developed disseminated candidiasis. He was hospitalized and treated with a powerful antifungal medication called amphotericin. The entire course of amphotericin lasted nineteen weeks. At first they tried giving it to him via peripheral I.V. sites, however, these were "blowing" every day. They soon were unable to obtain more sites for peripheral I.V.'s, so they placed a very small PICC line (peripherally inserted central catheter) through a vessel in this scalp. This allowed Sammy to be discharged from the hospital after a one and a half month stay. Steve and I were trained on administering the amphotericin and flushing protocol, so we were able to give it to him at home. The PICC lasted several weeks, but it ended up breaking due to its small diameter. Another PICC line was placed in his arm, and it only lasted several weeks before breaking. Sammy still required the amphotericin due to the severity of the candidal infection, so we had no alternative but to put in a central line.

The central line, commonly referred to as a CVL (central venous line) or a "broviac" (which is a name of a common manufacturer), had to be inserted surgically. Sammy was admited as an in-patient while waiting for the surgery. He was placed under general anesthesia, and had an incision made at his neck where they inserted the catheter in the major vein. The tube was burrowed in under the skin of his chest to exit above his right nipple. After a very brief training session on how to change the dressing on the exit site, and how to maintain patency of the line by flushing with heparin, we were sent home.

The tube that was placed in Sammy was a Cook french 5 dual lumen. This means it was made by a company called Cook, and there were two lumens of size 5. There are several advantages and disadvantages to having a dual lumen. The dual lumen is useful because one port (blue) can be used to administer medication, and the other port (red) can be used to draw out blood. It is also good to have another port in case one of the lumens becomes occluded. The problem, however, is that each lumen is very small since there are two. This increases the probability of becoming blocked. In the case of an infant whose blood vessels are so small, the lumens are exceptionally small (about the size of a pencil mark). A dual lumen is also twice as much work as a single lumen because both lines must be flushed and maintained at least once a day.

In our case, one of the lumens did become occluded. It happened when we were flushing the line with heparin. The line broke open at the narrow junction of the two tubes and heparin gushed out. We had a special clamp in our emergency kit, and we clamped the line at the skinny point of the line between the break and his chest. This was to prevent pathogens from being able to enter through the break.

As luck would have it, this happened when we were at the doctor's office for a visit. We were right next to the hospital, so we were seen right away to repair the line. We didn't know why the line had burst since we had been following the flushing protocol that we were taught. The nurse clinician, who was the specialist in pediatric central lines, told us that it probably happened because blood cells had migrated into the line and had clotted. She gave us in-depth instructions for a saline surge technique. We were told to flush the line with 5 cc's of sterile normal saline and apply an alternating heavy/light pushing force. This created a turbulence in the line which was supposed to help prevent occlusions. This was then followed by flushing with 100 unit/cc heparin. The heparin that we used was preservative-free since that is recommended for infants.

Sammy's central line was kept in him for 22 months. We were so glad that we had it because we were able to give IVIG (antibody/gammaglobulin) infusions through it. Sammy required IVIG due to his immunodeficiency called hypogammaglobulinemia in which he had severely low levels of antibodies. We also used the line to obtain blood for his various blood tests without having to stick him with a needle. The central line also qualified us for daily R.N. care for eight hours a day while my husband and I were at work.

The central line, however, was a constant source of work and worry. I had to spend many hours every month taking inventory and ordering any medications and flushing and dressing change supplies. We had two book shelves in Sammy's room that were filled with all of these supplies. We had to use sterile technique for flushing the line in order to prevent contamination. The threat of sepsis was always lurking in my brain especially due to his immunodeficiency. We had to keep an occlusive dressing over the exit site at all times. We would change the dressing and clean the exit site several times every week. We had to change the valve on the end of the lumen every five days and after every blood draw.

This is a picture of us doing the dreaded dressing changes. When Sammy was very small, we would put him in a "mummy hold" by holding his arms in with a blanket, and change the dressing while he was awake. As Sammy got older and stronger, it was almost impossible for the two of us to change the dressing because he would get absolutely hysterical, try to turn over and then projectile vomit. In our efforts to reduce the trauma for him and for us, we would do it after he was asleep at night. We would even give Sammy Benadryl (diphenhydramine) to keep him sedated, and to reduce the redness and irritation caused from removing the tape on his chest.

We also couldn't let Sammy get his chest wet because of the line and the dressing. He couldn't take regular baths. Sammy had reflux, and we had to be very careful that he wouldn't get vomit on the lines.

This is how we would give Sammy a bath. We would put several large pieces of a transparent dressing called "tegaderm" over the dressing on his chest. This worked very well to keep the dressing and the lumens dry. As Sammy got older, we would use this method and let him take a bath in our bathtub. We were able to wash his hair and let him splash away! We only did this on the days that we were going to change the dressing, just is case we were to inadvertently get the dressing and lumen valves wet. We would also change the valves on the lumens if we thought that they got wet during the bath.

Even though we were following the flushing protocol, and took meticulous care of the line, Sammy's line broke an additional three times. We even increased the frequency of flushing to prevent occlusion. We were flushing up to four times a day with saline surge followed by heparin. Part of the problem was that Sammy was growing into a toddler and becoming very active. He would often grab at the lumens and yank on them. To make this harder for him to do, we would thread the lumens through a hole we cut near the top of his one-piece undergarments, and we would tape the lumens down onto the onesie. Then he would wear a shirt over the onesie to prevent him from grabbing the lumens. One time when he wasn't wearing a shirt, one lumen got caught as he was climbing, and it broke open.

It became increasingly difficult to keep him from pulling at the line. We would take 2" tape and criss-cross and encircle his outer shirt to keep him from pulling the line. Part of the problem was that he was a two-year old. The presence of the dressing and tape on his chest really bothered him too. We couldn't take our eyes off of him for a second because he would try to rip the dressing off of his chest. When Sammy would get mad, he would deliberately yank at the lines because he soon learned that it got him immediate attention. One time he pulled on the lumens so hard when he woke up from a nap crying, that he broke the end. I didn't discover that it was broken until I found his shirt soaked with blood that had siphoned out of the line.

We also learned from several of the nurses at the hospital that the Cook brand of central lines was very prone to breaking. One TPN nurse said that the hospital stopped inserting Cook catheters, and that the number of patients with broken lines decreased dramatically. She recommended a Davol brand catheter. We didn't want to change the catheter, however, because it would mean another surgery.

MORE TO COME including a list of suggestions for taking care of a line . . .

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