Changing out fem lines

[turkeyjerky]

What's the practice at your institution for replacing fem, or other not fully sterile lines placed in the ED? I tend to think these should all be changed out as soon as the patient is stable, but I've been seeing these things left in for days on end sometimes.

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[inspirationmd]

What's the practice at your institution for replacing fem, or other not fully sterile lines placed in the ED? I tend to think these should all be changed out as soon as the patient is stable, but I've been seeing these things left in for days on end sometimes.

We change them out once they get upstairs under sterile technique. Ususally within 3 hours of them hitting the floor if able to stop infusions for a minute. 99.9% within 24 hours if tenuous status early on.

 

[Hernandez]

What's the practice at your institution for replacing fem, or other not fully sterile lines placed in the ED? I tend to think these should all be changed out as soon as the patient is stable, but I've been seeing these things left in for days on end sometimes.

Fem gets replaced in 24 hours even if sterile, and as soon as safe to do if not sterile. That is if it's safe to do so or if they have an alternate spot to put one

 

[jdh71]

What's the practice at your institution for replacing fem, or other not fully sterile lines placed in the ED? I tend to think these should all be changed out as soon as the patient is stable, but I've been seeing these things left in for days on end sometimes.

Depends.

The problem with making some sort of policy that you are supposed to follow every single time is that clinical context sometimes requires a fem line to be left in for long periods of time, EVEN IF, it wasn't "sterile" when it went it.

"ZOMG!!!! a fem line!!! Let's change it THIS second!!!" is stupid. If patient doesn't have other access issues that require it stay in, remove it in the next day or two when convenient.

 

[europeman]

I also change any line placed in operating room by anesthesia, because, unfortunately, at our institution, so many of them place these lines under sub optimal conditions. Often because they are done during a case whereby it's impossible to really it it perfectly.... But even preop elective lines by anesthesia, where we are at, is a problem cuz they don't use full sterile technique

 

[proman]

I also change any line placed in operating room by anesthesia, because, unfortunately, at our institution, so many of them place these lines under sub optimal conditions. Often because they are done during a case whereby it's impossible to really it it perfectly.... But even preop elective lines by anesthesia, where we are at, is a problem cuz they don't use full sterile technique

That's unacceptable. Why not try to get the practice changed? We've adopted the Arrow Max Barrier kits which have absolutely everything you need for a sterile line. I've put lines under the drapes but only in true emergencies.

 

[ORL10]

I think changing out the femoral line within 3 hours of arrival to an ICU is crazy. The data to suggest that femoral line infectious complications is much higher than subclavian is weak at best, and I would use those first few hours to figure out how to best resuscitate the patient. There is a Cochrane review on CVC insertion site that demonstrated that LONG-TERM CVC insertion in the femoral site resulted in more thrombotic complications, and more "catheter related infections," aka the tip of the catheter grew out a microorganism, but this is not a patient orientated outcome. In terms of patients with frank sepsis from their lines there was no statistically significant difference between subclavian lines and femoral lines.

These complications frequently occur later in the patients course. That being said if the CVC was put in the femoral site in the emergency department the chances are it wasn't placed under optimal sterile conditions (otherwise why did they choose the femoral site?), and this type of line insertion was not assessed in the aforementioned literature and therefore my assumption is they have a higher infectious complication rate. Therefore I would change the line whenever it was most convenient for me and the nurses to a SC, of IJ line.


Also one common misconception is that the central line is a life saving intervention, similar to intubation/antibiotics. While central lines make ours and nurses lives easier and provide access for centrally administered drugs, there is no data to suggest that a CVC improves patient orientated outcomes.


Merrer et al. Complications of Femoral and Subclavian Venous Catheterization in Critically Ill Patients. JAMA. 2001;286(6):700-707.

 

[inspirationmd]

I think changing out the femoral line within 3 hours of arrival to an ICU is crazy. The data to suggest that femoral line infectious complications is much higher than subclavian is weak at best, and I would use those first few hours to figure out how to best resuscitate the patient. There is a Cochrane review on CVC insertion site that demonstrated that LONG-TERM CVC insertion in the femoral site resulted in more thrombotic complications, and more "catheter related infections," aka the tip of the catheter grew out a microorganism, but this is not a patient orientated outcome. In terms of patients with frank sepsis from their lines there was no statistically significant difference between subclavian lines and femoral lines.

These complications frequently occur later in the patients course. That being said if the CVC was put in the femoral site in the emergency department the chances are it wasn't placed under optimal sterile conditions (otherwise why did they choose the femoral site?), and this type of line insertion was not assessed in the aforementioned literature and therefore my assumption is they have a higher infectious complication rate. Therefore I would change the line whenever it was most convenient for me and the nurses to a SC, of IJ line.


Also one common misconception is that the central line is a life saving intervention, similar to intubation/antibiotics. While central lines make ours and nurses lives easier and provide access for centrally administered drugs, there is no data to suggest that a CVC improves patient orientated outcomes.


Merrer et al. Complications of Femoral and Subclavian Venous Catheterization in Critically Ill Patients. JAMA. 2001;286(6):700-707.

I should clarify that we remove the femoral and place either a subclavian or IJ. I am not all that familiar with all the data out there and will certainly be reading the above article. I think the thinking is to get the presumed non-sterile line/non-ideal location line out ASAP and place it in a different location where it is less likely to be infected over the week (if they need it that long) before we change it out over the wire.

I will say though that it may not be the most patient oriented outcome but if we get a catheter associated infection it dings the hospital stats and I think Medicare does not pay for it since its preventable so I think that's one of the main driving forces of people pulling it ASAP. I am slowly learning it's about the patient (ideally above all else) and then the all mighty dollar.

 

[VentdependenT]

Fat peeps: change to SC or IJ.
Thin peeps: ok to keep IMHO.

As prior poster stated: no real difference in infxn. Again its all about technique and proper line maintenance. I have yet to replace a line over a guide wire.

When I need a CVC and shiley I place Them both on same side of neck. Only need to prep once.

 

[Hernandez]

I completely agree, and there was yet another article re-affirming this data come out this year . However at my place, it's a union run nursing place and the clip board nurses run amok. I got in trouble for not placing a radial a-line with full sterile barrier precautions. I quotes the CDC guidelines yet the clip board nurse was adamant that it saves lives. Sadly, this is the same idiot who can't seem to understand why yet another check list hasn't reduced CLABS in my shop.

302 days

 

[jdh71]

When I need a CVC and shiley I place Them both on same side of neck. Only need to prep once.

I don't think I would do that.

 

[VentdependenT]

Why? I try not to place lines bilaterally.

 

[jdh71]

Why? I try not to place lines bilaterally.

Possible procedural complications from multiple sticks and dilation on the same vessel in the same proximate area.

Patients aren't harmed from bilateral lines or from being prepped and draped twice.

What I'm not saying: You are wrong and you are a bad doctor.

What I am saying: I wouldn't do that.

 

[Trifling Jester]

Possible procedural complications from multiple sticks and dilation on the same vessel in the same proximate area.

Patients aren't harmed from bilateral lines or from being prepped and draped twice.

What I'm not saying: You are wrong and you are a bad doctor.

What I am saying: I wouldn't do that.

Is there any data on this? I ask because when I scrub in on ablations we'll sometimes put two 6 french and one 8 french catheter into a femoral vein on one side. Other staff put two on each side. I asked about potential complications with multiple access (three) on one side and was told there wasn't any. Just curious.

 

[Hernandez]

Is there any data on this? I ask because when I scrub in on ablations we'll sometimes put two 6 french and one 8 french catheter into a femoral vein on one side. Other staff put two on each side. I asked about potential complications with multiple access (three) on one side and was told there wasn't any. Just curious.

Ancedotaly.....PTs I see in micu who've had multiple central access are a bitch ti get new lines in and on u/s you can see them scarred down.

In crashing bleed PTs, I have placed an introducer an dialysis cath in the same leg to resuscitate with blood. Other than that, I prep twice.

I'm not aware of any other data outside of anecdotal evidence. Perhaps JD has something else

 

[jdh71]

Is there any data on this? I ask because when I scrub in on ablations we'll sometimes put two 6 french and one 8 french catheter into a femoral vein on one side. Other staff put two on each side. I asked about potential complications with multiple access (three) on one side and was told there wasn't any. Just curious.

No data I know about. Though, it might be hard to find people who'd publish that kind of thing these days. I suppose I'd be a little less anxious about a femoral site, but I just worry about more than one dilation in the same proximate location causing a tear that propagates from one site to the other and giving me a big nasty mess in the neck, possibly compromising my airway.

I suppose I could run this idea past a vascular surgeon, they might have a better idea if I'm completely FOS here.

I simply try to avoid doing anything, that I don't have to do (like place lines on the same side), that would require me to consult an additional service if I have a complication.

 

[VentdependenT]

only issue i could possibly see is thrombotic risk but i have no data to review as it relates to 2 ipsilateral CVCs.

Honestly id be more worried about an inexperienced resident/attending putting in a tlc or, even worse, a shiley/cordis. Ive seen some sloppy multiple stick/multiple dilation venous access cases without the vessel ripping open. Again im sure it does but just havent seen it. I have seen US guided CAROTID dilation with infusion....strokes are bad m'kay. Experience is key.

In anes id put a cordis AND a venoveno bypass line (maaaaaassssssiiiiivvvvveeee dilator, makes shiley dilator look like a 22g piv) in same IJ for bloody, push the novo 7 now!, liver cases. Never had an issue.

 

[jdh71]

only issue i could possibly see is thrombotic risk but i have no data to review as it relates to 2 ipsilateral CVCs.

Honestly id be more worried about an inexperienced resident/attending putting in a tlc or, even worse, a shiley/cordis. Ive seen some sloppy multiple stick/multiple dilation venous access cases without the vessel ripping open. Again im sure it does but just havent seen it. I have seen US guided CAROTID dilation with infusion....strokes are bad m'kay. Experience is key.

In anes id put a cordis AND a venoveno bypass line (maaaaaassssssiiiiivvvvveeee dilator, makes shiley dilator look like a 22g piv) in same IJ for bloody, push the novo 7 now!, liver cases. Never had an issue.

ok

your experience is noted and entered into the minutes

I still wouldn't do that

practice however you want homes