Line Holidays

[Doctor Bob]

We talk a lot about giving our long term patients "line holidays" when there's a question of bacteremia (but unproven). So we pull their lines, get by with peripheral lines, then replace the CVCs, trialysis catheters, etc, after 24 hours.

If there's no culture-proven bacteremia, is there any evidence to say that you need to wait 24 hours before replacing lines? Why couldn't you just replace them right away? Either the bloodstream is infected or it's not. I just feel like I'm missing something and maybe it's institutional dogma rather than EBM.

Although... in my mind, if there's no bloodstream infection or catheter infection there's no need to pull the lines in the first place if your plan is to replace them shortly thereafter.

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[Hernandez]

Do you actually have an indication for a central line or are you appeasing nursing staff?

 

[Doctor Bob]

Yea, this person needed one (TPN). I don't put in CVCs for failure to gain peripheral access.

 

[Hernandez]

Most of what we do is dogma, in this instance, I'm not aware of any data to suggest you have to wait 24 hours, and without signs of local infection or positive blood cultures I likely wouldn't pull the line unless my suspicion for line sepsis was very high

 

[Bostonredsox]

Yea, this person needed one (TPN). I don't put in CVCs for failure to gain peripheral access.

Out of curiosity, what do you do for the pt that truly needs IV access that peripheral access cannot be obtained in? Tell them to drink there meropenem?

 

[Hernandez]

Out of curiosity, what do you do for the pt that truly needs IV access that peripheral access cannot be obtained in? Tell them to drink there meropenem?

Find someone else to put in IV. Failed peripheral IV access should almost NEVER be an indication. Especially with ultrasound, and the other new techs to help find IV sites.

 

[Doctor Bob]

Out of curiosity, what do you do for the pt that truly needs IV access that peripheral access cannot be obtained in? Tell them to drink there meropenem?

Umm...

Find someone else to put in IV.

This.

 

[Bostonredsox]

Find someone else to put in IV. Failed peripheral IV access should almost NEVER be an indication. Especially with ultrasound, and the other new techs to help find IV sites.

We do not have anyone trained to use an US for access but us as physicians. US techs do not put in any ivs. And we outsource PICCS so there are no vascular access nurses available. So if an floor nurse , followed by an ER nurse, followed by a MICU nurse, followed by anesthesia, cannot get a piv, which is very common with our large, obese, dialysis population, what would you do to obtain access in the pt? I said a pt that piv access truly cannot be obtained despite multiple personnel trying. You speak as if this is an oxymoron. I assure you it is not. There are some pts that you just cannot get a peripheral IV in. I ultimately then evaluate if they truly need the Iv therapy, ie can there antibiotic be converted to PO, etc. but if they truly need an IV, for whatever reason, and 3+ people have tried to get a piv including gas, they're getting a line. I don't know what kind of time you have at your shop, but at night I don't have time to dick around for 30 minutes trying to get a 20 in a vasculopath dialysis pt when I can put a jugular in in 6 minutes.


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[Bostonredsox]

Umm...



This.

Yeah you can call person x then person y then person z and then after an hour a half goes by and all you get is, still no one could get one in, what's you next answer? You going to ask every nurse in the hospital one after the other or are you gonna stick a line in so your pt can actually get there meds so you can go back to seeing everyone else you still need to see?


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[Hernandez]

We do not have anyone trained to use an US for access but us as physicians. US techs do not put in any ivs. And we outsource PICCS so there are no vascular access nurses available. So if an floor nurse , followed by an ER nurse, followed by a MICU nurse, followed by anesthesia, cannot get a piv, which is very common with our large, obese, dialysis population, what would you do to obtain access in the pt? I said a pt that piv access truly cannot be obtained despite multiple personnel trying. You speak as if this is an oxymoron. I assure you it is not. There are some pts that you just cannot get a peripheral IV in. I ultimately then evaluate if they truly need the Iv therapy, ie can there antibiotic be converted to PO, etc. but if they truly need an IV, for whatever reason, and 3+ people have tried to get a piv including gas, they're getting a line. I don't know what kind of time you have at your shop, but at night I don't have time to dick around for 30 minutes trying to get a 20 in a vasculopath dialysis pt when I can put a jugular in in 6 minutes.


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Last time a nurse gave me a similar reply I placed a 14 guage, if your hospital does not have a difficult IV access team with access to u/s or Infrared imaging systems, then they're behind the times.

 

[deleted547339]

Yeah you can call person x then person y then person z and then after an hour a half goes by and all you get is, still no one could get one in, what's you next answer? You going to ask every nurse in the hospital one after the other or are you gonna stick a line in so your pt can actually get there meds so you can go back to seeing everyone else you still need to see?


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A large portion of our ER nurses have been trained in US. They're actually pretty dang good at it.

 

[Doctor Bob]

Yeah you can call person x then person y then person z and then after an hour a half goes by and all you get is, still no one could get one in, what's you next answer? You going to ask every nurse in the hospital one after the other or are you gonna stick a line in so your pt can actually get there meds so you can go back to seeing everyone else you still need to see?

Yes. I'm going to do it. And I'll do it with ultrasound... usually a midline.
I'm sure the day will come when I can't get a peripheral no matter how hard anyone tries, or I try. At which point I'll reassess how badly the person needs that specific medication by that specific route. Or I'll just place an IO. I've done that when I can't get venous access but there's no real need for a central line.
I've sono-guided EJs. If the person is so obese that nobody can get a peripheral by any other means, then they're gonna be a risky central line also. So I sono-guide something in nearby but without the risks.

To each their own, but for me, a central line, placed purely because of failure to gain peripheral access, isn't something I'll do.

 

[Bostonredsox]

Last time a nurse gave me a similar reply I placed a 14 guage, if your hospital does not have a difficult IV access team with access to u/s or Infrared imaging systems, then they're behind the times.

Very behind the times. But that's irrelevant. I work with what I have.

 

[Bostonredsox]

A large portion of our ER nurses have been trained in US. They're actually pretty dang good at it.

Our er nurses can barely place an ngt...

 

[Bostonredsox]

Yes. I'm going to do it. And I'll do it with ultrasound... usually a midline.
I'm sure the day will come when I can't get a peripheral no matter how hard anyone tries, or I try. At which point I'll reassess how badly the person needs that specific medication by that specific route. Or I'll just place an IO. I've done that when I can't get venous access but there's no real need for a central line.
I've sono-guided EJs. If the person is so obese that nobody can get a peripheral by any other means, then they're gonna be a risky central line also. So I sono-guide something in nearby but without the risks.

To each their own, but for me, a central line, placed purely because of failure to gain peripheral access, isn't something I'll do.

This is reasonable. But I've placed about 10 u/s guided pivs compared with hundreds of cvcs. It takes me quite a while to place one most times and it's just time I don't have as the solo night guy.

 

[deleted547339]

This is reasonable. But I've placed about 10 u/s guided pivs compared with hundreds of cvcs. It takes me quite a while to place one most times and it's just time I don't have as the solo night guy.

It's an invaluable skill. Since I learned how to do it well, I only put in CVLs when a patient is on pressors.

 

[Bostonredsox]

It's an invaluable skill. Since I learned how to do it well, I only put in CVLs when a patient is on pressors.

Agreed. And I do try and practice them when I have time to become more proficient and thus in the future be able to avoid a few lines. But my point was that I disagree with the notion that the inability to gain peripheral access in a pt who truly needs access isn't a reason for a line when other options have failed.

 

[TooMuchResearch]

We do not have anyone trained to use an US for access but us as physicians. US techs do not put in any ivs. And we outsource PICCS so there are no vascular access nurses available. So if an floor nurse , followed by an ER nurse, followed by a MICU nurse, followed by anesthesia, cannot get a piv, which is very common with our large, obese, dialysis population, what would you do to obtain access in the pt? I said a pt that piv access truly cannot be obtained despite multiple personnel trying. You speak as if this is an oxymoron. I assure you it is not. There are some pts that you just cannot get a peripheral IV in. I ultimately then evaluate if they truly need the Iv therapy, ie can there antibiotic be converted to PO, etc. but if they truly need an IV, for whatever reason, and 3+ people have tried to get a piv including gas, they're getting a line. I don't know what kind of time you have at your shop, but at night I don't have time to dick around for 30 minutes trying to get a 20 in a vasculopath dialysis pt when I can put a jugular in in 6 minutes.


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Train your nurses to use US.

 

[Bostonredsox]

Train your nurses to use US.

/sigh. You don't read do you. I barely have time to piss at night. Taking the time to teach a nurse to use an US is a joke.


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[fakin' the funk]

I don't put in CVCs for failure to gain peripheral access.

Even though this is an indication to place a CVC?

You turf your difficult peripheral access to "someone else?" ... the difficult peripheral access situation that you created because you won't do the low-risk procedure of placing a CVC for this indication?

 

[fakin' the funk]

If the person is so obese that nobody can get a peripheral by any other means, then they're gonna be a risky central line also.

No it's not.

 

[Doctor Bob]

Even though this is an indication to place a CVC?
You turf your difficult peripheral access to "someone else?" ... the difficult peripheral access situation that you created because you won't do the low-risk procedure of placing a CVC for this indication?

We will just have to agree to disagree that failure of nursing staff to place a peripheral line in and of itself is an indication for placing a CVC.
And I don't turf my difficult peripheral accesses to someone else. I do them myself.
When the day comes that I can't get a peripheral IV with ultrasound and a midline (and it certainly will happen eventually)... well, then I will consider the options.

If the person is so obese that nobody can get a peripheral by any other means, then they're gonna be a risky central line also.

No it's not.

The morbidly obese patient whose clavicles aren't even palpable? And whose ears are half occluded by their shoulder fat making access to their IJ nigh-impossible?
I get these 600+ lb behemoths on a (sadly) regular basis. They're certainly a risky line. Primarily from an infection standpoint because their neck and groin folds are so full of excoriated skin and yeast. Pneumothoraces are pretty unlikely because my needles won't reach their chest cavity.
But, I can find peripheral veins on them, either in the hand or using a midline in the AC.

<shrug>; lets just call this a difference in practice style.
And if their clinical condition changes and the people need pressors, TPN, etc, etc... well then yes, they get a CVC.

 

[Bostonredsox]

Even though this is an indication to place a CVC?

You turf your difficult peripheral access to "someone else?" ... the difficult peripheral access situation that you created because you won't do the low-risk procedure of placing a CVC for this indication?

/agree

 

[Hernandez]

/agree

Agree all you want but it's a bad indication to place one. Keep in mind, if you're billing CCT, placing a peripheral should count in CCT time, and it's better for the patient in long run. It's different in his gas population as they typically have much shorter LOS and lines don't stay in as long but in a medical ICU population, long term central lines are not a great place to be, it's not uncommon for me to come in and pull the lines the night guys place for this very reason.

 

[Bostonredsox]

Just not going to agree with you. A pt who needs IV access for medication administration where peripheral access cannot be obtained has an absolute indication for central access. They need access, however it can be obtained. If all that can be obtained is central so be it. No ones looking to put in extra lines. But if the pt needs access and all other attempts available at a particular institution have failed, a line is indicated. End of story.

 

[tartesos]

We do not have anyone trained to use an US for access but us as physicians. US techs do not put in any ivs. And we outsource PICCS so there are no vascular access nurses available. So if an floor nurse , followed by an ER nurse, followed by a MICU nurse, followed by anesthesia, cannot get a piv, which is very common with our large, obese, dialysis population, what would you do to obtain access in the pt? I said a pt that piv access truly cannot be obtained despite multiple personnel trying. You speak as if this is an oxymoron. I assure you it is not. There are some pts that you just cannot get a peripheral IV in. I ultimately then evaluate if they truly need the Iv therapy, ie can there antibiotic be converted to PO, etc. but if they truly need an IV, for whatever reason, and 3+ people have tried to get a piv including gas, they're getting a line. I don't know what kind of time you have at your shop, but at night I don't have time to dick around for 30 minutes trying to get a 20 in a vasculopath dialysis pt when I can put a jugular in in 6 minutes.

I feel your pain and agree with you.
Sometimes is too time consuming and even after that impossible to get.
If a midline or picc is not available, no IO, and several people have failed... You've earned a cvc.


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