Femoral CVLs- do you change the site?
- 0Jun 29, '12 by Ashley, PICU RNI recently learned that, in the adult ICU in our hospital, if the patient has a CVL placed in the femoral site, it has to be changed within 24 hours. This is due to the increased rate of infection of the femoral site. Our PICU has an excellent infection rate, and it's never been our policy to put in a new CVL if their current femoral line was inserted using proper technique. I can't quite understand the rational of even placing a femoral line in the first place, much less exposing the patient to another chance of infection (not to mention the sedation and discomfort) of another central line insertion, just because of the site of their line.
I'll mention that femoral lines are often our last resort for CVL insertions. If we have to place a femoral, it's usually because there isn't a better option. We even choose IJ's over the femoral site. Some of our kiddos have horrible venous access- even centrally.
Our hospital is surveying central line documentation in an effort to reduce infection rates. (Like I said, the PICU hasn't had a CLABSI in over two years.) The surveyor, a nurse from infection disease, was adamant that the CDC guidelines stated that femoral lines had to be changed to another site within 24 hours. (She also wanted us to use bio-patches, like the adult's do, which also isn't in our policy- but that's another story.) The particular patient who had a femoral line was one of our sickest, most chronic kids. It had taken hours to get that line in the first place- and he had coded during the attempts. There was no way any of our intensivists would have agreed to attempt another line placement.
So, my real question- do you change the site of your femoral line CVLs within 24 hours?
- 1Jun 29, '12 by umcRNDefinitely not! Like you said, most of our kiddos have terrible access and if it's in and it works then we use it though I will say they tend to stay in longer in the newborns than any other population. If it's obvious they will need long term access then we eventually try for a picc but when the kiddo is stable enough for transport. In my hospital they also cannot go to the floor with a fem line so then obviously something is changed. In the NICU it's actually common to have fem broviacs and those are never pulled until discharge.
- 2Jun 29, '12 by marycarneyNo! We leave them as long as needed as long as they work and have no evidence of infection. We have not had a CLABSI in > 1 year. Our intensivists address the necessity of central lines in every patient during every rounding. We do have a good PICC team, and obviously try for a PICC if long-term access is going to be needed.
I am horrified at the thought of pulling a working line in a critically ill child because of an ADULT ICU policy.
- 0Jun 30, '12 by sapphire18 GuideQuote from Sun0408I've never heard of this. I would think infection rates wouldn't be much different since they're both central lines? Especially if cared for correctly. Is that the rationale for that practice?Yes we do. We also change out our TLC's within 7 days to a PICC if the pt still needs a central line. We also use bio-patches.
PS. I work with adults but while we try not to leave fem lines in for long, I did see one in for >1 week on someone that they had tried all other sites multiple times with no success. Kinda crazy. I also don't see what would be the problem with biopatches on the kids? They can't hurt; only help!
- 1Jun 30, '12 by woohI've noticed adult policies tend to like changing sites a LOT more than peds policies. When I did adults, any lines placed pre-hospital were changed within 24 hours of admit. Had to change PIVs every 3 days. Peds, if a PIV will stay in and keep working, we keep it as long as possible.
I understand the desire to change femoral lines. But they're not put in femorally because someone thought it would just be convenient. Especially with kids, it's so easy to quickly use up their available access sites.
Honestly, with your unit's great infection rates, I'd be thinking the adult ICU should be looking at changing to YOUR policies rather than your PICU changing to their policies.
- 0Jun 30, '12 by DeLanaHarvickWannabeQuote from woohI work with adults, and we do this also.Had to change PIVs every 3 days.
As for changing the femoral line in 24 hours? Ummm...no. That sounds plain ridiculous to me! I hate femoral lines because of their location, and we have to change the dressing on them more frequently than other CVCs, but not the lines themselves. I can see maybe changing the DRESSING after 24 hours, but removing and reinserting a line? Wow.
- 0Jul 1, '12 by Ashley, PICU RNOur adult units also change PIV's every 96 hours. Even though the newest best practice evidence states that there is no difference in the rate/severity of complications from PIV's between changing routinely and leaving them in until discharge or there is a problem.
The reason we don't use biopatches is because, according to NACHRI (National Association of Children's Hospitals and Related Institutions) research related to central lines there is no significant statistical difference between infection rates when biopatches are used in conduction with chlorahexidine scrubs, or when chlorahexidine is used alone. We've also found that biopatches make it more difficult to assess the immediate insertion site and some of our patients are prone to skin breakdown from the patch.