Femoral CVLs- do you change the site?

[Double-Helix, BSN, RN]

I 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?

[Sun0408, ASN, RN]

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.

[umcRN, BSN, RN]

Definitely 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.

[meanmaryjean, DNP, RN]

No! 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.

[umcRN, BSN, RN]

I forgot to mention that we do also use bio patches (but not on premature infants less than 32weeks).

[sapphire18]

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.

I'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?

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!

[wooh, BSN, RN]

I'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. :)

[Penelope_Pitstop, BSN, RN]

Had to change PIVs every 3 days.

I work with adults, and we do this also.

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.

[sapphire18]

We change PIVs every 5 days (adults here).

[Double-Helix, BSN, RN]

Our 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.

[iluvivt, BSN, RN]

There is no recommendation in the 2011 guidelines form the CDC stating that femeral lines must be removed in 24 hours..not even in adults. What they do say is to avoid using the femeral veins with your first choice being the Subclavian (avoid this approach with HD pts). In adults this is b/c of the higher infection rate in this site due to a variety of reasons. In some studies as high as 19 percent BUT in children the association between use of a femoral line and CA-BSI is not as clear as it is the adult population. When deciding what is the best CVC for any given patient ..you need to ALWAYS weigh the risk to the patient vs the benefit. So for example, if a proceduralist thinks the risk is too high (for whatever reason) for a pneumothorax or other complication b/c of a difficult access by all means they can and should try a femeral line. I often find that if a femeral line is placed..other sites such as SC and jugular have been attempted or were not attempted b/c of urgent need for the CVC. The femeral vein is easy to hit doing a blind stick

[NicuGal, MSN, RN]

Our IR places PICC's in the femoral for us. We rarely use broviacs anymore. We do use biopatches on our kids, we have only had 2 in the past 3 years that had a reaction to the patch, but we think it was more that the fellow didn't wipe off all the chlorohex before placing the dressing, and it left a nasty burn We leave lines for as long as we can. Even our adult floors don't change PIV's and central lines the way they used to. If it ain't broke, leave it be!