Central Lines in Burn Patients

marienm, RN, CCRN · Sep 28, 2020

In brief... peripherals are changed only PRN at my hospital. They may be placed through burned skin though obviously that's not our top choice. Our normal dressing is tegaderm, no chevron taping or anything like that. If it's near a burn we'll still use tegaderm but often the burn dressing covers the IV and we assess the site by either cutting a hole in the dressing or by palpation.

PICCs are placed in the arms by vascular access RNs and they will not place them through non-intact skin. They do all the dressing changes for their lines (occlusive dressing and stat-lock securement device). They don't mind if we wrap part of a burn dressing over the site and they usually coordinate with us to check/change the dressing during wound care.

CVCs are placed by MDs and may be through burned skin if necessary. Ideally they are in the IJ or subclavian but if the femoral is unburned they go there. Lines are sutured in place. Bedside RNs change these dressings. Our hospital uses central line occlusive dressing kits that include biopatches, but these should not be used on broken skin. For sites that are really wet with drainage we use aquacel and just change it a lot. Site changes are per MD. (Routine changes would probably be ideal, but it's not my decision!)

Hope that helps a bit! Our hospital policies don't directly address these lines in burn patients, and we try to follow the policies as much as we can with sensible adaptations for each situation.

Loloberry · Sep 28, 2020

26 minutes ago, marienm, RN, CCRN said:

In brief... peripherals are changed only PRN at my hospital. They may be placed through burned skin though obviously that's not our top choice. Our normal dressing is tegaderm, no chevron taping or anything like that. If it's near a burn we'll still use tegaderm but often the burn dressing covers the IV and we assess the site by either cutting a hole in the dressing or by palpation.

PICCs are placed in the arms by vascular access RNs and they will not place them through non-intact skin. They do all the dressing changes for their lines (occlusive dressing and stat-lock securement device). They don't mind if we wrap part of a burn dressing over the site and they usually coordinate with us to check/change the dressing during wound care.

CVCs are placed by MDs and may be through burned skin if necessary. Ideally they are in the IJ or subclavian but if the femoral is unburned they go there. Lines are sutured in place. Bedside RNs change these dressings. Our hospital uses central line occlusive dressing kits that include biopatches, but these should not be used on broken skin. For sites that are really wet with drainage we use aquacel and just change it a lot. Site changes are per MD. (Routine changes would probably be ideal, but it's not my decision!)

Hope that helps a bit! Our hospital policies don't directly address these lines in burn patients, and we try to follow the policies as much as we can with sensible adaptations for each situation.

Thank you! That is very helpful. I am finding some hospitals have wildly different practices for their burn patients as opposed to their non-burn patients. It is interesting that your hospital follows the general SOP! I am trying to determine if routine line changes reduce CLABSI in burns patients. In the general population routine changes are not at all recommended.

frozenmedic · Sep 28, 2020

12 hours ago, Loloberry said:

I am trying to determine if routine line changes reduce CLABSI in burns patients. In the general population routine changes are not at all recommended.

This probably depends on many factors, in patients where a central line is not placed through burned skin it can probably be managed like any other line.

Lines placed through burned skin are impossible to keep clean: no dressing sticks, and the burned tissue is colonized by a multitude of different organisms that can then be transferred into the blood stream via the line.

When I worked in burns, we changed our lines routinely every 3 days. Does this reduce actual physiologic CLABSIs? From a clinical standpoint, almost certainly.

What it also does really nicely is reduce CLABSIs on paper..... A central line has to be in-dwelling for at least 48 hours before an infection can be attributed to it....or from a charting perspective...greater than two completed central line dwell days. Change your lines every 3rd day, and you never have a line with greater than two completed dwell days, and therefore no documented CLABSIs. Possibly ever. Seriously, I saw a burn unit with no CLABSIs for 2 years.

Do I really think no patient ever had their blood stream seeded with skin flora from a central line in two years? Of course not. But tie a metric like CLABSIs to reimbursement, and people will find all sorts of creative solutions.

Loloberry · Sep 29, 2020

4 minutes ago, frozenmedic said:

This probably depends on many factors, in patients where a central line is not placed through burned skin it can probably be managed like any other line.

Lines placed through burned skin are impossible to keep clean: no dressing sticks, and the burned tissue is colonized by a multitude of different organisms that can then be transferred into the blood stream via the line.

When I worked in burns, we changed our lines routinely every 3 days. Does this reduce actual physiologic CLABSIs? From a clinical standpoint, almost certainly.

What it also does really nicely is reduce CLABSIs on paper..... A central line has to be in-dwelling for at least 48 hours before an infection can be attributed to it....or from a charting perspective...greater than two completed central line dwell days. Change your lines every 3rd day, and you never have a line with greater than two completed dwell days, and therefore no documented CLABSIs. Possibly ever. Seriously, I saw a burn unit with no CLABSIs for 2 years.

Do I really think no patient ever had their blood stream seeded with skin flora from a central line in two years? Of course not. But tie a metric like CLABSIs to reimbursement, and people will find all sorts of creative solutions.

Thank you so much for your response! You just explained what many who I've spoken to have not been able to answer! Most of the answers I've gotten have been along the lines of, "There isn't much research, and we've always done it this way, so...". This makes so much sense.

Leadkrm, RN · Jun 26, 2021

I know this is an old thread, but I figured I would chime in on what we do on large TBSA burn patients on my unit. We do central lines either in the upper arm or IJ. They are sutured in place and our dressing is just a sterile 4x4 gauze soaked in Iodine. We lay it on the entry site. It is changed every 2 hours minimum. We haven't had a CLABSI in like 6 years. It's a tough patient population to work with in that department. We do dressing daily or sometimes BID but leave the entry site open so that we can assess and replace these line dressings often.

Caroline Keith · Aug 16, 2021

In my old burn unit, we didn't regularly replace PIVs or central lines unless indicated, but it still happened, as everything gets ooey-gooey and stuff happens. If the central line was in intact skin, we did our standard CHG patch + sterile central line dressing, changed q7 days or PRN by either bedside or IV RN. BUT if the line HAD to be placed in burn skinned, like with our very large burns, we would clean the site with CHG sponge/wand q12 or q24 (I don't remember, I don't work there anymore), try to keep a CHG patch on it, and sterile gauze on top, replaced frequently. We had very few CLABSIs, but I don't remember the exact data ?

eileendg1989, RN · Feb 25, 2022

Sterile, Sterile, Sterile, anything on a burn patient is done in a sterile environment.