CLABSI - Multiple lumens vs Y sites

[CN21IVT]

I have a question about multiple lumen practices with regards to decreasing CLABSI risk. In my practice, we try to get by with the least amount of lumens, especially central line lumens, but in general, my thought process is, the least amount of access points I can get by with, whether it be PIV or central lines, the better for CLABSIs/PLABSIs. Recently I came across an ICU patient with a triple lumen IJ, with a triple lumen extension hooked to one of the lumens of the IJ for a total of basically 6 lumens. I would typically recommend Y-siting compatible medications rather than using the triple lumen extension, but I don't ever recall seeing any literature as to which would be better as far as decreasing CLABSI risk. I am aware that a triple lumen extension on one lumen can cause compatibility issues, but would like to know if anyone has any other thoughts regarding what would be better for decreasing CLABSI risk other than trying to get some of the meds d/c'd?

[IVRUS, BSN, RN]

WOW!, 6 lumens.. Is the patient that much of a sick puppy??? First of all, like you, I know that the more lumens means more manipulation, and an increase in CRBSI's. But, also remember that this is an ADD-ON device. According to INS, add on devices are a no-no, as this too causes an increase in infection. Filters, manual flow control devices (Dial-a-flows) or elongated tubing should be part of an integral set, and add on devices prohibited. Secondly, I too would be worried about compatibility issues. AND, last, but not least, the catheter you said that this patient has is known to HAVE THE HIGHEST INFECTION RATES OF ALL C-LINES. All of these things bring me to the need to evaluate the situation more closely...I am so glad that you are there to advocate for this patient.

[chare]

3 hours ago, IVRUS said:

WOW!, 6 lumens.. Is the patient that much of a sick puppy??? First of all, like you, I know that the more lumens means more manipulation, and an increase in CRBSI's. But, also remember that this is an ADD-ON device. According to INS, add on devices are a no-no, as this too causes an increase in infection. ...

Does the INS actually consider add-on devices a "no-no?" Or do they recommend there use only when clinically indicated?

ETA: Are the INS 2016 Infusion Therapy Standards of Practice the most current?

[IVRUS, BSN, RN]

On 6/1/2020 at 10:04 AM, chare said:

Does the INS actually consider add-on devices a "no-no?" Or do they recommend there use only when clinically indicated?

ETA: Are the INS 2016 Infusion Therapy Standards of Practice the most current?

Standard 36 specifically addresses add-ons and it states, " When indicated, preferentially use systems that minimize manipulation and reduce components, such as integrated extension sets" Therefore, it is saying, that if at all possible, don't use add-ons as they greatly contribute to bacterial introduction. And, yes, 2016 is that last one. They update standards every 5 years.

[adventure_rn, MSN, NP]

This is fascinating, since the triple/quad extensions are standard practice in most NICUs and some peds/PICU settings. Pretty much every patient has at least one open lumen/extension port that you can hook into at any time (which is clamped when not in use). My NICUs have never y-d things in, and the PICU I worked in would rarely do it (occasionally people might y lipids into TPN, nurse preference). It wasn't uncommon to see multiple quad-ports stacked on top of each other (like a tree branching out).

Part of the rhetoric was that if you needed to run extra things together at a later point (like drips or compatible meds), you could decease infection risk by steriley stringing the extra extension/ports into the line ahead of time, rather than breaking into the line once it's already attached to the patient (a huge infection risk no-no in NICU).

NICU/peds tubing also tends to be so tiny that it often doesn't even include a port on the line to y into; you have to use an extension bi/tri/quad-port if you want to run multiple things simultaneously through a line. NICU access is so challenging to establish/maintain that we also tend to run a lot more things together that adult nurses usually wouldn't (like bolus meds running in a lumen with sedation drips, or TPN being paused so an incompatible med can be given through the 'TPN lumen.'

[MunoRN, RN]

Multiple ports to a single lumen does make that single lumen more than one lumen, at least based on how the term is commonly used.  A "lumen" is where a single or combined flow of infusions exits into the bloodstream.  

Y-siting compatible medications can be extremely dangerous and should only be done when it's safe to do so, otherwise more appropriate multi-access device should be used.  Keep in mind that when you y-site multiple infusions into each other you are going to be infusing another medication for some period of time before the intended medication reaches the common lumen.  This might mean that when your patient's BP crashes and you start your epi infusion, you might be pushing nicardipine and/or nitroglycerin ahead of it (for instance), this is potentially negligent practice.

Instead of Y-siting, appropriate access device should be used to manage multiple infusions to ensure appropriate pharmacokinetics of the infusions.  This also is an important factor in reducing the risk of infection.  While the INS doesn't do a great job of explaining their rationale regarding add-on devices, the overall goal is to reduce connection manipulations, since each one increases the risk of infection.  You shouldn't be adding add-on devices that won't be used, but devices that allow for multiple infusions to be safely connected, and remain connected, to an infusion system is a very important part of reducing unnecessary manipulation of connections which then increases the risk of introducing bacteria.  

There seems to be a misunderstanding in the vascular access community about what sort infusions therapies are required by hospitalized patients.  One of our more common patients in the ICU is the post-OHS patient, at a minimum they typically have 10-12 different infusions connected, how they connect and interact is extremely important to ensuring they receive safe and effective care.  To suggest we shouldn't be using add-on devices pretty much negates the reliability of these 'expert sources' makes them effectively irrelevant, which is unfortunate since the profession of Nursing should be a reliable source of practice guidelines.