CVC's and # of Lumens

[blondy2061h, MSN, RN]

I work on a very busy unit where nearly all of our patients' meds are IV and literally everyone has a central line.

I've seen CVC's with 2-5 lumens.

It's not uncommon for this to be a typical med list for a shift:

TPN

PCA pump

Insulin drip

IV cellcept and prograf (over 2 hrs each)

maintenance fluids

IV vanco

IV zosyn

IV anidulafungin

IV acyclovir

IV protonix

IV zofran

IV reglan

IV ganciclovir

IV lopressor/hydralazine/dopamine/something for their BP be it high or low

Plus multiple blood/platlet transfusions throughout the shift...

It makes me think there's a special place in hell reserved for docs who give out patients double lumen CVCs- especially if they have pre-existing conditions coming into the transplant. It sometimes has me deciding if I should transfuse them for their 7.0 hgb or give their immunosuppresans on time. They usually end up getting a double lumen PICC later on in the game (when they're generally less stable and we're realizing we don't have nearly enough access) when they only have a double lumen CVC.

So here's my question. I can't find anything suggesting benefits of double lumen over triple lumen. Why would they even think of just doing a double lumen? Are triple lumens riskier?

[icyounurse, BSN, RN]

I have had similar frustrations and once I asked a doc, and he told me the triple lumens are a bit longer and therefore have a bit greater chance of causing a pneumo?? Don't know if this is true or not. He said thats why if anesthesia puts the CVL in they will do a double every time since they are a little easier to get in due to length. I did notice after he told me this that all the patients who get one placed by anesthesia get a double, which I agree is very annoying. You really need that 3rd line sometimes.

[Daytonite, BSN, RN]

i would suggest that you ask these patients who inserted their cvcs and then ask these persons why they use double lumens as opposed to triple lumen's. i suspect you are going to find that the reason is because that is the equipment that is available to them or it has to do with cost. i had a single lumen picc line placed for chemotherapy and it was done by a radiologist as an outpatient. a week later i was hospitalized for a septic infection (not related to the picc) and multiple iv lines were needed. who could have foreseen that? throughout my 6 months of chemo i had to be placed on antibiotics several times and that was also not expected. stuff happens. with each lumen added to a line, the chance of line complications increases so the conservative approach is to start with the smallest number needed.

[blondy2061h, MSN, RN]

Daytonite, I totally agree, however, a lot of what you mentioned in your post was- as you said- unexpected. In BMT, none of this is really unexpected. IV antibiotics are a way of life for at least a month, if you're having an auto-transplant, IV tacrolimis and mycophenalate is also a given. Daily blood transfusions for about a 2 week period are expected, and daily electrolyte replacement is a given too. None of it is unexpected in this case.

Also, unfortunately, going down hill kind of is expected too somewhat. BMTs still just don't have great statistics associated with them.

I'll definitely ask the docs placing the lines what they were thinkng.

Hope all is well with you now and that your personal oncology experience is long behind you.

[fins]

The thing is, swapping out a CVC over a wire is a ten-minute long bedside procedure. If you find that you need more lumens, why can't a doc just put in a CVC with more lumens. It seems like less of an infection risk than putting in a PICC in addition to the existing CVC.

[Roy Fokker, BSN, RN]

I may be speaking out of league/term here as an ED nurse but:

The general argument/consensus I've come to see is:

* The number of lumens inserted is directly proportional to the ability/confidence/availability of such CVCs to be inserted sucessfuly. As un-popular as I may sound - I'm fairly certain that most physicians aren't blind to what their patients needs are when they insert CVCs. Meaning: they don't purposely insert less lines than they could have just because they can...

As 'miniscule' as 'one extra lumen/port' might seem - it is not as 'miniscule' when the procedure is being attempted. An analogy I'd like to draw is one that we as nurses come across everyday - will that peripheral vein accomodate an 18g Vs 20g? A 20g Vs 22g? etc.

* Every extra port/lumen is yet another source/route of infection.

* Medical science isn't like mathematics i.e. 2+2 doesn't always equal 4. Right now we may think "we need access now!" ... and twenty minutes later we end up having patient deteriorate to the point of requiring pressors and other concurrent drips".

* Last, but certainly not the least - cost/need is always a factor. You may have a patient with great, tree trunk veins ... but that doesn't mean you stick 'em with an 18/16 g when a 20/22 g will suffice, right? Each extra lumen adds onto the total cost. I guess this ties in with point #2 above.

cheers,

[Sillynicunurse]

We also seem to have a lumen shortage in our ICU. Patient comes in septic the docs order every antibiotic known to man, they need blood so you are already out of ports. Then the poor patient needs to be intubated and requires sedation and as luck would have it nothing is compatible with anything else. So here you are at 0000 still hanging the 2100 and 2200 abx :)

I have asked docs what drives their choice of 2-5 lumens and basically it comes down to what is available at that moment to them. I even had one doc admit that he didn't really think about all of the meds ordered for the patient when he places the line and that nursing just seems to make it work every time. Bless his heart for at least being honest.

[meandragonbrett]

Double or single lumens are often placed so that a swan can be placed. I've never seen a TLC or QLC that you can place a swan through.

[RazorbackRN, BSN, RN]

Double or single lumens are often placed so that a swan can be placed. I've never seen a TLC or QLC that you can place a swan through.

I have seen many swans floated through a TL.

[shouldhavebeenanunRN]

okay.. i'm a rookie... what is a swan?

[Pedi-Gree, BSN, RN]

A swan is a nickname for a pulmonary artery catheter. The evidence for their use is dwindling and more and more evidence suggests that they increase morbidity without decreasing LOS or mortality.

In peds we often will get transplant or oncology patients with single lumen tunneled catheters for long term use that really complicate the nurse's day. The OP's list is pretty close to some of ours. The thing that most often falls by the wayside for us is nutrition. If I have to choose between gancyclovir and TPN, it's gonna be the gancyclovir every time. We used to say that one night when it was quiet we were going to sneak into the OR and remove all the single lumen lines in the place so they'd be forced to give us more access.

[suanna]

I've had the same question. At my hospital the TLCs are approved for 10 days of placement but the double lumen lines are only good for 72hrs by policy. Average LOS post CABG is 5-6 days so if a patient has a TLC and needs central line access for thier entire post-op stay the line is good till discharge, but if they have a double lumen they have to have it changed out (by the resident) over a wire on post op day 3. What a waste! Anesthesia places the lines peri-op and it seems if they feel if the line was good enough to get them through the case it is good enough for them. 9 out of 10 times they place a DLC instead of the 10 day TLC. Not to mention, another available port is always usefull!