Frequent Broviac Infections - eek!

[Baboosh123]

Hello,

I'm a pretty new nurse and I am currently doing home care nursing while I wait for this dismal economy to bounce back so I can get a hospital job. (Still holding my breath...) Anyway, I have a pediatric patient with an indwelling Broviac catheter. The child has had a lengthy history of catheter infections/other infections before I started to care for her, and I have gathered that they had been occurring about once a month! I am no expert, but that definitely seems too frequent. For the past 5 months, she has been admitted to the hospital one time, and again in early April. She also developed an infection under the care of another nurse in January. So that makes 3 hospital admissions in the past 5 months, 2 of them while being under my care. I know that central venous catheters, (especially those used for TPN administration like my patient's) get infected regularly, but are these numbers too high? Is she just prone to infection?

[umcRN, BSN, RN]

Seems too high, I have heard of patients going months to years without infections. Do they remove the catheter everytime there is an infection? That is usually a standard of care that a line with an infection has to be removed and you have to wait for the infection to clear before placing a new one. How often are dressing changes (sterile!) being done? What precautions are being taken to avoid contact with bathwater, is the dressing changed everytime it is wet/soiled? TPN should always be set up as sterile as possible and make sure the catheter hub is getting a good 20 sec scrub before being accessed. Also where is the line located? At the hospital I work at, parents who have children with long term lines are told the keep the line as far away from the diaper area as possible, so if it is a chest line then the line/dressing is secured with the catheter extending up over the shoulder, not down towards the waist area. Means you might have to be creative with clothing but also helps prevent infection

[Baboosh123]

Well, mom is the one who does the dressing changes since she prefers it that way. But to my knowledge they are done about 3 times a week (sterile.) They also seem to be changed when wet from what I've seen. I'm never around when she is bathed, but mom is pretty good with compliance and following directions, so I can only assume she is doing a good job with that. When I ask her about it, she says she is careful. Perhaps I should try to see for myself what her technique is like?

She does wear a diaper at night sometimes so perhaps I will suggest that technique to the mom. And I will be more diligent about rubbing the hub with alcohol.

[msjellybean]

Maybe dressing changes are being done too often?

At my facility, central line dressing changes are done once weekly (unless visibly soiled, wet, etc.). For our neutropenic patients, we used to change them every 3 days; but according to our unit educator, this practice has actually been shown to increase rates of infection. So we've now transitioned to once a week across the board.

[apocatastasis]

Not accusing this mother of anything by any means, but there is Munchausen syndrome by proxy. And I only say that because I have seen it. Mom was videotaped wiping feces on her daughter's central line. They set up a videocamera because they just couldn't figure out how the girl was getting so many infections. Made the news here in Austin a couple years ago... and some of my classmates had taken care of the patient in clinical.

[PhilaBSNstudent]

I definitely think it is important to watch mom's technique with the dressing change. Even when we think we've educated our patient's well, they may have interpreted our information in a totally different way. You can't know how she is doing it, unless she demonstrates the skill to you. Find a non-accusatory way to ask mom if you can watch her do the dressing change and then go from there.

I am also curious about whether use of an "antibiotic lock" could be helpful in this case. I don't know much information about it, but one chronically ill child who is a frequent flier on our floor has his Broviac "cipro locked." From my understanding, once a week, his Broviac is accessed for a short period of time and a small amount of high concentration Ciprofloxacin is instilled into the lumen for about 12 hours. I honestly don't know enough about the evidence to support this technique but there seems to be tons of research done about antibiotic locks and central venous lines. It's just another idea to discuss with her provider if you are concerned about the infections. More information about this technique can be found here: http://www.medscape.com/viewarticle/500842

[MedSurgeMe]

Maybe they could place a port. or use a Biopatch or other chlorhexidine impregnated dressing. The biopatch costs money but many studies prove that it saves money by preventing infection / hospitalization

[roser13, ASN, RN]

Not accusing this mother of anything by any means, but there is Munchausen syndrome by proxy. And I only say that because I have seen it. Mom was videotaped wiping feces on her daughter's central line. They set up a videocamera because they just couldn't figure out how the girl was getting so many infections. Made the news here in Austin a couple years ago... and some of my classmates had taken care of the patient in clinical.

I wasn't brave enough to say it, but that was my first thought. Unfortunately, reality sometimes sucks.

[apocatastasis]

Speaking of the devil, this mom made the front page of the Statesman's website this evening: http://www.statesman.com/blogs/content/shared-gen/blogs/austin/courts/entries/2011/04/04/mom_gets_25_years_for_smearing.html

Very sad.

[Isabelle49]

Not accusing this mother of anything by any means, but there is Munchausen syndrome by proxy. And I only say that because I have seen it. Mom was videotaped wiping feces on her daughter's central line. They set up a videocamera because they just couldn't figure out how the girl was getting so many infections. Made the news here in Austin a couple years ago... and some of my classmates had taken care of the patient in clinical.

This was my line of thought also, apo. Not uncommon either.

[blondy2061h, MSN, RN]

Was the line changed? The infection won't always totally clear with antibiotics alone. For infections that frequent the line should be changed, especially if it's growing the same organism each time.

[MegNeoNurse]

I also agree that this is pretty frequent for line infections.... I work in a PICU and I'm sure every kid who has had a central line and been outpatient has ended up with an infections atleast once. The majority of the patients I care for are transplant kiddos, so they are immunosuppressants which obviously increases the risk for infection. Is that the case with this little girl? Also, 3x/wk is far too frequent for dressing changes. Maybe mom needs some re-education on dressing changes? Do you use chloraprep or just alcohol?