Hickman line positive for s.aureus bacteremia. Do not flush

[findingfeet]

Hi,

Im in Australia so my terminology may not make sense. Also I am a new grad with 9months experience, so still learning.

A patient has a Hickman line (Central Venous Line) for TPN 12 hours per day. The line has tested positive for staph aureus infection, with bacteremia also present, as tested from a peripheral blood sample.

As I see now this is a relatively common but unfortunate complication with CVLs.

Following the test result, we were informed to cease TPN and lock the line with 3ml Gentamicin and Sodium Citrate lock (as had been done daily following TPN being taken down).

We have recently been having problems drawing back on the line and so difficulties removing the gentamicin lock prior to starting TPN administration. However the line could be flushed with no apparent blockage. What does this mean when no backflow is present? It previously was present a few days prior.

I have a couple more questions:

What is the danger of giving the gentamicin and sodium citrate bolus? I suppose the risk of toxicity from the gent increases if the bolusing was ongoing.

The doctor instructed "do not to flush the line". I assume this is because this would push the infection in the line into the patient? Or is this also because the Dr did not want us to push the gentamicin into the patient?

Thanks

I can clarify if need be.

[traumaRUs, MSN, APRN]

Hi and welcome to AN, the largest peer to peer nursing network. While I can't answer your specific question, I'm sure someone will be along soon that can help you out. Glad you joined!

[Asystole RN]

The first consideration is we have to evaluate is the bacteremia. Just because the patient has a central line and is receiving a high infection risk infusion does not definitively determine that the cause of the infection is the central line. Granted, it is the prime suspect but correlation is not the same as causation. The presence of S. aureus does strongly imply that the line has a strong role in the infection but it is not unheard of that bacteria introduced through other sources such as surgical wounds, gastrointestinal injury, and peripheral IV sticks instilled the bacteria which seeded the catheter after.

The most common cause of the inability to draw but no resistance to flushing is a fibrin tail/sheath.

The risk of a gent/citrate bolus entirely depends upon the dose although every gent lock I have used did not have a dosage large enough to cause any real harm.

The main issue of not flushing can be two different rationales. One is yes, you may not want to instill a large amount of gent but you would have to know the dosage, and the other is possibly not to dislodge a bacteria laden piece of fibrin into the body or instill a large amount of bacteria seeded fluid lock. If the later is the rationale being used then it would be best just to pull the line and get something fresh in.

Most of the time, unless there is a real clinical reason why this is not feasible, it is best to pull the line and replace with something more temporary like a PIV or just replace with a fresh catheter. Removing biofilms from implanted devices can be a real pain.

[findingfeet]

Thanks very much, that is a helpful reply