Vascular Access: Amanda Ullman at DFTB18

Cite this article as:
Team DFTB. Vascular Access: Amanda Ullman at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.18669

We were pleased that Amanda Ullman took up our offer to speak at DFTB after the great post she and the Vascular Access Management Service wrote for us on management of paediatric central access devices. This talk comes complete with trigger warnings. We’ve all been in the situation when we have been confronted with doughy armed toddlers and no sign of a vein in site. The parents, and that patient, are relying on you to get it right.


Given the prime directive of physicians of Primum Non Nocere (First Do No Harm) it is worth considering if we should be cannulating the child in the first place. In a study by Holloway et al. (2017) they found that 22% of PIVCs were unused after insertion. With a success rate of around 60% in our well children, we really to sway the odds further in our favour.

But is also worth considering the flipside – cannulation may be less painful than heel prick for blood sampling in neonates. Amanda asks us to consider if you are the right person to put in that cannula. Should you just ‘give it a go anyway’? Have you been up half the night and can barely focus? Have you just missed you last six cannulae and have something to prove?

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story‘ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

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Selected References

Deitcher SR, Gajjar A, Kun L, Heideman RL. Clinically evident venous thromboembolic events in children with brain tumors. The Journal of pediatrics. 2004 Dec 1;145(6):848-50.

Hollaway W, Broeze C, Borland ML. Prospective observational study of predicted usage of intravenous cannulas inserted in a tertiary paediatric emergency department. Emergency Medicine Australasia. 2017 Dec;29(6):672-7.

Kleidon TM, Cattanach P, Mihala G, Ullman AJ. Implementation of a paediatric peripheral intravenous catheter care bundle: A quality improvement initiative. Journal of paediatrics and child health. 2019 Jan 31.

Stolz LA, Cappa AR, Minckler MR, Stolz U, Wyatt RG, Binger CW, Amini R, Adhikari S. Prospective evaluation of the learning curve for ultrasound-guided peripheral intravenous catheter placement. The journal of vascular access. 2016 Jul;17(4):366-70.

Takashima M, Schults J, Mihala G, Corley A, Ullman A. Complication and failures of central vascular access device in adult critical care settings. Critical care medicine. 2018 Dec 1;46(12):1998-2009.

Ullman AJ, Cooke M, Kleidon T, Rickard CM. Road map for improvement: point prevalence audit and survey of central venous access devices in paediatric acute care. Journal of paediatrics and child health. 2017 Feb;53(2):123-30.

CVADs – a survival guide

Cite this article as:
Amanda Ullman. CVADs – a survival guide, Don't Forget the Bubbles, 2016. Available at:
https://doi.org/10.31440/DFTB.10530

This guest post is from Amanda Ullman, Tricia Kleidon, Anna Dean and the Paediatric Vascular Assessment and Management Service, Lady Cilento Children’s Hospital, Brisbane.

We all love reliability. Central venous access devices (CVADs) are everywhere – across disciplines and departments, and we just want them to work reliably, without complication.

But every day, somewhere in your hospital, we are problem solving CVADs gone awry. And in many hospitals no specialist vascular access teams are there to help you. 

Being a CVAD survivalist will help you – most likely at 3am. Some situations will need escalating to specialists, but many can be quickly and effectively managed with simple, evidence-based techniques.

 

Needling a totally implanted device (ports)

Some totally implanted devices – or ports – are a pain. This is especially a problem in children with large amounts of adipose tissue, or poorly positioned ports.

But when problem solving this – everyone is different. Ask the child to sit up in the bed (or on their parent), and take off any restrictive clothing (e.g. bras for teenage girls). Use a rolled up towel under their back/shoulder blade and ask the patient to push their chest out, allowing less tissue to cover the port – making it become more prominent.  Make sure you have a firm grip of the port and stretch the skin out over it to reduce the amount of tissue you have to go through – this cannot be overemphasised.  There should be no slack in the skin.  You may need to change your grip a couple of times to get this just right. Also consider your own position when inserting, often placing yourself at the head of the bed is helpful.

 

Post CVAD insertion bleeding

Bleeding after the insertion of CVADs can require frequent dressing changes – not the easiest task on a post-anaesthetic child or toddler.

The application of small drops of medical-grade superglue, or tissue adhesive (cyanoacrylate), directly on the CVAD insertion site results in immediate haemostasis, without resulting in significant skin injury [1, 2]. Most practical on peripherally inserted central catheters (PICCs) and non-tunnelled CVADs, make sure the site is completely dry before applying the glue, try not to stick yourself to the child or the CVAD, and allow the glue to dry completely before covering it with the usual CVAD dressing.

 

Lumens that won’t aspirate or flush

Many factors can result in blocked CVAD lumens. A step-by-step approach is necessary…

  1. Don’t over complicate matters! Check for external occlusion due to a kinked line etc.
  2. Change the needleless access device (i.e. the bung) – these frequently dysfunction and result in blockage.
  3. Try small, pulsatile aspirates, and then flushes of normal saline using a 10mL syringe. Never use a syringe smaller than 10mL or be tempted to use excessive force – this can result in catheter breakage. Ask the patient to cough, breathe deeply, or change their position while aspirating and flushing.
  4. Assess for correct placement (chest x-ray, angiography).
  5. Instil a thrombolytic agent, such as Urokinase or Alteplase (unless contraindicated), allow it to dwell for at least 60 minutes, and then aspirate and/or flush with normal saline. This may need to be repeated several times.
  6. In the case of total occlusion where you can’t administer a thrombolytic agent by a simple push – use a 3-way tap and additional empty 10mL syringe.  Turn the 3-way tap off to the thrombolytic agent, pull back on the empty 10mL syringe to create a vacuum.  Turn the tap so it is open to the drug and patient, and the drug should infuse under negative pressure.
  7. If the blockage is a result of drug precipitation or build of lipid products; talk to the pharmacist for an appropriate dissolving agent such as hydrochloric acid or sodium bicarbonate.
  8. Phone a friend, preferably someone who can insert a replacement device.

 

Local CVAD site irritation vs local infection

Identification is of the issue is key.

If there are any signs of inflammation or infection (e.g., raised red area, ooze ) take a swab for microscopy, culture and sensitivity (MC&S).

Early libe sire infection

For uncomplicated exit site infections (i.e., no signs of systemic infection, purulent drainage or positive blood cultures) in long-term CVADs, the Infectious Diseases Society of America recommends the use of topical antimicrobial agents specific to the MC&S results, (i.e. mupirocin ointment for S. aureus infection and ketoconazole or lotrimin ointment for Candida infection). If it is a short-term CVAD (e.g. PICC) take it out and organise a replacement device.

If infection doesn’t seem likely, identify what is causing the skin irritation.

Contact dermatitis

Most frequently it will be the decontaminant (2% CHG in alcohol) that has not been left to dry adequately.  Some patients have a reaction to the fibres in the decontaminant stick. If this is a possibility use bottled (2% CHG in alcohol) with gauze and forceps.  Additionally, consider the use of a barrier film product, provide symptom relief (i.e. itch, pain), and if symptoms persist recommend changing to a less-irritating silicone-based dressing product.

 

Broken lumens

Oh God, it snapped. This happens – a lot it seems.

Broken lumens don’t always result in the end of the entire CVAD, but it does depend on the type of CVAD. Silicone CVADs, such as HickmansTM, have catheter repair kits that sit with skilled clinicians, such as paediatric oncology and haematology. Peripherally inserted central catheters vary by brand and catheter material in their ability to be repaired. This is definitely a phone a friend situation. When repairing a broken catheter, always consider the circumstances in which it fractured and environmental exposure. Blood cultures and prophylactic antibiotics might reduce the risk of subsequent infection.

References

1. Rickard, C.M., et al., A 4-arm randomized controlled pilot trial of innovative solutions for jugular central venous access device securement in 221 cardiac surgical patients. Journal of Critical Care, 2016. 36: p. 35-42.

2. Ullman, A.J., et al., Central venous Access device SeCurement And Dressing Effectiveness (CASCADE) in paediatrics: protocol for pilot randomised controlled trials. BMJ Open, 2016. 6(6).

3. Simcock, L., Managing occlusion in central venous catheters. Nurs Times, 2001. 97(21): p. 36-8.

4. Mermel, et al., Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis, 2009. 49: p. 1-45.