# Prehospital Access of Central Lines



## NPO (Nov 27, 2016)

Do your protocols allow you to access central lines? If so, what do they say? Only in cardiac arrest, or when ever you deem necessary? Do they go into detail? Likewise, if not, do they say why and do they provide an alternative?

I recently brought up the subject of accessing central lines to my medical director because our protocols don't mention it. 

He acknowledged that our protocols don't mention it, but encountered their use when justified in an emergency. He even went so far as to say that if a dialysis access line is all we have in a true emergency, then do what you have to do, but understand that the nephrologists will hate you for it.

I'd like to hear the input of others, and what you practice in regards to central lines. 

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## SandpitMedic (Nov 27, 2016)

We don't play around with that stuff. I think of most procedures in emergency medicine this carries some hefty risks both during and after.


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## Carlos Danger (Nov 27, 2016)

Do you mean med ports, dialysis catheters, and/or PICC lines? 

I think the "only in an emergency" caveat makes good sense. These devices aren't rocket science and you probably aren't going to harm the device or the patient by accessing it. But....replacing them can be a real PITA and cost $$ so you aren't doing the patient or their doctors any favors by pulling it out or otherwise damaging it. But in a true emergency, no one is going to hate you for it.

Have someone (someone who actually uses them - probably a nurse - not just a buddy who thinks he knows everything) show you how to access them and don't be afraid of them at all if you need to use them.


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## TXmed (Nov 27, 2016)

I think access of a true central line or PICC line in a true emergency is fine, i wouldnt necesarrily play around with the other stuff. their should probably be a protocol describing how to properly access it.

If you arent comfortable or confident then just do an IO. dont dwell on it too much.


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## WolfmanHarris (Nov 27, 2016)

Under my directives I can access in an arrest or pre-arrest situation when IV access is unavailable. (Don't have to actually attempt just consider and rule out) However, since it's in my scope I can patch for an order to go ahead and access if the need arises outside of this.


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## NomadicMedic (Nov 27, 2016)

We have a port/central access protocol, "only in extremis" or with a med control okay. We also have huber needles for ports. I've used a PICC for meds and fluid in the past.


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## VentMonkey (Nov 27, 2016)

NPO said:


> Do your protocols allow you to access central lines? If so, what do they say? Only in cardiac arrest, or when ever you deem necessary? Do they go into detail? Likewise, if not, do they say why and do they provide an alternative?
> 
> I recently brought up the subject of accessing central lines to my medical director because our protocols don't mention it.
> 
> ...


It was left vaguely in our protocols for a reason (before this director took the helm), provider discretion. He basically answered your question in regards to its use.

This is in line with many other prehospital protocols as well, as others above have stated. If it's all you, it's all you have. Be sure that it is in fact all you have, make sure you're accessing the proper ports particularly with subclavians, and/ or the aforementioned dialysis catheters.

FWIW, huber needles for port-a-caths have to been one of the more simplistic central lines to access _if _properly trained.


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## Handsome Robb (Nov 27, 2016)

We can use them if the patient is "in extremis". We also carry huber needles for the same scenario.


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## VentMonkey (Nov 27, 2016)

Handsome Robb said:


> We can use them if the patient is "in extremis". We also carry huber needles for the same scenario.


I wish we had them---at least on CCT---and were properly trained to access them (as CCT paramedics). Ahhh yes Kern County, sooo forward thinking.


Remi said:


> Do you mean med ports, dialysis catheters, and/or PICC lines?
> 
> Have someone (someone who actually uses them - probably a nurse - not just a buddy who thinks he knows everything) show you how to access them and don't be afraid of them at all if you need to use them.


I think he meant any, and all of the above. I think Remi has a good point in regards to them really not being that difficult, but it is best taught by nurses or others comfortable in accessing them frequently. Sublclavians and IJ's (med ports) work great as well, and are straightforward enough.


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## VFlutter (Nov 27, 2016)

You would be surprised how much training we are required to be able access central lines in the hospital. There is a huge drive to reduce CLABSI. Even in a "clean" ICU they are so hard to avoid so I completely agree with not routinely accessing lines in the field, even though it may not seem like a big deal. Obviously in extremis is totally different.


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## VentMonkey (Nov 27, 2016)

That being said, a patient in extremis (i.e., cardiac arrest) with an IJ in place seems the right candidate to forego IO access.


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## TransportJockey (Nov 27, 2016)

PICC lines only in extremis and usually with orders. With teh general caveat of aspirating 10cc of blood and discarding. But considering we carry EZ-IO, and it's preferred and almost as quick, the times our crews use a PICC is very very rare.
We rarely see other types of central veinous access. And we don't carry huber needles, so implanted ports are a big nono for us.


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## NomadicMedic (Nov 27, 2016)

We have a PICC/port inservice once a year and have to demonstrate clinical competency on the port manikin. As almost everyone else mentioned, I'd rather just drill an IO and be done with it.


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## NPO (Nov 27, 2016)

DEmedic said:


> We have a PICC/port inservice once a year and have to demonstrate clinical competency on the port manikin. As almost everyone else mentioned, I'd rather just drill an IO and be done with it.


Problem is, we don't have EZIO, just the manual ones. 

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## NomadicMedic (Nov 27, 2016)

NPO said:


> Problem is, we don't have EZIO, just the manual ones.
> 
> Sent from my SM-G935T using Tapatalk



Twist,twist,twist,twist,twist,twist,twist,twist,twist,twist,twist,twist, "damn." Twist, twist, twis...POP.


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## NPO (Nov 27, 2016)

DEmedic said:


> Twist,twist,twist,twist,twist,twist,twist,twist,twist,twist,twist,twist, "damn." Twist, twist, twis...POP.


Yes yes. But we don't have a high success rate with them. I'm one for two. I know most other medics struggle too

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## VentMonkey (Nov 27, 2016)

NPO said:


> Problem is, we don't have EZIO, just the manual ones.


Says you.


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## VentMonkey (Nov 27, 2016)

NPO said:


> Yes yes. But we don't have a high success rate with them. I'm one for two. I know most other medics struggle too.


It is most unfortunate both sides don't have EZ-IO's, bougies, or X-series (I am about done with those E-series we have; very outdated), but I digress...


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## NPO (Nov 27, 2016)

VentMonkey said:


> It is most unfortunate both sides don't have EZ-IO's, bougies, or X-series (I am about done with those E-series we have; very outdated), but I digress...


I think we're moving away from them. Now that we've broke the ZOLL wall with our new PCR program. I'd be happy with an X series though. 

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## VentMonkey (Nov 27, 2016)

NPO said:


> I think we're moving away from them. Now that we've broke the ZOLL wall with our new PCR program.


Speculation or proof? If cold hard facts, PM me.


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## Carlos Danger (Nov 27, 2016)

NPO said:


> Problem is, we don't have EZIO, just the manual ones.
> 
> Sent from my SM-G935T using Tapatalk



I'm no attorney, but at this point in the history, I would speculate that this potentially puts your service at some legal risk. 

Not to mention the sheer idiocy of not using the EZ-IO, from a clinical perspective.


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## Handsome Robb (Nov 27, 2016)

VentMonkey said:


> It is most unfortunate both sides don't have EZ-IO's, bougies, or X-series (I am about done with those E-series we have; very outdated), but I digress...



Wait timeout. The Kern cult doesn't have the EZIO or bougies and still uses the E-series? 


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## VentMonkey (Nov 27, 2016)

Handsome Robb said:


> Wait timeout. The Kern cult doesn't have the EZIO or bougies and still uses the E-series?


With the exclusion of our CCT division, yes.

As a side, I really love how the "cult" term transcends all threads in reference to Hall Ambulance, lol good times. I can't thank, @CALEMT enough.


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## NPO (Nov 27, 2016)

Handsome Robb said:


> Wait timeout. The Kern cult doesn't have the EZIO or bougies and still uses the E-series?
> 
> 
> Sent from my iPhone using Tapatalk


Yes. Thats correct. We use manual IO needles, and while we are permitted to use Bougies, we don't have them. 

E-Series is our monitor of choice. Our CCT division received X series monitors a couple years ago. 

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## WolfmanHarris (Nov 27, 2016)

We're finally getting EZ-IO's at my service, just in time for me to start my precepting for ACP. Hoping we'll be getting the glidescope next, I know a neighbouring service is trialling them and our Service Quality Unit will probably advocate for them from a patient safety standpoint.


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## TXmed (Nov 27, 2016)

The EZ-IO was meant to be put in manually, so that shouldnt effect success rates.

One of the inventors teaches a cadaver lab in san antonio, he is openly honest about it. he also says the only reason for the pedi size is for FDA approval and suggests using the adult needle even for pediatrics. pretty interesting class.


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## VentMonkey (Nov 27, 2016)

There's also these. @NPO they come to California quite often TMK, and I am told they're quite insightful.
http://www.teleflex.com/en/procedural-lab-registration/usca.html


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## Never2Old (Nov 27, 2016)

My Medical Director say's use an EZ-IO, don't touch the port.


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## zzyzx (Nov 28, 2016)

You should follow your protocols, but there is no reason to be afraid of central lines.
With a little bit of education, I don't see any danger in paramedics using central lines. It's too bad some medical directors are not onboard. The last two places I worked allowed central line access.


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## Tigger (Nov 28, 2016)

We have a similar "extremis" protocol, but given that I've never received any training on it, I think I'll just use the EZIO...


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## zzyzx (Nov 28, 2016)

Tigger said:


> We have a similar "extremis" protocol, but given that I've never received any training on it, I think I'll just use the EZIO...



Okay, but when you show up to an ER with an IO on a patient with a central line that you could have accessed, you will lose credibility points with the staff. I don't mean that you are not in fact a great paramedic, only that you will leave a bad impression among the ER staff who have not see you working in the field.

When you have a beautiful PICC line right there in front of you--the most perfect IV line you could ask for--and just waiting to be accessed in, and instead you drill a needle into someone's bone...well, I don't know man.

Again, not beating up on you personally, just saying that experienced people in the ER are going to be scratching their heads.

Why not do the right thing and question your EMS agency's QC officers about why you have not received proper training for something that is in your protocols and that you should therefore be responsible for knowing? If you haven't received this training, then your co-workers likely have not either, so here is a perfect way to improve the professionalism of you and your co-workers.


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## NPO (Nov 28, 2016)

zzyzx said:


> Okay, but when you show up to an ER with an IO on a patient with a central line that you could have accessed, you will lose credibility points with the staff. I don't mean that you are not in fact a great paramedic, only that you will leave a bad impression among the ER staff who have not see you working in the field.
> 
> When you have a beautiful PICC line right there in front of you--the most perfect IV line you could ask for--and just waiting to be accessed in, and instead you drill a needle into someone's bone...well, I don't know man.
> 
> ...


Worth noting, that PICC are not great for volume depleted patients. But then again, I've never achieved great flow rates from an IO either...

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## Tigger (Nov 28, 2016)

zzyzx said:


> Okay, but when you show up to an ER with an IO on a patient with a central line that you could have accessed, you will lose credibility points with the staff. I don't mean that you are not in fact a great paramedic, only that you will leave a bad impression among the ER staff who have not see you working in the field.
> 
> When you have a beautiful PICC line right there in front of you--the most perfect IV line you could ask for--and just waiting to be accessed in, and instead you drill a needle into someone's bone...well, I don't know man.
> 
> ...


Perhaps where you work, but not here. We do not have Huber needles, nor does any other local agency. I cannot think of a recent time in which anyone I know has accessed a PICC line either. If it's already accessed I'd of course use it.

I am not going to drill a patient that is not quite ill, coincidentally such a patient's level of illness probably allows for the use of IO access. IO access is not looked at as cheating or a last ditch effort here, and is actually in the EMT scope of practice. Incidentally my partner and I recently caught some good natured ribbing from our medical director for not going to the drill sooner on a hyperK patient, who was awake and mostly alert.


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## VFlutter (Nov 28, 2016)

zzyzx said:


> Okay, but when you show up to an ER with an IO on a patient with a central line that you could have accessed, you will lose credibility points with the staff. I don't mean that you are not in fact a great paramedic, only that you will leave a bad impression among the ER staff who have not see you working in the field.
> 
> When you have a beautiful PICC line right there in front of you--the most perfect IV line you could ask for--and just waiting to be accessed in, and instead you drill a needle into someone's bone...well, I don't know man.



I don't necessarily  agree. As mentioned a PICC is far from the most perfect IV in terms of resuscitation.

A patient getting an IO is better than the hospital having to replace the central line, potentially having to perform a "line holiday" and requiring multiple PIVs,  Abx, etc. We even go as far as replacing central lines placed at another hospital.


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## zzyzx (Nov 28, 2016)

Chase said:


> I don't necessarily  agree. As mentioned a PICC is far from the most perfect IV in terms of resuscitation.
> 
> A patient getting an IO is better than the hospital having to replace the central line, potentially having to perform a "line holiday" and requiring multiple PIVs,  Abx, etc. We even go as far as replacing central lines placed at another hospital.



Chase, why would a well trained paramedic not be able to properly access a PICC line? You and I both work as nurses and paramedics. What makes you think that a paramedic is going to cause a central line infection? I really don't understand your logic, but if you have a reasonable argument as to why that is the case, I'd like to hear it.


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## zzyzx (Nov 28, 2016)

NPO said:


> Worth noting, that PICC are not great for volume depleted patients. But then again, I've never achieved great flow rates from an IO either...



How do you suppose that a PICC line is not for volume depleted patients? Are you familiar with using PICC lines? Is this just something that some other paramedic once told you?[/QUOTE]


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## zzyzx (Nov 28, 2016)

"Perhaps where you work, but not here. We do not have Huber needles, nor does any other local agency. I cannot think of a recent time in which anyone I know has accessed a PICC line either. If it's already accessed I'd of course use it."

Tigger, you don't need a Huber needle to access a PICC line. If central line access is in your protocols, I would encourage you to become more familiar with them.


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## NPO (Nov 28, 2016)

zzyzx said:


> How do you suppose that a PICC line is not for volume depleted patients? Are you familiar with using PICC lines? Is this just something that some other paramedic once told you?


[/QUOTE]
PICC lines do not allow for rapid infusion of fluids compared to large peripheral IVs. Combined with the fact that we do not have pumps, rapidly infusing fluids via a PICC is not ideal.

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## VFlutter (Nov 28, 2016)

zzyzx said:


> Chase, why would a well trained paramedic not be able to properly access a PICC line? You and I both work as nurses and paramedics. What makes you think that a paramedic is going to cause a central line infection? I really don't understand your logic, but if you have a reasonable argument as to why that is the case, I'd like to hear it.



I am saying that central line infections happen even in "clean environments" with much care taken to prevent them so it seems prudent to only access these devices when necessary in the field. Risk vs Benefit. In extremis the risk is obviously outweighed however for routine infusions it is hard to justify. I am not saying that prehospital providers are incapable but there are many unknown factors. When was the last time the dressing/caps was changed? Did they change refulx valves after blood draws? When was the last time it was actually accessed/flushed? Was it heparinized? etc.

How many providers, Nurse or Medic, actually access lines correctly? Scrubbing the hub for a full 15 seconds, which is a long time, scrubbing the hub between each and every medication and flush? Actually performing hand hygiene and changing into clean gloves before accessing the line.

https://www.urmc.rochester.edu/medi...tions/documents/clabsipresentationdumyati.pdf



zzyzx said:


> How do you suppose that a PICC line is not for volume depleted patients? Are you familiar with using PICC lines? Is this just something that some other paramedic once told you?


[/QUOTE]

PICC line has the slowest infusion rate of any access device, much slower than peripheral lines or IOs. PICCs can not be used with Rapid Infusers. Poiseuille's law; Flow rates are determined by the length and diameter of a catheter. PICCs are long and small bore.

http://emupdates.com/2009/11/25/flow-rates-of-various-vascular-catheters/


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## zzyzx (Nov 28, 2016)

You don't need a pump to use a PICC line. Why do you think that you do?

You can run high flow rates through PICC lines and other central lines. Can you run infusions faster through a 16 gauge oeripheral IV? I don't; probably. But that is not what we are talking about. We are not discussing running on  a GSW and finding that homeboy just happens to have a PICC line in his arm. 

I don't mean to beat up on you guys and I understand that you don't have the experience with central lines that most nurses have. (I'm a paramedic, ER nurse, and ICU nurse). However, in the interest of furthering your education, I would encourage everyone to become familiar with the different types of central lines you may encounter as paramedics.


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## NPO (Nov 28, 2016)

zzyzx said:


> You don't need a pump to use a PICC line. Why do you think that you do?
> 
> You can run high flow rates through PICC lines and other central lines. Can you run infusions faster through a 16 gauge oeripheral IV? I don't; probably. But that is not what we are talking about. We are not discussing running on  a GSW and finding that homeboy just happens to have a PICC line in his arm.
> 
> I don't mean to beat up on you guys and I understand that you don't have the experience with central lines that most nurses have. (I'm a paramedic, ER nurse, and ICU nurse). However, in the interest of furthering your education, I would encourage everyone to become familiar with the different types of central lines you may encounter as paramedics.


Why aren't we talking about homeboy GSW? No one specified why the patient needed prehospital access. But a more likely scenario would be a septic patient with a PICC.

And no one said you NEED a pump either. I just said I don't have one, which means my fluids are by gravity, which is going to be limited, more than a pump. 

Fact is, PICC lines do not allow for rapid fluid resuscitation compared to other routes. So I wouldn't be reaching for a PICC line in my GSW patient unless I couldn't get anything else. 

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## VFlutter (Nov 28, 2016)

zzyzx said:


> You don't need a pump to use a PICC line. Why do you think that you do?
> 
> You can run high flow rates through PICC lines and other central lines. Can you run infusions faster through a 16 gauge oeripheral IV? I don't; probably. But that is not what we are talking about. We are not discussing running on  a GSW and finding that homeboy just happens to have a PICC line in his arm.
> 
> I don't mean to beat up on you guys and I understand that you don't have the experience with central lines that most nurses have. (I'm a paramedic, ER nurse, and ICU nurse). However, in the interest of furthering your education, I would encourage everyone to become familiar with the different types of central lines you may encounter as paramedics.



Not trying to be ignorant but I think you need to further your education on the maximal flow rates of infusion devices. Reference the link provided above. Multi-Lumen central lines, especially PICCs, are vastly inferior for rapid volume resuscitation. It has been proven, it is basic physics. The maximal flow rate on the 16g port of a (Short) Triple lumen CVC is 116ml/min vs 334ml/min for a 16g PIV. Have you ever used a rapid infuser? I.e. Level 1 or Belmont? I am a little perplexed that I have to argue this...

Does not have to be a trauma patient to need rapid volume resuscitation.


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## zzyzx (Nov 28, 2016)

Chase, as a nurse, how many times do you use a central line when you are caring for your patients? On my last shift in the ICU last night, I probably did so dozens of times. If you are saying that these lines are so dangerous to use, then why do we have them?

Yes, many nurses get lazy and don't scrub the hub for 15 seconds, just as many healthcare providers don't wash their hands long enough. That is a problem with training and education. That said, most central line infections are not due to improper use after they are inserted, but rather during the placement of the line. 

You seem to think that pre-hospital is a dirty environment and the hospital is a clean environment. I would say that somebody living in a trailer is living in a cleaner environment than someone staying in a hospital. Think about it. Hospitals are a great place to pick up call kinds of infections you are unlikely to find in the community.

I don't think this discussion is about how fast you can infuse through a PICC line or some other central line, but for the record:

http://www.avajournal.com/article/S1552-8855(12)00006-2/abstract


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## NPO (Nov 28, 2016)

zzyzx said:


> http://www.avajournal.com/article/S1552-8855(12)00006-2/abstract



Thats 2100-6000ml/hr with a pump maxed out. 

6000ml/hr is slower than a standard 18g PIV, and twice as slow as a 16G PIV.

Point being, volume, no no.
But in an emergency, yes.

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## zzyzx (Nov 28, 2016)

Yes, Chase, I'm aware you can't use a Level One on a PICC line. I don't think that's what we are talking about since the paramedics on this forum, who are asking in general about using central lines, have Level One's in the back of their ambulance.

So you are saying "The maximal flow rate on the 16g port of a (Short) Triple lumen CVC is 116ml/min." Okay, so that means the maximum flow rate per hour is about 7 liters per hour! Again, we are not talking about what infusion rates are faster, so I think all this is beside the point.

I feel that this discussion is beginning to get a little silly. I don't want to get in an argument with anyone, so I'm going to stop here. I would encourage any paramedic who is afraid of using central lines to spend some time learning about them. Besides what you will find on the internet, ER nurses are a great resource. And of course, follow your protocols and talk to your agency's training officers.


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## NPO (Nov 28, 2016)

Yes, but that's a theoretical maximum. We all know we can't expect that in the field. 

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## VFlutter (Nov 28, 2016)

zzyzx said:


> Chase, as a nurse, how many times do you use a central line when you are caring for your patients? On my last shift in the ICU last night, I probably did so dozens of times. If you are saying that these lines are so dangerous to use, then why do we have them?
> 
> Yes, many nurses get lazy and don't scrub the hub for 15 seconds, just as many healthcare providers don't wash their hands long enough. That is a problem with training and education. That said, most central line infections are not due to improper use after they are inserted, but rather during the placement of the line.
> 
> ...



I have used a central line once or twice. I am not saying they are dangerous to use but they do carry risks. The standard of care is to only use central lines when necessary and to remove them as soon as possible.

You stated that a PICC line is the "best IV access "and that it can handle high flow rates. I was simply disputing that fact for those who may not know.

That was the maximal flow rates of various PICC lines on pump outside the body. Does not necessarily correlate to actual flow rates intravenously. Also a pretty big range between 2 and 6 Liters. The fastest being a single lumen PICC which is rarely used outside of home infusions compared to the slowest being a triple lumen, the most common.


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## Kevinf (Nov 29, 2016)

I've been witness to CVCs becoming occluded due to patient positioning, something I've yet to see happen with a properly placed PIV.


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## Akulahawk (Nov 29, 2016)

Kevinf said:


> I've been witness to CVCs becoming occluded due to patient positioning, something I've yet to see happen with a properly placed PIV.


A CVC shouldn't occlude because of positioning alone. I can that happening with certain positions though. Same thing happens with PIVs too, especially if placed in the AC.


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## Carlos Danger (Nov 29, 2016)

Kevinf said:


> I've been witness to CVCs becoming occluded due to patient positioning, something I've yet to see happen with a properly placed PIV.



I have PIV's occlude constantly when they are placed in the hand or the AC space.


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## Summit (Nov 29, 2016)

PIVs occlude all the dang time... it is why nurses make memes like this:


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## DesertMedic66 (Nov 30, 2016)

Our county actually put out a notice to everyone a couple of weeks ago. We are not allowed to use any form of central line, PICC line included, under any circumstance. Either we establish an IV or an IO.


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## Akulahawk (Nov 30, 2016)

DesertMedic66 said:


> Our county actually put out a notice to everyone a couple of weeks ago. We are not allowed to use any form of central line, PICC line included, under any circumstance. Either we establish an IV or an IO.


Sounds like someone from your area either was implicated in causing a central line infection OR someone in the EMS agency got paranoid about central line infections caused by prehospital care providers. While I certainly admit that I'm a bit lax on scrubbing the hub of PIVs every time I access it with a syringe (always before), I'm quite paranoid about central line infections so I will pretty much burn through a box of swabs because I scrub the hub of central lines and mid-lines (rare at my work) every time I access the line, even between med admin and flushes as I'm not accessing the line under sterile conditions with sterile equipment.


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## phideux (Dec 6, 2016)

On the ambulance, our protocols say we can't access them, unless it's a total, last ditch, life saving emergency. 
I also work in the ER and access Ports and PICCS all the time. 

I don't see any problem with being able to access PICCs in the back of an ambulance and keeping them clean, Ports are a different story, I would drill them before pulling out a Huber and sticking a port in the back of an ambulance.


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## medichopeful (Dec 6, 2016)

Akulahawk said:


> Sounds like someone from your area either was implicated in causing a central line infection OR someone in the EMS agency got paranoid about central line infections caused by prehospital care providers. While I certainly admit that I'm a bit lax on scrubbing the hub of PIVs every time I access it with a syringe (always before), I'm quite paranoid about central line infections so I will pretty much burn through a box of swabs because I scrub the hub of central lines and mid-lines (rare at my work) every time I access the line, even between med admin and flushes as I'm not accessing the line under sterile conditions with sterile equipment.



We're supposed to scrub the hub on peripheral IVs? 

Do you guys use the Curos caps and biopatches?  At my ICU job I don't think we've had a single CLABSI (maybe 1 or 2?) since we started using them.


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## Summit (Dec 7, 2016)

I love Curos caps... they were my little green friends... miss those cuz the current facilities don't use them.


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## VentMonkey (Dec 7, 2016)

Summit said:


> I love Curos caps... they were my little green friends... miss those cuz the current facilities don't use them.


They somehow always ended up in a drawer on our ground CCT unit


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## NPO (Dec 7, 2016)

VentMonkey said:


> They somehow always ended up in a drawer on our ground CCT unit


I wish we carried them. 

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## VentMonkey (Dec 7, 2016)

NPO said:


> I wish we carried them.


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## Akulahawk (Dec 7, 2016)

medichopeful said:


> We're supposed to scrub the hub on peripheral IVs?
> 
> Do you guys use the Curos caps and biopatches?  At my ICU job I don't think we've had a single CLABSI (maybe 1 or 2?) since we started using them.


Technically speaking, we are supposed to scrub the hub of the PIV, for the same reason we scrub hub of a PICC or CL. Now then, all that being said, the PIV just isn't left in all that long so the chance of getting an infection from the PIV is much lower. Central Lines, Mid-lines, and PICC lines are typically left in much longer so greater precautions need to be taken to prevent the line from becoming the source of an infection. 

I wish we had Curos caps. They're great! One hospital I was in during my final semester in nursing school required their use on all ports of any line that is connected to a patient. Apparently they had a very low rate of IV line-associated infections simply because of this practice. Probably all due to the fact that few nurses were actually scrubbing the hub...

Yes, we do have biopatches but we only use them for central line dressing changes.


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## medichopeful (Dec 7, 2016)

Akulahawk said:


> Technically speaking, we are supposed to scrub the hub of the PIV, for the same reason we scrub hub of a PICC or CL. Now then, all that being said, the PIV just isn't left in all that long so the chance of getting an infection from the PIV is much lower. Central Lines, Mid-lines, and PICC lines are typically left in much longer so greater precautions need to be taken to prevent the line from becoming the source of an infection.
> 
> I wish we had Curos caps. They're great! One hospital I was in during my final semester in nursing school required their use on all ports of any line that is connected to a patient. Apparently they had a very low rate of IV line-associated infections simply because of this practice. Probably all due to the fact that few nurses were actually scrubbing the hub...
> 
> Yes, we do have biopatches but we only use them for central line dressing changes.



I was just joking around about scrubbing the hub of the PIV (don't think it came across well via text!). The likelihood of serious complications from a PIV is pretty small, but better safe than sorry. I will admit, however, that just like you I'm more careful with central lines. 

I wish we had the Curos caps in the ER, but unfortunately we don't (for that rare port access or CIV insertion). In the unit, though, we have them and I use them all the time, and love them. They're a great addition in the fight against CLABSIs, but the ports still need scrubbing even when they're on. I don't use them on my PIVs, and I think I can count on one hand the number of peripheral IV infections I've seen. I'd be curious to see if they actually make a difference on PIVs, but that might be a hard study to do considering how short the life span of a PIV is.


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## Akulahawk (Dec 7, 2016)

medichopeful said:


> I was just joking around about scrubbing the hub of the PIV (don't think it came across well via text!). The likelihood of serious complications from a PIV is pretty small, but better safe than sorry. I will admit, however, that just like you I'm more careful with central lines.
> 
> I wish we had the Curos caps in the ER, but unfortunately we don't (for that rare port access or CIV insertion). In the unit, though, we have them and I use them all the time, and love them. They're a great addition in the fight against CLABSIs, but the ports still need scrubbing even when they're on. I don't use them on my PIVs, and I think *I can count on one hand the number of peripheral IV infections I've seen. I'd be curious to see if they actually make a difference on PIVs, but that might be a hard study to do considering how short the life span of a PIV is.*


I might tend to agree with you on this. I've only seen a couple instances of phlebitis from a PIV, and no infections so far, at least in the ED precisely because the vast majority of our PIV lines are pulled within hours. I originally was taught that a PIV can only stay in place for a max of 3 days, but lately the prevailing thought is to rotate the PIV site only when there's evidence of a need to. For patients that are long-term inpatients, that can save them a ton of (probably) unnecessary pokes. The other thing that we were taught was to pull Field PIV lines within 24 hours due to "high risk of infection." I was taught to start lines in the field in basically the exact same way I was taught to start them in nursing school. Properly done, there's no difference in risk. A couple years or so ago, I delved a little more deeply into it and it seems there were 2 things going: one was the fear that the paramedics were't doing things "the right way" so those sticks were "dirty" and the other (more likely) was that the hospital has little to no clinical oversight of field personnel so if a problem did develop with an IV, they can't directly go back and retrain the "offender" and therefore cannot unequivocably state that the PIV was emplaced to _their_ standards. Same reasoning behind why lines placed at one hospital (PIV and central) may be changed very soon after arrival at a new facility. Basically they're changed out for legal defense reasons rather than clinical reasons.


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## Brandon O (Dec 7, 2016)

I'd say the same number of nurses are scrubbing central line ports for thirty seconds with chlorhexadine as are taking 2 minutes to push Protonix.


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## Summit (Dec 7, 2016)

Brandon O said:


> I'd say the same number of nurses are scrubbing central line ports for thirty seconds with chlorhexadine


30 seconds?

10-15 seconds with alcohol is fine. I just do 15 solid twisting scrubs with the prep pad.


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## Brandon O (Dec 7, 2016)

Summit said:


> 30 seconds?
> 
> 10-15 seconds with alcohol is fine. I just do 15 solid twisting scrubs with the prep pad.



I think it's 30 for chlorhexadine.


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## Akulahawk (Dec 7, 2016)

Brandon O said:


> I'd say the same number of nurses are scrubbing central line ports for thirty seconds with chlorhexadine as are taking 2 minutes to push Protonix.


I actually take the time to push Protonix...


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## VentMonkey (Dec 7, 2016)

Akulahawk said:


> I actually take the time to push Protonix...


Is this truly a reason it's typically infused?


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## Brandon O (Dec 8, 2016)

VentMonkey said:


> Is this truly a reason it's typically infused?



Heh, no, just commenting on how typical practice often doesn't quite match what the textbooks suggest.


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## MackTheKnife (Dec 20, 2016)

NPO said:


> Do your protocols allow you to access central lines? If so, what do they say? Only in cardiac arrest, or when ever you deem necessary? Do they go into detail? Likewise, if not, do they say why and do they provide an alternative?
> 
> I recently brought up the subject of accessing central lines to my medical director because our protocols don't mention it.
> 
> ...


Accessing CVPs is not a big deal. It is overhyped. Depending on the line, there are usually 1-3 ports. The blue port is usually the one that "we" nurses are allowed to access. The biggest point is to "scrub the hub" as central-line associated blood stream infections (CLABSI) is the main concern. Except for IVADs (Portacaths), you only have to flush with normal saline and not heparin. IVADs are implanted under the skin and you must use sterile technique to access them and flush with heparin afterwards. And access is with a Huber needle (special type) as previously mentioned. We waste 5cc of blood initially, not 10.


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## Summit (Dec 20, 2016)

MackTheKnife said:


> Accessing CVPs is not a big deal. It is overhyped.



CVP from a PICC is of very little use.


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## MackTheKnife (Dec 21, 2016)

Summit said:


> CVP from a PICC is of very little use.


Not inferring Central Venous Pressure. Central Venous Port I.e., line.


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## Shishkabob (Dec 21, 2016)

Yes, we can access central lines.  

"Indications for invasive line access:  Cardiac arrest, hemodynamic instability, or currently accessed".  So you're sick for a day with nausea?  Not going to access your central line for Zofran.  Septic with hypotension?  Sure.


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