# "Um, what is that thing hanging out of this kid's chest?" - Broviac caths



## LucidResq

From the awesome EMS Coordinator and Director of EMS Outreach and Education at The Children's Hospital (Denver), Stephanie Haley-Andrews, BSN: 



> It occurred to me the other day after DHMC PD ran one helluva great resuscitation on a complex cardiac kiddo that perhaps a pictorial on pediatric central lines, tubes and VADs would be useful for EMS.
> 
> The first thing we'll tackle is the Broviac® catheter. The Broviac® catheter is a long, white, hollow tube made of silicone that has at least one lumen and often two or three. There is no communication between the lumens so different medications, fluids, blood products can be infused at the same time. It's a catheter usually placed in the superior vena cava to provide central circulation access.
> 
> Brovic catheter hubs may be color coded red, blue, white, etc. It is a common misconception that one tube is venous (blue cap) and another is arterial (red cap) when they are only in venous central circulation.
> 
> Broviacs can be used by Paramedics to infuse medication and fluids. Instant central access is a beautiful thing. Just please clean the available hub with rubbing alcohol or whatever your agency uses to promote aseptic technique, and don't forget to unclamp it (been there, done that..."Why isn't this thing WORKING!!! Oh...that's why").
> 
> If the patient only has one hub and a continuous medication is infusing (vasoactive meds, prostaglandin, etc.), it's best to contact medical control for advice. Turning the medication off even momentarily may not be worth the risk, and pushing another medication or fluid through the same line may bolus the continuously infusing medication.








Broviac double lumen 





Broviac single lumen





Broviac triple lumen


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## Ridryder911

Good idea but one has to remember that those are central lines. Not all States or services allows one to access central lines as many consider such within the level of Critical Care. Alike any other medical device there is risks and complications, so be sure you have been properly trained and educated and you have protocols or direct order to do so. 

R/r 911


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## Aidey

A big thing with these lines that I've found people don't know about is that whenever you access one you, the patient, and anyone in the back of the ambulance should be wearing a mask. Lines like this are fairly prone to infection, and standard technique involves wearing a mask.


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## Ridryder911

Aidey said:


> A big thing with these lines that I've found people don't know about is that whenever you access one you, the patient, and anyone in the back of the ambulance should be wearing a mask. Lines like this are fairly prone to infection, and standard technique involves wearing a mask.



Mask? To connect a line into an exitisting port. It's not an invasive procedure, and does NOT require mask. Some consider it a sterile procedure where others may not and acclaim aseptic technique only to be used. 

Now, the fact the likelyhood of some of your patients that have these maybe immunosupressed I definitely could agree upon. Even with that I recommend the patient to be reversed isolation. 

R/r 911


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## VentMedic

We could also expand the topic to Port-A-Caths.​


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## ResTech

One time in the ED, the RN wore a mask and had me wear one as well for accessing a central line (port-o-cath).


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## VentMedic

PICC line (Peripherally Inserted Central Catheter)


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## VentMedic

http://www.lakeridgehealth.on.ca/pa...iology/presentations/venous_access/slide9.htm

Slide presentation on venous access options:

*Peripherally Inserted Central Catheters (PICC Lines)*
*Subcutaneous Port*
*HickmanTM and BroviacTM Catheter*
*Translumbar*
*Transhepatic*


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## VentMedic

Pulmonary Artery Catheter (formerly known as the Swan-Ganz catheter)


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## JPINFV

"Swan-Ganz catheter"

Hehe... The drawing is someone getting a pulmonary wedge pressure.


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## VentMedic

*Hickman Catheter  or Broviac*







*Groshong Catheter*







*VasCath*
Pheresis catheters are larger and sturdier than Hickman catheters. Pheresis catheters can also be used for hemodialysis, and are often called "dialysis catheters". 

*Huber Needles*







These photes were referenced from this page:
http://faculty.mercer.edu/summervill_j/iv.htm

Those who believe a simple IV can do not harm should take note of the complications listed and shown on that page also.


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## twnshpfireman3417

Question for the experienced medics out there. Currently in medic school and we just got done talking about these, something the RN that lectured that day made sure to point out is make sure you always flush them first or draw off them because they usually are flushed with heparin and their will still be some still in the lines as well as use at least a 10cc syringe when attaching to them because small syringes can create to much pressure and blow the line. For those of you out there that have seen them and used them in the field or the hospital what are your protocols dealing with them..


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## Aidey

Yes Rid, a mask. I'm aware it's not a sterile procedure, but that doesn't mean the BSI recommendation doesn't include a mask. 

twnshp - This information is specific to dialysis catheters, someone else will have to answer about the others. In dialysis catheters you should always draw off 5cc to 10cc from each port because they are usually packed with Heparin, unless the pt is allergic to it. You will get blood out when you do this, but that is normal. These catheters can be very temperamental, and sometimes you can't draw back on them, or you can only draw back on one side, and not the other. In these cases, flushing the heparin in with saline is sometimes your only option, mostly because if you are accessing a catheter it better be because the pt is unstable, and if you need access, you need access. 

You should always leave a cap of some sort on the end of the port, even if you aren't using that particular port. Even if you just screw on a syringe to the end and leave it there, you don't want to leave it un-capped. 

Our protocols are rather ambiguous about accessing these lines. Port-a-caths are totally out of the question, because we don't carry the proper needles to access them. However, our medical director has stated that in true emergency situations, such as cardiac/resp arrest, major hemorrhage, shock etc we can access dialysis catheters/PICC lines etc without calling as long as we feel comfortable doing it. 

In non-emergency situations, we are to call first and get on-line direction to access the line. 

Our protocol for access dialysis fistulas/gafts is almost exactaly the same.


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## Ridryder911

We use the standard policies of withdrawing 10ml and wasting and then flushing the line with Saline to ensure patency. Important questions I always ask is when was the last time the device was used or flushed. One has to be concerned if it has been a while since it was utilized or flushed, as developments of clots and not being patent. 

The devices as well are sometimes temperamental as effected by breathing patterns and positions when initially flushing. It is not unusual to have some initial difficulty as many patients/family members will inform you of the "tricks" sometimes associated with their device. Since it is a central line though, once it has been flushed should infuse well. 

Our protocol is to use sterile procedure (i.e sterile gloves, alcohol, 10cc syring, flush kit) and tegaderm and or dressing. We also carry Huber needles of various gauges for port-a-cath. 

We do not routinely access A/V fistulas or Pheresis cath's but I will specifically contact medical control to access (since I am familiar with the use of these). We have several dialysis centers and routinely have critically ill and arrest in them. Venous access is routinely poor. 

I promoted and wrote our policy to access PICC, Port a Cath, Triple lumens, etc.. as a ER nurse, I was tired of seeing peripheral sticks being performed needlessly. Patients that receive these devices do so for a reason. Many of the toxological medications and underlying diseases cause havac on veins and make it very difficult to locate peripheral veins. 

R/r 911


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## Ridryder911

Aidey said:


> Yes Rid, a mask. I'm aware it's not a sterile procedure, but that doesn't mean the BSI recommendation doesn't include a mask.



BSI precautions may include shield but mask as for respiratory measures is not normal BSI and maybe undue in just attaching a line or syringe to a port. Remember, this is a routine procedure performed at home and clinic settings. If you want to wear or protocols state so; so be it but in general it is not a normal or recommended procedure. 

The main emphasis as well should to be sure the ends are cleansed well and all air is expelled. Close monitoring needs to be addressed as well. 

R/r 911


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## Aidey

Maybe it's a regional variance, but both in the hospital I trained in, and in the agency I work for now masks are routine when access caths. As part of Paramedic education we spent time in the "procedures" unit at the hospital. They did out patient colonoscopies, endoscopies, PICC line checks, infusions etc. Every time we accessed a PICC line or a cath of some sort we were all wearing masks. 

Maybe it's because the type of people that have these are generally immunocompromised due to advanced disease process, or cancer and it's just assumed they have a low white count, I don't know. All I can say is that I've always been taught a mask is standard.


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## TransportJockey

Vent, correct me if I'm wrong, but out of all the central lines you've posted, isn't the Port-a-cath the only one that we really don't carry the proper equipment to access. I've seen them used at work and in my ED clinicals, and they use a 90* needle to make access. I've always been told that we can easily core them if we try to access with a conventional needle, which would precipitate total replacement of the cath

EDIT: what I'm referring to is like the Huber needle shown above


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## marineman

Our protocols state we're allowed to use them but only in an oh **** moment and we must contact med control first.

Mask or no mask is based on the patients condition and reason for having the cath not the fact that it's there. A child with leukemia, yes we wear masks and it's treated as a sterile procedure. Dialysis, not so much.


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## Aidey

Believe it or not, per medicare* masks are to be worn when accessing a dialysis catheter. Sterile gloves aren't always standard, but masks are. 

*Medicare has the say so because all dialysis pts are on medicare, so they get a lot of sway in dictating how dialysis units are run.


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## Ridryder911

jtpaintball70 said:


> Vent, correct me if I'm wrong, but out of all the central lines you've posted, isn't the Port-a-cath the only one that we really don't carry the proper equipment to access. I've seen them used at work and in my ED clinicals, and they use a 90* needle to make access. I've always been told that we can easily core them if we try to access with a conventional needle, which would precipitate total replacement of the cath
> 
> EDIT: what I'm referring to is like the Huber needle shown above



I'm not Vent but most of the caths have lure lock device so no special equipment except cleansing material and dressings. I routinely insert PICC lines and access most of the lines described. 



Aidey said:


> Believe it or not, per medicare* masks are to be worn when accessing a dialysis catheter. Sterile gloves aren't always standard, but masks are.
> 
> *Medicare has the say so because all dialysis pts are on medicare, so they get a lot of sway in dictating how dialysis units are run.



I believe the reason would be that many of those on dialysis therapy maybe considered high risk of auto immune problems, not because of standardization of BSI although it would not be a bad idea. Respiratory involvement should be considered but may not be enforced in all patients. 

I have yet seen any dialysis areas where masks are routinely used but definitely shields, flash resistant gowns, as spurting blood is common. 

R/r 911


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## Aidey

Maybe it was the company I worked for, but you absolutely did not access a dialysis catheter without both you and the pt wearing a mask. The one time a patient refused to wear a mask under any circumstance they had to fill out an AMA form and a disclaimer acknowledging the fact that they were going against clinic policy before we were allowed to start their treatment. 

The patient and provider also had to wear masks anytime the dressing was changed on the catheter (which was done at the beginning of every treatment). 

Patients didn't have to wear them the whole time they were on dialysis unless otherwise ordered by their doc, it was just when the caps were off the ports or the skin around the catheter was exposed.

I worked for the big national company known for providing dialysis, so I'm guessing that the mask policy was in place at more clinics than just the ones in my area. 

Rid, I'm not trying to be super argumentative about this, I'm just saying what my experience has been.


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## Ridryder911

Aidey said:


> Maybe it was the company I worked for, but you absolutely did not access a dialysis catheter without both you and the pt wearing a mask. The one time a patient refused to wear a mask under any circumstance they had to fill out an AMA form and a disclaimer acknowledging the fact that they were going against clinic policy before we were allowed to start their treatment.
> 
> The patient and provider also had to wear masks anytime the dressing was changed on the catheter (which was done at the beginning of every treatment).
> 
> Patients didn't have to wear them the whole time they were on dialysis unless otherwise ordered by their doc, it was just when the caps were off the ports or the skin around the catheter was exposed.
> 
> I worked for the big national company known for providing dialysis, so I'm guessing that the mask policy was in place at more clinics than just the ones in my area.
> 
> Rid, I'm not trying to be super argumentative about this, I'm just saying what my experience has been.



I am not disagreeing, I have attempted to research this and the reason why? I cannot find any documentation (even in Medicare web site for HCFA reimbursement) other than particulant masks should be used while treating those with known infection(s). 

I personally have never worked in dialysis unit other than through clinicals and observation and caring for those in ICU and of course response while in EMS. 

I will attempt to research more, just for my curiosity. 

R/r 911


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## medicdan

Some resources:

http://www.cdc.gov/ncidod/dhqp/pdf/dialysis/NW17Meeting7_20_08.pdf 
slide 60

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5005a1.htm


> Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Such protective clothing or gear should be changed if it becomes soiled with blood, body fluids, secretions, or excretions. Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. However, patients can be served meals or eat food brought from home at their dialysis station. The glasses, dishes, and other utensils should be cleaned in the usual manner; no special care of these items is needed.


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## Ridryder911

Actually this is not much different than those for EMS. It states the same procedures for BSI as ..."or mask" as describing those with eyewear. to prevent splash. 

Many of those in EMS are not aware, food, drinks, lipstick, gum, etc.. is not supposed to be in an EMS unit also. 

R/r 911


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## JeffDHMC

Lucid, where did Stephanie post that?


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## LucidResq

Facebook! Look up Pedi EMS


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## mycrofft

*I have had pts selfaccess them...*

One was in his car inthe hospital parking lot, wearing a gown, and shooting heroin into it.


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