We have a 13 month old who needs long term vascular access. He has a diagnosis of EDS-Ehlers -Danlos Syndrome- a connective tissues d/o which manifests with skin extesnibility, joint hypermobility, and general tissue fragility, including vessels (ggod reviw article in AJN 2015 Jluy for anyone interested). He had a Broviac placed. Within 2 weeks it migrated internally totally out of the vein where the tip rested at the tunnel site. Another Broviac was placed and the exact migration occured at 2 weeks again. Both Broviacs were IJ approaches. The surgeons considered a subclavian aproach but, too, are concerned about risks. the patient needs access for fluids and right now TPN.
I am wondering how those of you inserting PICCs and dealing with VAD choices would weigh in on a recommendation for vascualr access. My concern with a PICC is that it may migrate more easily. My concern with a port is that the needle may become dislodged in this active toddler about to walk alone. Not sure a Broviac is still on the table of options.
Thanks in advance for your thoughts on this challenge. Be gald to discuss with any of you.
Linda Tirabassi
Miller Chilren's and Women's Hospital Long Beach CA
562-933-0614
My first thought is would there be any possible way to not insert any type of CVAD? Then I have 2 questions. Your message did not describe migration - it actually described dislodgment. Migration is when the tip changes position but the external segment did not change. Dislodgment is when the external segment changes causing tip migration. I am basing that on your comment of "totally out of the vein." Was the SC cuff still in place or had it been moved? My questions 1) where was the original tip location? and 2) how was this tunneled cuffed catheter secured while the cuff was healing?
Given the disease, SC tissue changes may have prevented the cuff from growing in. With an active 13 months old, within the first 2 weeks, the cuff has not healed so focus on adequate securement is critical.
The catheter tip for all ages is CAJ, anything higher in the SVC will increase risk of tip migration if the external segment and cuff has not changed.
Was the tunnel directing the catheter in the traditional manner on the chest? Would it be better to tunnel it toward the back so the toddler can not reach it? out of site our of mind.
With this disease is there any component that changes intrathoracic pressure that is one cause of migration? I would try to correct this problem before inserting any other CVAD.
I agree that a PICC does not seem to be the best choice. External catheter dressing, protection from a toddler hands, activity level, disease issues, etc. I also see your issue with an implanted port, but that depends on the types and lengths of infusion therapy needs. Continuous vs intermittent, vesicant or irritant vs nonvesicant or nonirritating?
Like all assessments for CVAD need, it requires more information than what is in your message. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Thanks Lynn for your response. I wil clarify some of these details for you, hopefully. Both Broviacs had documented RAJ tips. The cuff had not completely healed due to the time factor fro insertion (~ 2 weeks). The site sutures were intact. In fact the second Broviac had a coil and was sutured on the external coil. No evidence of the external portion movement. So the tip did change position and the external segment did not.
Securement for Broviacs have traditionally used transparent dressing without much problem and a coil under the dressing. I used a sorba view with a built in securement (we just started carrying this product). We then use a stretchable mesh net dressing fashioned in a t-shirt and tuck the IV tubing under it with ithe IV tubing coming out the back to avoid him stepping on it. Because he is in the hospital, he is somewhat confined. He does not pull on the IV tubing. The parents just purchased a "broviac vest" which apparently has helped others, but they never got the chance to try it.
He needs access for IV fluids with a modified nutritional solution. He cannot tolerate high doses of dextrose or AA, just some K and NA and some trace mineral. He cannot tolerate full TPN. He is a highly allergic pt. As far as I know I have not read anything about different thoracic pressure issues r/t this dx. I think there is alot to learn about this condition (EDS) and mast cell activation syndrome. I don't now what his long term life needs with access will be. We need to focus on now but not wipe out access options for his future. It is very challenging. His mother has the same dx and she has a PICC with IV fluid hydration several times/week. She developed a more symptomatic case as she got older. This little patient is quite severe. She has had her PICC for about a month without issues.
I thank you for your thoughts, I don't know if with this additional information it will shed any different light on this issue.
Linda
Linda Tirabassi PhD RN CNS CPNP
Wow very difficult case. I agree that this is migration but still concerned about the cause. I fear this will keep happening to any CVAD if not addressed. Usually changes in intrathoracic pressure are involved with migration. Any coughing, vomiting, sneezing? Any cardiac issues? Also assuming that he has not required a ventilator. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Yes, I have been extremely challenged by this group of patients. We have a handful hospitalized right now.....all with a spectrum of issues, all with skin issues of their central lines. This is the group I reached out earlier this summer about another patient who is a mom who anaphylaxes with alcohol, and she has a PICC, her daughter has a PICC.
Anyway for this toddler, he has not had any of the above, vomiting, coughing, vent, sneezing, but great thoughts. The surgeon that placed this particular Broviac did add a coil (for growth) saying he placed the line so well, it would not become dislodged; of course he was thinking of dislodgment from an external segment even though he knew about the migration in the first Broviac of the patient. It is possible with activity the coil contributed to the migration....As I said, we have had many active toddlers with Broviacs and have not seen this. That said, I do have several 2 3 year olds with the same diagnosis with Groshong PICCs and they have done well. I think I mentioned that I reached out to their national society to inquire if anyone with specialty centers have encountered this. Not sure how it will will unfold at this point, and I agree I would love to understand the dynamic of the cause, we all would. I will let you know the final outcome for information once we figure out next steps. Thank you again for engaging in this discussion.
Linda Tirabassi PhD RN CNS CPNP
Please post what you learn about this! Thanks Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861