Very frustrated at the moment, have a patient with hickman catheter that has been in place for 8 years for daily TPN, pt has recently had temp spikes that no source has been found for. Blood cultures are always negative both peripheral and from hickman. CDC guidlines state do not remove CVC due to fever alone but to use good clinical judgement etc. When on antibiotics pt has no fever as soon as antibiotics stopped fever is back. The only other tests I have seen are urine tests that have been deemed acceptable. I am being asked to place a PICC prior to hickman removal today, patient will then have another hickman placed in a few days and PICC removed. Am I missing something here?!?
I'm sure this coming too late but did you try alcohol locks?
Darilyn
Darilyn Cole, RN, CRNI, VA-BC
PICC Team Mercy General Hospital Sacramento, CA
I don't think the alcohol locks are a good idea as this is a long term pt. The alcohol locks would not be a long term solution due to catheter degradation, and would not effect any biofilm on the outside surface of the catheter.
Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness
Sounds like good clinical judgment to remove catheter and replace. No other source of fever? Makes sense that the biofilm is probably pathological, gets calmed down but not killed by ABX, and here comes the fever again after they stop. Blood cultures are really ineffective at picking up many organisms in a biofilm. Sounds like the Hickman is a lifeline, better to replace it before septicemia sets in. I can think of no argument to replacing this line in the scenario you describe. It would be ideal to remove the Hickman before the PICC is placed, but that might not be possible in your situation.
Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness
There was a very good study published in 2004, author's last name was Jones. It showed successful catheter slavage by comining thrombolytic treatment of the catheter with antibiotics. Instill the thrombolytic and allow to dewll an hour, then remove the solution with a generous waster. Continue antibiotics for 24 hours, then instill the thrombolytic again. At the end of the hour dwell time, pull the solution and waste. Continue the antibiotics.
I would agree that this tunneled cuffed catheter should be removed as it is more likely than not the source of the infection. There could be many reasons why the blood cultures are not growing anything. After 8 years, I would say remove it. I don't think you are missing anything, but I do think the tunneled cath is the problem. In this case, I think it is far too late to attempt the salvage techniques with ethanol or thrombolytic locks. It would seem that going without any type of line is not an option even for a few days with this patient. If that is not possible, then the PICC as a bridge to the new tunneled cath is the best option. You may also want to ask for a scan to rule out a silent DVT that could be the source of the infection. If the cath is removed and this infected thrombus is left, the patient is still not going to get better. If there is an infected silent DVT, nothing you instill into the lumen will have any impact on that DVT. 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
I placed the PICC and the hickman was removed, the patient will get a new hickman next week. Lynn, as I was assessing the patient her daughter did say that the pt had a clot "somewhere in the chest" its been there a long time and that is why she is "still on coumadin". Not sure about the history on that since the patients main physician is at Mayo Clinic however pt and daughter felt that the clot was still there for whatever reason. Thanks for all the input, I have been looking into antibiotic locks but will also pull articles on alcohol locks as well.
Search for ethanol locks. When a new tunneled cuffed catheter is placed, make sure it is made of silicone as ethanol locking of a polyurethane catheter has the potential to damage the catheter. 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
I would echo Lyn - search for ethanol locks - we have been doing them on our HPN patients for a few years now and have kept the lines clear and clean. We had one patient who was growing up to 7 different bugs and since being on ethanol he has not had any CVL infections - 3 years this month! He also has not had to have his CVL replaced because of line degradation - accidentally dislodged this week after trampolining but that is what 8 year old boys do. He has his line locked by his mother every day and has done so since we started the process. We will consider whether there is value in having this as a routine part of HPN protocol in the coming years because of our success with no ADR's Worth considering for these patients who need to access daily.
Karen Rankin
Clinical Nurse Consultant
the Children's Hospital at Westmead - Australia