Prehospital Access of Central Lines

[NPO]

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]

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.

 

[zzyzx]

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

 

[NPO]

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]

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.

 

[NPO]

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

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[VFlutter]

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

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.

 

[Kevinf]

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

 

[Akulahawk]

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.

 

[Carlos Danger]

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.

 

[Summit]

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

 

[DesertMedic66]

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.

 

[Akulahawk]

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.

 

[phideux]

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.

 

[medichopeful]

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.

 

[Summit]

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

 

[VentMonkey]

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

 

[NPO]

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

I wish we carried them.

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[VentMonkey]

I wish we carried them.

 

[Akulahawk]

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.