Hello Everyone,

Does your unit change IVF from an old central line ( UVC fluid) to a new central line (PICC)?

 

On rare occasions we ran into a problem where a UVC fluids was infusing with TPN fluids and a new PICC line was inserted a few hours later. To minimize the cost to the patient, fluids are switched until new TPN comes available on the next pm shift. Our TPN comes at 2100 every day. The IV tubing is not changed when the switched is made because there is not enough fluids to prime it again. We have been zero CLABSI for the past two years, our last incident was from a UVC line.

 

Any guidance would be greatly appreciated.

Thank you,

From Twitter:

 

We also change fluids from an umbilical catheter to a PICC line, "scrubbing the hub" carefully at the switch. We also have a very very low rate of CLABSI.

Great to hear more people's feedback on this every-day question.

@Vicky Payne - how do you do it?

Hi! Thanks for the tag Stefan.

I think on the whole we would put up brand new TPN onto a new long line, though on some rare occasions  other fluids may be switched from UVC to Long line. Central to central generally accepted as ok, peripheral to central a clear no, no! 

However, we are lucky to have standardised stock TPN  bags kept on the neonatal unit, so we have easy access to this, and once warmed we can attach immediately with no waiting around - we only have to wait till the evening for bespoke TPN. We have salt free vamin for first few days, and then we have a preterm and term bag.  We would try to avoid long periods of additional 1ml/hr of saline running in the smaller/ELBW babies, due to the additional fluid volume and salt.

We have switched back to Scrubbing the Hub technique over alcohol impregnated caps which (spoiler alert) made no difference and cost us almost £10, 000 a year- abstract submitted on this just this week so watch this space!

However,  our rates are not low (though we don't use the CDC definition which I think is more specific about "infection from another location") and despite multiple efforts, our central line sepsis rates have not really changed much over 5 years, so I cannot claim to know the right thing to do! 

However, if you would be willing @MVNICU I would love to organise a conversation with you about your setting, your local practices and your zero rates. It would be really helpful for us 🙂

On 5/20/2020 at 6:43 AM, Vicky Payne said:

Hi! Thanks for the tag Stefan.

I think on the whole we would put up brand new TPN onto a new long line, though on some rare occasions  other fluids may be switched from UVC to Long line. Central to central generally accepted as ok, peripheral to central a clear no, no! 

However, we are lucky to have standardised stock TPN  bags kept on the neonatal unit, so we have easy access to this, and once warmed we can attach immediately with no waiting around - we only have to wait till the evening for bespoke TPN. We have salt free vamin for first few days, and then we have a preterm and term bag.  We would try to avoid long periods of additional 1ml/hr of saline running in the smaller/ELBW babies, due to the additional fluid volume and salt.

We have switched back to Scrubbing the Hub technique over alcohol impregnated caps which (spoiler alert) made no difference and cost us almost £10, 000 a year- abstract submitted on this just this week so watch this space!

However,  our rates are not low (though we don't use the CDC definition which I think is more specific about "infection from another location") and despite multiple efforts, our central line sepsis rates have not really changed much over 5 years, so I cannot claim to know the right thing to do! 

However, if you would be willing @MVNICU I would love to organise a conversation with you about your setting, your local practices and your zero rates. It would be really helpful for us 🙂

You may already be doing all of the following, but these are some of the things we do to prevent CLABSI:

1. TPN changes are performed as a sterile procedure; nobody is allowed within 10 feet of the bedspace without hat and mask. The RN doing the change is gowned up, hat, mask and sterile gloves. Of course, new tubing with every change of TPN

2. Standardized feeding guidelines to prevent days with a CVL in place

3. Minimizing breaks into the line for medications. Medications such as caffeine are changed to po as soon as baby demonstrates ability to tolerate po feeds (at about 60 mL/kg/day)

4. Changing from a UVC to what we call a "midline" if we anticipate the need for access beyond 5 days. A midline uses the same equipment/procedure as a PICC, but is not inserted all the way into a central vein. We treat theses as PIVs with respect to osmolarity/osmolality of TPN. 

 

Our last CLABSI was a baby who had a mild bloodstream infection which we identified as the same clone of bacteria we found in mother's EBM, but since the baby had a CVL in place, it was classified as a CLABSI - this was last year. We are not a huge NICU, but in general, about 30% of our census has had a CVL in place at some time. Based on our VON reporting, we regularly go more than one year without a reported CLABSI. 

Thanks- we do some of these things (in principle!)

1. Change TPN using "surgical ANTT" but not with a hat or mask. We have lots of "traffic" in our nurseries, though recently we have moved to preparing the fluids in a separate room to avoid this traffic (doesn't appear to have made much difference to our rates so far)

2. Yes, we have these

3. We try to do this, though I am not sure how well it is adhered to. We do try to avoid putting any medications via central lines i.e caffiene, fluconazole but I think that infusions such as morphine/KcL piggybacks, inotropes e.t.c may get changed at different points in the day sometimes when it is busy, rather than waiting till the TPN is changed.

4. We don't do this! What do you think is the benefit of this over inserting a central line?

How many beds do you have (just by way of comparison)? Do you do surgery?

We do not have very many months of zero. Zero is the rarity or the outlier for us!! We have a mixture of pathogens such as Staph aureus and gram negatives, but also plenty of CoNs- staph capitis, epidermis e.t.c

Thanks for the suggestions 🙂

Best wishes, 

Vicky