Blood From a Turnip - Central Line Partial Occlusion
Every other week, Adeline gets blood drawn for labs, from her CVAD (Central Vein Acccess Device). In conjunction with weekly weight checks, this is done for a few reasons. It ensures she’s getting everything she needs nutritionally, helping to assess the efficiency of her PN. The results of these blood tests guide any changes in her clinical course. Some hospitals don’t do this type of monitoring, some do Some hospitals run these labs less frequently (depending on the patient), and some don’t do this type of monitoring at all. There’s a good bit of research that suggests, this type of monitoring can reduce the rate of PN complications. It’s just good practice.
The problem with Addie’s BROVIAC is that it will flush, fluids can go through, but we get little-to-no blood return. Blood return is when you draw back on the line, and blood begins to flow back through the line and into the syringe. Blood return is important! If you’re not getting blood, the solution shouldn’t just be to get blood from somewhere else and move on! Blood return is an indicator of patency (“the quality or state of being open, unobstructed”) and proper function of the line. Patency has a direct impact on the flow of fluids through the line and plays a key role in preventing infection from bacteria that can linger behind clots or obstructions. Infections are a central line patient’s worst enemy.
Patency is pretty freakin’ important.
When blood won’t return, but the line flushes and PN infuses fine, it’s a sign of a partial occlusion. Signs of occlusion also include sluggish blood return, an inability to flush or pressure when flushing, frequent occlusion alarms on the pump, or swelling and leakage at the entry site.
But I’m just a parent.
Why do I need to know this…?
Having a central line is a rare thing. Johns Hopkins, a hospital ranked 10th [nationally] in pediatrics, admits 150 kids per day, serves thousands of patients, but only has 25 kids that receive PN via a central line at any given time. Not a lot. What I’ve learned is that parents of children with central lines must take ultimate responsibility for its care. Because sometimes you are the only one in the room with the training and the experience. Even in a hospital.
The surgery service is responsible for the on-going care of the line itself. Your first interface with surgery may be a surgical resident. A typical surgical resident does rotations across different surgery specialties for 6-8 weeks at a time. They may be interested in orthopedics in adults, but as a resident, they must do a rotation in pediatrics. As a comparison, residents in other pediatric services are generally planning to work in the pediatric space, within their given specialty. So your surgery resident, who dreams of performing knee surgery on pro athletes, may be in this rotation at the same time your child gets admitted for a central line issue. Given the rarity of children with central lines, how many lines have they actually seen? Have they been trained in evaluating issues with an existing line, or only in initial surgical placement? How much experience do they have using sterile procedures with a CVAD? Do they understand the importance of line patency? Although final decisions regarding the line are deferred to the pediatric surgeon on services at the time, they are the ones evaluating the line, checking it, accessing it, etc. Sterility and careful handling are critical to the line’s function and your child’s health. Parents of children with central lines must take ultimate responsibility for its care.
So there’s a partial occlusion and no blood return. Now what…?
We use Cathflo (prescribed by our doctor, and delivered weekly with her PN supplies) to restore function to the line, to break down the unwanted blood clots. It’s a medication that is inserted into the catheter. It sits in the line, breaking up those unwanted clots. Most people would have Cathflo administered at the doctor’s office, clinic, hospital, or by an in-home nurse. Because Adeline is getting this so regularly, we have been trained to administer it at home, well before the nurse comes to draw the blood.
If Cathflo does not work the first time, let it sit longer! We’ve learned that Adeline needs the meds to sit for hours before it works! It was only prescribed to sit in the line for 30 minutes, but that didn’t work for her. On my Short Bowel Syndrome support group, parents have shared stories of the replacement of lines after only letting Cathflo sit within the line for an hour. Give the Cathflo time to sit in the line. And always insist on trying two doses before even considering replacing the line due to a partial occlusion.
Cathflo has been shown to restore patency in 75% of catheters after two hours. A second dose improved that rate by another 10%. If that still does not work, there are two hour infusions that can be used to clear the sluggish catheters and dissolve clots. There are also stronger clot dissolving treatments that can be administered in the hospital. Ask for these. Your first instinct should not be to replace the line.
No matter what is going on with your child’s CVAD – call your doctor and do your own research. This information will hopefully help you to be a better medical advocate for them, ask the right questions, understand some of the treatment option. We hope that you can use our family’s experience and the tips we’ve learned along the way. Every child is different, so it’s important to consider all factors before making any sort of medical decision with your child’s team. All lines are different – our experience is with a BROVIAC. Make sure to follow your facility’s guidelines for CVAD care and maintenance based on manufacturers recommendations and on standards developed by national organizations
Here are some general guidelines to assess, treat, and try to prevent partial occlusions:
Be slow & gentle – too much force can impact blood return and could even cause a break in the line.
Try a smaller syringe (e.g. if using a 5 ml, try a 3ml) as it generates less force.
Change your child’s position while drawing; raise their arm, move their shoulder, etc. Certain positions can cause the catheter to lean against vein wall, preventing blood return.
Make sure the cap is changed regularly (our routine at home is weekly).
Check the entry site; is it warm or swollen? Is there any discharge?
Flush the line several times with saline and Heparin (or whatever flush/lock combination recommended by your doctor).
Palpate the site before & during the flush.
Flush consistently with saline (our routine is before and after each access of the line)
Use a Heparin (or other clot-killing line lock) when the line is not in use.
Ensure that the line has no kinks or angled bends when securing it to the body.