Here's a situation we encountered here. Pt. comes into the ER. ER is unable to establish access and called ICU to come place a line under US. 2 lines were placed - one long PIV and a midline. These were inserted prior to ABX. Blood cultures were drawn at the same time as insertion. 4/4 bottles came back + with gram + cocci clusters. Because the midline was placed prior to abx therapy, intensivist is requesting to have both midline and long PIV removed as they could be seeded. It seems a bit odd to me that had we waited until the Pt. got a does of Vanc, we could retain the midline.
Does anyone have any input/thought?
This is the prevailing reference
1.Mermel LA, Allon M, Bouza E, et al. Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection: 2009 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2009;49(1):1-45.
This is now in revision but there is not a new version yet. Basically it provides guidance on obtaining cultures and making meaning from those cultures taken from the suspected catheter and a separate peripheral site at the same time. If you remove the present lines, how are you supposed to infuse the medication? Any VAD can become colonized, so putting in a new PIV can also become colonized. I would not remove what I had until I have culture results to indicate that the cause is more probably than not to be the VAD in question.
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Thanks Lynn. That was my thought. BC came back + with MRSA finally. BC were repeated from JUST THE MIDLINE yesterday (less than 24 hrs after the previous set and less than 24 hrs of abx), and they came back with...wait for it...MRSA. Based on that, they are afraid that the line is seeded, and the line is going to be pulled. The plan will be to insert either a CVC, long PIV, or another midline to give abx therapy.
It doesn't make sense to me that we would pull a line and then insert another into the same exact environment. To me, it would seem to be more prudent to wait and then remove the line only if cultures from it come back + and peripheral fail to.
M.K.
ICU Nurse
RN, PHRN, VA-BC, NRP
Well, MRSA is certainly cause for concern. How long has this midline been in place? Is patient responding to ABX with this current midline still in place? If not, the catheter may need to be removed.
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Pt. presented to ED on 9/12, and midline was placed the same day. Pt has been covered with ABX since day 1. VS have been stable, and Pt. has been afebrile. WBC's have varied, but are only a touch north of 12 at this point. Midline was removed this AM after rounds and discussion between pharmacy and critical care attending.
M.K.
ICU Nurse
RN, PHRN, VA-BC, NRP
From the guidelines:
32 Long-term catheters should be removed from patients with CRBSI associated with any of the following conditions: severe sepsis; suppurative thrombophlebitis; endocarditis; bloodstream infection that continues despite >72 h of antimicrobial therapy to which the infecting microbes are susceptible; or infections due to S. aureus, P. aeruginosa, fungi, or mycobacteria (A-II). Short-term catheters should be removed from patients with CRBSI due to gram-negative bacilli, S. aureus, enterococci, fungi, and mycobacteria (A-II).
The Pt. grew out MRSA, so the S. aureus applies, but the dx of CRBSI is not in play yet, b/c we haven't definitively nailed down that the midline is colonized. Is that correct?
Also:
M.K.
ICU Nurse
RN, PHRN, VA-BC, NRP
First, according to the FDA, a midline is a peripheral catheter and therefore a short term catheter, not a long term catheter. I don't think a midline was in the minds of these IDSA authors when they wrote this guideline. So your medical decision-makers would need to make a choice of how this guideline is applied. How is the diagnosis of CRBSI going to be made? Were blood cultures drawn from the midline and a peripheral venipuncture at the same time as described in that guideline paper? RE your last question, I would not apply this in that manner. The cultures are drawn before ABX treatment starts. I am not sure what you are trying to achieve - retaining midline or simply understanding guidelines application? Please read section of guideline about when it is and is not appropriate to leave a catheter in and treat it. I don't think this would meet that criteria.
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861