Tips for pediatric central line set-ups
Nurses play a large role in meeting the many unique challenges to setting up central lines in pediatric patients.
"We need to be as prepared as possible," says Sharon Smarto, RN, BSN, CEN, education specialist in the ED at Children’s Hospital of Pittsburgh. Here are some tricks of the trade. (For more tips on this process, see story, p. 12.)
• Have spare supplies on hand.
"We have various sizes of spare guide wires on hand that match the kits we keep, so in case a piece gets dropped or the guide wire gets bent or contaminated, we have a spare wire there," says Kim Basso, RN, BSN, pediatric transport coordinator at the Medical College of Georgia Children’s Medical Center in Augusta. "Since that’s all they need to replace, they can still use the same kit they’ve been using."
• Prepare for the worst with trauma cases.
"As long as we have advance notice, we set up our entire room as if the kid is the worst ever," says Smarto. "We won’t open everything because it’s a waste of money if we don’t use it, but it’s ready to be snapped open when the kid hits the door."
• Provide a large syringe at the start of the procedure.
"They can draw out heparin at one time in a big syringe, so they have it there sterile, which frees me up to do other things, instead of having to draw it up two or three times," says Basso. "I also provide a large 18-gauge needle for them to draw up the heparin so it doesn’t take so long, because needles in the kits will frequently bend as they’re trying to insert them into the vial."
• Take the patient’s advice.
"If they are an older child, and they are verbal and have had [experience with central lines] for a while, they’ll tell you what makes their blood flow better," says Smarto. "If they cough, sneeze, or roll from side to side, it can make a big difference."
• Prepare room in advance.
"Make sure there’s good lighting, and elevate the bed to the right level so the physician doesn’t have to bend over," Basso says. "I also make sure we have a big enough sterile area and enough drapes so the wire, which is frequently long, won’t extend over the drapes."
• Protect staff from contamination.
"In the heat of the moment, people will open tray after tray and can sometimes get careless," Smarto says. "If things get thrown around and no one ever clears anything away, you will have no idea what is sterile and what isn’t."
• Don’t let the wire become contaminated.
"We take a piece of gauze out of the kit and thread the end of the wire into the gauze," says Basso. It keeps the wire stable so it doesn’t slide off the drape. It’s still easy to get undone, but this keeps it not quite as unwieldy.
• Keep an extra pair of gloves available.
"I keep an extra pair of the appropriate size, so there’s not a big delay if they contaminate," says Basso.
• Position patients in advance.
"When positioning for femoral lines, some doctors prefer the frog leg position, and some prefer the legs be kept straight with the toes turned in," says Basso. It’s just a matter of technique, but you should know ahead of time which position they prefer so you can get the child in the appropriate position ahead of time.
Restraints save time
It helps to have adequate restraints to position the child, so you can make it as quick as possible.
"We frequently tape the legs down to the bed, from one side to the other, and that prevents somebody from having to hold the child’s legs down, so we can usually do the procedure with one person to assist," says Basso.
• Have plenty of fresh heparin flush on hand.
"I’ve gone through as much as a 20 cc vial of flush before, so I make sure I have a large vial of fresh heparin to use," says Basso.
• Streamline work after the procedure.
"If it’s single lumen, I have at least one connector or cap," says Basso. "And as soon as they open their kit, I just drop it onto their sterile field so they already have it flushed and ready to go."
• Have dressing supplies at the bedside before the procedure starts.
"That way, there’s not a big delay after they finish, when it’s in but without a dressing yet," says Basso.
• Use Betadine swabs.
"We don’t always bother with the Betadine solution in the kits instead, we use packets of Betadine swabs that we use for other purposes," says Basso. "Once they get their gloves on, we’ll frequently tear open one of those, so sterile ends stick out, and grab the ends of the sticks and swab with those to save a little bit of time."
• Use a topical anesthetic.
"If you know the procedure is going to happen and you have 20 minutes or so, Emla cream is wonderful because it numbs the skin and makes it much easier," says Basso. "Even if there’s not much time for it to work, we still use it."
A local anesthetic may need to be used, and for an extensive procedure, sedation should be considered, says Basso.
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