Central Lines...WHAT? - Richelle Guinigundo - APP Conference 2026

Good afternoon. My name is Rochelle Gina Gundo. I am a pediatric surgery NP as well here at Cincinnati Children's, and I am our CBC or central line NP related to surgery. And we're gonna talk about central lines, and most people when I say central lines get a very glazed look over their eyes unless you maybe work in one of our ICUs and you're like, I have no idea what you're talking about. So our objectives are we're going to talk about some fundamental components of central lines, and then we're going to apply some troubleshooting strategies for common complications. I expect some audience participation at this point. You guys need to get up and move, and I do not care if you shout out answers at me. So kind of just. What do you think? How often do you see them? Are you in the group that sees them every day? I work in an ICU. I'm really comfortable with them. This is kind of how they go. Are you in the group that says, hm, I see them sometimes. I still have lots of questions, how they work, how I'm supposed to treat it, what should I do with this? And then we have the, I know what they are, but I have no idea what to do with them because I never see them. And last but not least, I never see them. Just not something in my world. I appreciate it. I feel like most people have seen them or do see them on a routine basis, but really have no understanding of. What your role is in taking care of them. I'll move past this. So let's talk about Central Venus access, my lovely little guy and his vessels and his line. So these are our access sites for central venous catheters. We have our internal jugulars on both sides of our necks. Everything is on the right on this patient, but we have, most patients have the exact vasculature on the left as well. We have subclavian, so coming across the chest, we have our femorals in our groin. If you're using a PC in the upper extremities, you might hear us talk about our cephalic, our brachialic. We have a variety, and then if you're talking lower, we are talking about the fem or the popliteal. Typically, we can have some other vessels we can go in. Important piece to realize is not where the catheter comes out of the skin is what makes it central. It's actually where the tip ends up. So we like it to end up in the SVC, typically the lower SVC. We like it at the junction of the SVC and into the right atrium. We like it sometimes in the right atrium. If we're coming lower, we like it into the lower SVC or lower VC. So you'll kind of hear those things. How you know, you'll hear terms like it's tunneled, it's not tunneled. It's a pick, it's a midline. Those are kind of all descriptions of how the device got under the skin and into the vessel. So what I tell families frequently, you have a non-tunneled line, that literally just means my catheter entered the skin and the vessel at the same time. So a PIC is a non-tunneled line. Or you have a tunnel line, that means that the catheter entered the skin somewhere else, than it entered the vessel and it tunnels underneath the tissue. 99% of the time that catheter is going to have what's called a cuff, and I promise I'll go over that in a little bit. Um, a totally implantable Venus device would be a meta port. You can't see it. It's all under the skin. So now I've named all these devices and now you're like, oh my gosh, I don't know what they are and why you use one. And this is a picture of most devices and those of you who work in the NICU, if you're here, I'm sorry, I did not go get a UAC or UVC. But there's a pic in this picture. There's a tunneled line, there's a non-tunneled line, there's an HD line, and there are two meta ports and a tunneled HD line. So how do we choose which of those? If you work at Cincinnati Children's, you know that we have a vascular access order, and if you did not know this, it is based on the Michigan Appropriateness guide for intravenor cat catheters in pediatrics, or commonly called the Mini magic. You can actually download an app on your screen or on your phone to help you. It runs a little better on an iPad, but you can do it on your phone. It starts with peripheral access and ends up with central access. You can ask it, you ask you where your patient is located, inpatient, outpatient, emergency room, ER, is it an oncology patient? It will direct you to which catheter is best used for that patient, how many lumens, and that's kind of where that we get this from. It's an evidence-based method of guidance. It improves safety in our catheters, but also supports something called preservation of vascular health. We know that our catheters can cause damage to the epithelium. We can cause clots, we can cause obstructions of the vessel entirely, and so we want to be safe about what we're doing. OK, I'm done talking about crazy stuff. I could talk about that all day. More what you want to know. I have something in my clinic or in my space that I work. How do I deal with that scenario? OK, we're gonna pick on somebody who works in primary care, maybe Emily over here, kind of know. So you're doing a well child visit and this lovely cute little 7-year-old walks in. He had a single lu in meta port placed 7 days ago. It's not accessed. When can he access it? Or when can we use it? So, MediPort is completely underneath the skin. If we do not access it in the operating room, that means we do not leave a needle behind. So the system is closed and locked, and it's just waiting for its use. Lots of people at Cincinnati Children will tell you, you can't use that for 7 days. That's actually not the correct statement. It goes with a, a guideline that we have here. This port came out of the OR actually ready to use, can be accessed at any time. You should be cautious. In the 1st 7 to 10 days, it's healing. Also, it has surgical swelling. The needle size that you might choose to use in that 1st 14 to 17 days may not be the needle size that you use down the road. It's also quite painful in that time. So even though we use lidocaine or Elema on it to access it, the kids are going to be a little more uncomfortable. So it's a nursing initiative to decrease pain when we're starting IVs, and this is included in it. It does not mean it's not ready to use. And if you've never seen one access, this is a lovely video. There it goes from open pediatrics, oh. I don't know this may not run. Oh. Actually, I'm gonna skip it. Somebody didn't cut it shorter. I had an access. If you ever want to see one access, come find us and we will do that. My second scenario is somebody just throw out where they work. I don't, I'll figure it out from there, anywhere. TCC perfect. You have a patient, let's say they're 10, who transferred from an outside hospital for, um, pulmonary rehabilitation. They have, we're gonna say a meta port. Actually, I'll say a tunnel line. It's a little easier. They have a tunnel line. You cannot lovingly and Epic, find the history that's related to this line. You know nothing about it. So, kind of, what are the first things that you can do to figure out where you are? My first, kind of when I know nothing about a line other than physically looking at the line, and I, it has some characters that we can look at, is just take an X-ray, just a single view. It tells me that the tip, and this is an adult patient, so I'm sorry, but it's a little easier to see, the tip of the catheter is central, right there. So, we say our catheters are central. If you go from the bifurcation and two vertebrae down, that's the central area we try to hit. I don't expect you to read that, I promise the radiologist will read that for you very quickly. I can tell by looking at this catheter, just this image, this is an HD line. This is just what they look like on X-ray. The clamps that we see on them are radio opaque, and so we get to see it. I can tell this line has a cuff, cause I can see it again. Remember, I read these all day long. It's right there. So that means there's this piece of fabric underneath the skin that's holding this line in. Let's say it's a, a metaport that came. You have a metaport under the skin, you can't find stuff out. So, what do we know? I can't always tell you what franchise things are without looking at manufacturers have labeled tongue lines, but in metaports, I don't have that. But I can tell if they are flipped the correct way. And I can tell if they're CT or power injectable. So on the very far, and I won't do this, on the very far side is a double loom line that very nicely says CT. And yes, you will see that on the X-ray. It's great. The one next to it, the CT is down low, but the third one over, there are no letters on it anywhere. That is not a power injectable meta port. Um, the CT on the power port is on the bottom. It looks a little different now. But I want to go to this right side of that 2nd or the 1st image. People will ask me if they're having difficulty accessing a port. Is my port flipped? Meaning in the pocket in the chest, has the port actually flipped over and the wrong side of it is facing. An X-ray can help me. Um, the first one on the top line, CT is correct. So I can read the letter CT. On the other one, the T and then the C is the wrong way. It's flipped. I can actually tell by X-ray if I have flipped. It's a little bit easier. That double metaport makes lots of things easier. It's just bigger to read and see. The bigger they are. That also gives me a hint a lot of times that if I can't, like the CT is a little harder to see, it's probably a smaller French sized port. So scenario 3. Oh, do I have any oncology friends here because this happens frequently. No, OK. We're going to say that one of the oncology floors here at Cincinnati Children's gave me a call. Oh, I'm sorry, I made this shortcut. Uh, I'll go with that. So we're going to say 8th floor, South called me or Central called me because they have a shortcut 3 year old who has a line that was placed 120 days ago. And when we place them, then we put sutures on them to help hold them while they heal. And they'll tell me the sutures are out. So, kind of what am I thinking? Well, I'm worried, is my cuff mature? So, cuff is a dicon piece of plastic. See if it goes back. I don't know, I believe that there we go. And in this picture of this white line, which is a bard, it is that piece of material right there. Um. Think of it like a piece of Velcro. It actually has little nubs on it. It's softer than Velcro, and the body takes its time and heals with it and makes skin tissue kind of granulation tissue to heal to it. So I need that to happen over time once they're placed. Typically, it takes us. About 21 to 36 days for that to happen. If you were not a shortcut kid or even a shortcut kid, but you're an oncology patient, that may take you longer. You're neutropenic and you're going through things. And so people worry. Well, why would you worry if your cuff is what we call exposed? So if the cuff were exposed, the cuff is also antimicrobial, so we would worry about an increased risk of infection of that line with the cuff exposure. We would worry that the line wasn't central because I don't have anything holding it in place any longer. So those are things that help me. So here at Cincinnati Children's, we say at day 42, actually, day 43, I will say I no longer need sutures. If you told me it's day 42, I probably would say you still need no sutures. And the line in the middle actually has, you can see it has suture material on, but it's no longer connected to the skin. This patient also has some granulation tissue, and this just proves Bessie's point. Granulation tissue happens on a lot of our lines, and it's not a bad thing. It's nothing is wrong. It's just the patient is trying to heal a hole that we don't want to close, um. The other interesting piece on the slide, why are my catheters two different colors? Does anybody know? And this goes for pics too. Oh, you guys are no fun. My line, that's white, which is a bard, and it's silicone, that's what it's made of, is not power injectable. My line in the center is purple and made of polyurethane and and power injectable. Also, if you know picks, you would be like, how do you know that's not a pick? Cause that looks just like our barred pics. Um, mine has a cuff on it. Theirs doesn't, and you can't see that without an X-ray. Sorry, we joke about it all the time. Um. Even funnier, and I do not know why manufacturers make me look like an idiot, our meta ports are purple too when they're power injectable. I'm not quite sure why. I mean, I, the surgeon knows they don't really care, but the rest of you can't see that clue once we put it in the chest. And yes, they really are purple. It's just a weird phenomenon. Um, and PIs are done the same way. It's just a clue when you're looking at a line. And what is it? Does anybody know what it means to be power injectable? So a power injectable line or a CT uh capable line means that that particular material the line is made of will accept up to 325 PSI in that line. That means that I could take it to one of our CT scanners, use the power injector on it, and shoot contrast through it, and it would not break the line. If you put power contrast through the silicone line, or you were to put it on the rapid infuser, if I have any ED friends here, it will break. It just will not tolerate that pressure. This is um a 12 year old who has a meta port. We'll say they were placed for an oncology reason. They are not currently accessed, but they present to clinic with this. Lots of people say, can I access through that? You cannot. I'm very worried that I have cellulitis or I have a port pocket infection, which is an infection in the port pocket. If you were to access through it, you would actually take it into the bloodstream. So no, I wouldn't want you. There's a chance we can salvage the port, meaning we can save it. We can draw a peripheral blood culture and see if we can get something to grow and maybe help us. And sometimes we do that and try to get ourselves out. Or sometimes we feel like we can't salvage the port, that the pocket is too infected, and we run the risk, we'll actually remove the entire system. Um, this is an adult patient. It's actually kind of hard to see a surgical line, but it's actually right above the redness, like before the redness fades out. Um, we take it out through that same incision that they made. You just open it up, get in the port pocket, and pull the whole system back up. My next scenario. We're on a general pediatric floor, so. Maybe 6 or 7 or maybe even 3, and you have a 4 month old who has a pick. It was placed 2 weeks ago and now it will not aspirate. It will flush or maybe it won't. Kind of what's our next best step? Um, And there's at Cincinnati Children's, we have vascular Access Team, and I know we're really lucky to have them, and they help you troubleshoot all of these scenarios before you would call me. Or they'll just call me and we'll have the discussion, um. But they have a chart on what to do next. And if you didn't know this, this is actually on our website. I did not do all of it because I didn't want to go through all of it. But here at Cincinnati Children's, you would put in a vascular access consult. They would rule out a mechanical complication with the catheter at the site. Is it kinked? Is it doing something funny? We're going to take a, we're going to take an X-ray. Sorry, that films are our things. We're going to make sure that the tip is in a good position. When a tip is not in the correct position, we do call that a malposition tip. For if you were a malpositioned tip, they would readjudjust or replace the catheter. And then um. If it, that wasn't it, so we're going to go to the other side. Typically, that will, that will solve the problem because we placed a new catheter. We go and they'll assess what's the reason for the occlusion. I'm going to work right to left. A mineral occulsion. They gave something that typically maybe the TPN itself, the concentration is off, um, and then they can use, depending on what it was, sodium bicarb. To try to instill it, and they'll lock it with it for a period of time and then withdraw it or flush it through. Or if we think it's a lipid, L-cysteine will work nicely. I'm sorry, a lipid would be ethanol. An asset would be the L-cysteine. Again, they lock it for a period of time, try to aspirate it out or flush it through. All of these products become inert after a period of time. So that your dwell time is to get past that so that if you were to push it through, that it wouldn't hurt the patient. If you had a thrombus or a clot, I didn't put this up, but it's TPA. It's probably most of what we deal with when you talk to us. That's the biggest one, and we kind of go from there. Um The other piece to this is if, let's say this catheter, I'm gonna go back to my scenario. Instead of non-aspirating, the nurses call you and say, it's bleeding, it's bleeding from the catheter. Something is wrong with the catheter. It's probably a a cracked catheter. Nursing should have an emergency kit at bedside that contains a pair of hemostats and some gauze. They should take the gauze, wrap it around the line, hemostat. Above, between the patient and the crack and clamp it. The line is broken, it needs to be replaced, but the, the quick emergency room thing to do is to clamp it. If you have patients who are at home with central lines or PICS, they should still have their emergency kit with them so that they can do this at home and present to the emergency room. OK, I have another, I'm almost there, but I have a couple. I have one lovely little scenario we're going to talk about. Um, if you have your phones on you and you have Instagram, did you know that Cincinnati Children's Radilogy department has a page? It's called Ciny Kids Rat. FYI, if you ever want to learn radiology on a, like a daily basis, it's fantastic. They walk you through so many different crazy scenarios. Uh, it's, it images all the time. So, as I'm writing this earlier this month, On the 9th of this month, they posted a picture, flat film X-ray of a meta port. It looks beautiful, kid, meta port right here. You can see the metaport traveling, the catheter traveling under the skin. You can actually see where it makes the bend and enters in the vessel into the right IJ, and then there is no more catheter. It's, you're like, wait, it should come down into the heart. You just showed me pictures. I should have a line that travels down into the heart. The particular story is this young lady had had her port for a while, it's not important why she had it. She complained when they flushed it at home, it felt funny all of a sudden. So she presented to her primary team that was managing it. They, um, took a plain film to help themselves out, and lo and behold, the catheter had actually fractured in the vessel and broken off and traveled in. To the ventricle. So clearly not where we should be. So things we worry about is things ending up in places we didn't intend. Cardiac cath lab was promptly called. They took the patient to the cath lab. They retrieved said broken catheter from the ventricle, and they actually let us come up and we actually took out the rest of the catheter system while she was in the cath lab to prevent another. So again, X-rays are my friend all of the time. They tell me lots of things, and they should be your friend if you have a patient with a central line. I have, so my video was really nice. It showed, um, and it just didn't work, showed in excess of a port. And it showed clean. And if I would be very remiss in not talking about collapses when I was talking about. Oh, OK, they said they fixed my slide, let's go back to it. I wanted to say it, thank you. I'm short, I can't see things, I love you. I got that for you. Thanks, did it, let's see if it goes, it was supposed to be. Yeah, you just had to. No, it should be a bunch farther on, let me find it. Um, it's 3 minutes and 4 seconds in 3 and 4 seconds. No, she has the time. Yep, perfect. Be sure to check your institution's policy in regards to which antiseptic agent should be used to cleanse the skin prior to accessing the port. Cleanse the skin with chloroprep cleaning solution per your institution policy. Utilize a thirty-second scrub in a back and forth and up and down motion, including the entire area where your dressing will adhere. Palpate the area of the implanted port with your non-dominant hand, locating the center of the port's septum. Rotate the site with each access. Do not use the same hole for each access as it will lead to skin breakdown. With your dominant hand, firmly push the needle perpendicularly through the skin into the device until the needle meets the bottom of the device. It is important that there be a small space between the needle and the skin line. If flush with the skin, the needle length is too short and there is an increased risk of infiltration. If necessary, support the space between the needle and the skin with a folded 2x2 gauze to prevent rocking of the needle, which can cause damage to the septum and irritate the skin. Gently flush with 3 to 10 mLs of normal saline or aspirate for blood return to verify proper placement. Apply an occlusive dressing if necessary, cover. That's all I wanted to show. Thank you, um. This is not CCHMC guideline policies, but it's a really good example. So we around the nation all typically use some type of CHG to clean our sites. If our patients are allergic, you're gonna hear us use Betadine. It's a lot more about the friction than it is about the product, so a good 30 seconds of scrubbing helps us decrease. They used a 2x2 gauze. I feel like this is an older video, and that's how we used to do it. We want something to prevent rocking of the needle. We have some CHG pads and we have some biodisc you hear us use. We use tape across our needles to help us, and then we use an inclusive dressing. It isn't about the product. It's all about using the standard. So if you use it every time, that's what prevents your collapsing is doing those pieces every time. So when people ask me, that's what I say a lot. But if you hadn't seen a Metaport access recently, that's what it looks like. And a nice kid holding still, because we know that 3 year olds are never good. That is the end of my slides, and I'll go to my references. I am happy to answer any questions, um. It Thanks, Rochelle. I just had a quick question about for the providers out in the community that may be seeing some of these patients in their primary care, if they, um, have a concern in the office, is it like they would just call Priority Link or how would they contact like. The VAT team, when you know if I'm in urology and I need you, I call the VAT team. But who would that that is exactly so your first call out at Cincinnati Children's will always be to the VAT team. And if you didn't know, VAT team doesn't have clinic hours, but they can come to your clinic. Um, when we invented my job, I don't know that we ever thought that I'd have daily communication with VAT teams. So if you're having a problem in your clinic, and who's in neurology clinic this week, because I promised you they were on the phone with me when we were dealing with a patient, um, So they will come to your clinic, they will do the first steps of troubleshooting, and then they will say, if it's something they can't troubleshoot, they will typically text me if I'm around and I'll help them, or they'll say, you need to contact surgery. So that's the typical pattern. Um, it's the same for the emergency room. So you're in a clinic, if you're sending your patients to the emergency room, the first thing they do is contact VAT team, and then VAT team determines should they need surgery's help to deal with the problem. And yes, they can come to your clinic. A lot of times if you texted me and said, I'm having this problem, I'm going to tell you to have that come to your clinic and give me my first assessment. It isn't that I don't trust all of you. They're the experts when it comes to this. They have to feed me information and they're going to feed me information on a different scale. And what about for the outpatient, um, providers? Outpatient provider, the only real, those of you that are community providers and not a CCH basing, we send them to the emergency room is kind of your only thought, unfortunately, um. Sometimes it's nice when the managing team, which we say the managing team is the ordering team, has a clinic here. It works a little bit better. But sometimes I have kids who have infusions that just don't come to clinics frequently enough. So we send the emergency room. If they have a fever, you'll hear this one too. If you get a fever at home, we're going to, pretty much everybody's going to send you to the emergency room so we can do our workup. So I'm sorry to all the emergency room providers that I make you do work for me. Other questions? I think we get lunch next so.