If you are ever in charge of an ED I’m sure you have seen it happen. A kid turns up with a fever during treatment for ALL. They are triaged Cat 2- see within 10 minutes. You get the kid in and seen by one of your docs. You pester the doc “When was the last chemo? You’ve ordered the cultures? and the Tazocin? Does the kid look well?” The nursing staff are taking care of the cultures. You eyeball the kid and they look ok.
10 minutes later you ask again, “Antibiotics in yet?”
“We’re just waiting for someone who can access the port, the nurse in the cubicle can’t do it.”
“And who can do it?” you ask.
“I think Bill can. He’s on his way back from the ward. He just took a patient up.”
10 minutes later, “Antis in yet?”
“No, Bill can’t do it. But a nurse is coming from the kids ward who does it.”
Time slides by.
“Where’s the nurse who can access the port?”
“They said they were coming straight away.”
And then the sentence that gets ED docs and nurses moving like none other:
“Can I get a hand in here!”
Time just seems to slide away with these kids. We were lucky enough this week at Bendigo ED to get a visit from Chris Williams, Consultant Nurse Specialist from the Oncology Unit at RCH. He has the job of traveling around regional Victoria demystifying some of the care of paediatric oncology patients.
Here are some of the things we learnt (including how to access the ports- no more waiting while the bugs multiply)
Cancer affects about 1 in 6000 kids in the developed world.
The great bulk (60-85%) of cancers in children are leukaemias (mostly ALL, a smaller fraction of AML).
Of the remainder the bulk are CNS tumors (which often don’t come to ED during treatment as they are managed with surgery and radiotherapy rather than chemo) and lymphomas.
Time to antibiotics is really important. A study from the Texas Childrens Hospital demonstrated that time to antibiotics of greater than an hour led to worse outcomes.
The rate of positive cultures is proportional to the volume of blood drawn. We tend to under do the blood volume on blood draws for culture in kids. As a rough rule of thumb we should be drawing about 0.33mL/kg for each culture. The yellow paediatric bottles we use in most Victorian hospitals are for volumes up to 4mL so once a kid is kinder-prep aged (>16kg) we should be using an adult (green) bottle. Add an (orange) anaerobic bottle in kids over 5kg if there are GI symptoms, severe mucocytis or a GI or genitourinary malignancy (mostly Wilms tumours in kids). Kids smaller than 5kg (neonates) might need an anaerobic bottle sometimes but it is rare and it means you are dealing with something pretty bloody nasty so consult first. Here is a guide from RCH on how much blood to draw for the bottles we use here.
We no longer draw two cultures from two sources but we still want two bottles drawn off so take a bottle from the first blood you draw from the indwelling line (trying to catch all those line bugs) and then take some for counts and biochem and then take another culture off before you lock off the line or put up fluids. Peripheral cultures are only needed if the line can’t be accessed or won’t bleed.
The biggest cause of delay to antis is finding someone who knows how to access the line. Thankfully Chris has now taught all our registrars to do this safely which is brilliant.
What are the key elements to accessing a portacath?
- It is an aseptic procedure. It needs sterile gloves and a sterile field and an antiseptic wash. Kids from RCH will be expecting 3 washes with chlorhexidine. Not doing the three washes is likely to result in grumpy patient and parent.
- Use a non-coring needle. At the RCH they do so a lot of these in a year so they use a separate needle and line arrangement. At most regional places where the volume is lower we use a one-piece needle and line combo that is a bit more expensive and less fiddly. This may need some explaining to the kid and parents to avoid the “They don’t even use the right needle” complaint.
- Grip the port with 3 fingers in a triangle so it can’t get away and insert the needle into the centre of the port. You will feel resistance as you go through the silicone and then a hard stop as you hit the backplate. If you can’t reach the backplate you need a longer needle to be sure you are safely in.
- Aspirate now. The line should bleed back. If it will not bleed and you have definitely hit the backplate, try the following:
- Get the kid to cough, cry or yell out. The change in intrathroracic pressure and SVC volume may allow the catheter to shift away from the wall or dislodge from any little fibrinous cage that has grown around it.
- Get the kid to abduct their arms to 90 degrees and then put them back behind themselves. Ask them to turn their head one way and then the other. This can help to unkink a line that is kinked over the clavicle.
- Give the line a tiny flush (maybe 1-2mL) and draw back straight away. This comes far down the list as it may produce a septic shower.
- Give up and get a peripheral line. The portacath is probably salvageable at the referal centre but right now you need to treat the kid, not the line.
For a Hickmans line (much less common in kids) use a 15 second alcohol wash of the relfux valve and then aspirate. Simple.
Here is a demonstration sheet from RCH. Note that the pictures show them using the multi-piece device that they use there. Your hospital may buy something else (mine uses an all-in-one with a little detachable gripper like a clothes peg, similar to this). And here is a guide to troubleshooting.
Occasionally kids will have a two lumen portacath. These are mostly used in osteosarcoma where treatment involves incompatible drugs. When there are two lumens one culture should come from each and half the antibiotics should be delivered through each. Almost all Hickman’s lines are double lumen.
Never leave blood in the line. Usually when a line is accessed in ED some fluids will be going up, even if only at a “keep vein open” rate. If, for some reason the line is being locked off there are guidelines on when to saline lock it and when to heparin lock it which are beyond the scope of this post.
Another useful thing to remember is that these kids are pretty used to having their ports accessed and pretty clear about how they like it done. ALL kids might have their ports accessed 60 times or more in a course of treatment. In day oncology where they go for their chemo they usually sit up in a recliner chair, often on Mum or Dad’s lap. Assuming the kid is well enough this is a good way to do it in ED, with the trolley end raised and Mum or Dad sitting with the kid on their lap. Smaller kids can have their limbs controlled by the parent in this position. Most of the kids will want to watch and will be very clear about how they like things done.
One thing the kids will be used to from Day Onc that won’t be suitable for ED when febrile is EMLA cream or some other topical local anaesthetic cream over the port. Now some parents will put the EMLA on at home as soon as they realise the child is febrile which is great. And there is nothing wrong with your triage nurses routinely applying it to kids who present with fever on chemo so that any delay to having the port accessed is at least buying them some comfort. However, EMLA should not delay port access in a febrile cancer kid. Thanks to the wonders of intranasal fentanyl (1.5-2mcg/kg intranasal by mucosal atomising device) we can now have these kids pretty blissed out while we access the port if they haven’t had time to get the skin numb.
High risk or low risk?
We got some insights into the whole high risk, low risk febrile neutropenic kid thing. Essentially, AML kids are high risk throughout their treatment as they really get some pretty heavy duty chemo; they mostly stay in hospital through the whole treatment course (6 months). ALL kids are high risk during induction (aggressive chemo used in the first month with very high dose steroids and big infection risk) and delayed intensification (a second burst of induction-like treatment a month or so in). Lymphomas also require a period of more aggressive chemo during induction. Kids with ALL who are less than a year old are also high risk. BM transplant kids are high risk for varying times depending on the type of transplant. See the RCH Guideline for details.
The line fell out. Help!
This is a small but important thing. Should you ever be called upon to help a kid who’s Hickmans line has fallen out (apparently they snag on shopping trolleys and get left behind when Mum lifts the kid out of the trolley so beware at the shops) you might be tempted to apply pressure were the skin hole is. Wrong! There is a little scar on the neck, usually on the right side, where the line actually enters the Jugular vein. Put pressure on there. The tunnel exit might dribble a bit but it doesn’t really matter compared to an uncontrolled, 7 French hole in the jugular.