Broviac considerations management and tips

From Pahwiki

Contents 1 IV Dressing Changes 1.1 Dressing Change Steps 2 Tubing Replacment 3 Broviac Protection 4 Flolan Emergency Medicine Pack

[edit] IV Dressing Changes

IV dressing changes are one of the most stressful aspects of managing a young PH patient with IV medication. The dressing changes are painful to the child, and equally as painful to a parent who has to subject their child to this pain on a daily basis.

When our child was first diagnosed with PH, we were instructed to change the dressings every two to three days. Recent conversations with ours and other doctors now suggests that a slightly longer gap between dressing changes is allowable if the dressing is not spoiled.

In the winter, dressing change gaps can last as long as 1 week. In the summer, the gaps are typically reduced to one to three days. Sweat appears to be the primary culprit of a soiled dressing.

We typically replace the dressing when the edges of the Tegaderm bandage pulls away from the skin or when the sponge pad over the Broviac site swells with perspiration.

[edit] Dressing Change Steps

Preparation

[edit] Tubing Replacment

Our tubing replacement is likely no different than most others that take Flolan. We typically change the tubing two times a week.

Recently, our son's nurse suggested that we incorporate a threaded lock cannula that fits over the threaded end of the broviac. This device seals the broviac and helps to minimize contamination when changing the tubing. As a result, we've reduced the direct expose of the broviac to air to once per week, when the cannula is changed.

When we replace the tubing, we always add a cloth tape strain relief to the end of the tubing nearest the broviac. This strain relief tends to reduce the stress on the broviac joint if the tubing or the pump is inadverdently pulled. We would rather the tubing take the brunt of the load than the broviac itself.

[edit] Broviac Protection

With an active child on Flolan, many Broviac protections have been learned the hard way, through broken Broviacs. To understand the ways by which we protect our child's Broviac, I first describe two methods of Broviac failure that we have experienced:

• Broviac overstress failure - overstress failure results from high loads on the Broviac connector and tubing. These high loads have the potential to tear the smaller diameter portion of the Broviac tubing or to pull the Broviac connector from the Broviac tubing. Once these failures occur, repairing or replacing the Broviac at the hospital consitutes the only solution.
• Broviac fatigue failure - Fatigue failure results from the repeated straining of the Broviac tubing over an extended period of time. Eventually the fatigue causes the tubing to elongate and to weaken. At a certain point, the Broviac tubing can develop holes or break entirely. Our experience shows this problem appears to be far more likely with the smaller diameter Broviacs (.7 mm) than with larger diameter Broviacs that doctors would use with older children or adults.

To avoid both of these potential failure types, we have employed several techniques to protect the Broviac. The first technique, called "looping", involves looping the narrow part of the Broviac tubing under the Tegaderm bandage. In the event of high loading on the Broviac, the loop provides a degree of protection against pulling on the internal cuff of the Broviac itself.

The second technique, called "strain relief", involves attaching a small cloth tape tab on the line tubing. This tab is then attached with a safety pin to the child's clothing with enough slack to prevent the Broviac from being pulled if the tubing is pulled. Not only does the "strain relief" approach help protect the Broviac tubing by transferring any high loads to the child's clothing, but it also keeps the Broviac from twisting and thus helps to avoid fatigue related failures.

Another strain relief technique suggested is the use of a stat lock. It's a small plastic clamp on one side and a sticker on the other that attaches to the skin. Statlock website

[edit] Flolan Emergency Medicine Pack

An experience this weekend reminded me of why we always maintain an emergency kit for our child with PH. The emergency repair kit contains everything we need to deal with issues as significant as a Flolan disruption or issues as minor as supplies for dressing changes when we are away from home. Our pack contains:

• 1x Flolan medication kit in "dry" form
• 1x Flolan infusion pump
• 1x Dressing change kit
• 4x AA batteries for Flolan pump
• 2x Tubing replacements
• 1x Broviac tubing clamp (in case of Broviac tubing breakage)
• 1x Reconstituted Flolan with ice packs and contained within a water bottle parka
• 1x Broviac repair kit*
• 2x IV needles*
• Miscellanous supplies including alcohol swabs, bandages, etc.

Based upon a recent incident, I'm considering including a portable emergency oxygen tank with our emergency kit. The smallest one that I've found so far is the E-Pax M4A Emergency Oxygen. It's not cheap at $379.95, but is small and convenient.

'*'In the case of these items, we maintain them in case emergency personnel do not have the appropriate supplies with them to administer an IV or to repair a Broviac line. In more than one instance, our ability to give to the surgeon our Broviac repair kit reduced the emergency room visit by hours.