Frequently Asked Questions (FAQ) When on-call

• Refer patient to the emergency department. Do not reassure family over the phone. For red flag symptoms, tell them to dial 911 (altered mental status, chills, seizures). Tell family to anticipate admission for at least 48 hours.
• Call in Expect to ED saying that patient who is “central line dependent coming into ED”.
  • If going to BCH, tell operator to use “ED Short Gut/Home PN/Fever plan” (see image below), request someone to personally call you back to close loop on plan once patient has been seen. Consider notifying surgery on-call if concerning story.
  • If going another ED, recommend: CBC with diff, Chem 18, CRP, blood cultures from CVC and peripheral. If history of UTI, UA and urine culture.
  • Empiric antibiotics: Vanco/Zosyn. Use linezolid for Vanco allergy. Use meropenem for Zosyn allergy.

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• Refer patient to emergency department.  Tell family to anticipate admission for at least 48 hours and maybe longer if repeat blood cultures are positive.
• Call in Expect
• Ask for repeat blood cultures prior to initiation of antibiotics
• If CAIR patient, notify surgeon oncall.
• FYI: Patient should always be observed for first dose of IV antibiotics.

https://www.facebook.com/groups/HPNBostonChildrens/permalink/684079095130739/

"By calling ED team ahead of arrival, your HPN team can provide the following info proven to improve care: 
- Illness severity (stable vs. unstable)
- Patient summary (age, dx, treatment).
- Action list (to-do)
- Situation awareness & contingency plans (if-then, eg. If fevers, start such-and-such antibiotics).
- Synthesis by receiver (read back, feedback)"

 

• Ideally patient has been seen by a medical provider.
• If fever present, request blood culture from CVC prior to starting antibiotics.
• Hold IV iron.
• Low threshold for admission for observation.

• Check Xray for tip placement.

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• Refer to ED.
• Consult surgery
• Needs central line replacement.

"When paging, include your child's first & last name + date of birth.
- Helps HPN on-call identify caller If phone # comes through wrong (happens from time-to-time).☹️
- You can reach us by calling operator @ 617-355-6000 and asking for "Home PN on-call." 24/7.
- If no one calls back w/in 15 minutes, page back. Maybe there was a problem with page transmission. 
- If emergency, call 911 first."

• Dispose of PN bag, use new bag.  May need to reset PN pump.
• Family should notify home infusion company.

• Dependent edema?
• Check fluoroscopic catheter study (injection of contrast into CVC) for fibrin sheath.
• Consider upper extremity Doppler study for thrombus.

• Check Xray for tip placement.
• Check line study for fibrin sheath or thrombus.
• FYI: Differential diagnosis includes catheter malposition, thrombus, cathter fracture.

• Can you flush the line?  (If you cannot flush line, see instructions below)
• Flush slowly with 10 ml normal saline (NOT heparin).
• If recurs, then have patient seen in clinic for tPA.
• Check Xray for tip placement.
• Check fluoroscopic catheter study for fibrin sheath.
• Consider upper extremity Doppler study for thrombus.

• Make sure catheter is unclamped.
• Change cap in typical sterile fashion, then flush catheter with saline.
• Check to ensure the catheter is not kinked (consider changing central line dressing)
• If above are not successful, refer patient to emergency department or urgent clinic visit for tPA

• Change cap in typical sterile fashion, then flush catheter with saline.

• As soon as possible, change the CVC dressing in typical sterile fashion.

• As soon as possible, change the CVC dressing in typical sterile fashion.

• Clamp catheter, disconnect Yconnector, use a new Y-connector.

• Evaluation in HPN clinic or emergency department within 12 hours.
• Consider surgical evaluation to remove suture.
• Check blood culture.
• If there are any concerning symptoms, admit for IV antibiotics.  Otherwise may treat as outpatient (ceftriaxone).

• Clamp the catheter proximal to break using atraumatic clamps (example: blue smooth tooth clamps, Kelly clamps), which should be universally provided by home infusion companies.
• Refer patient to emergency department
• Call in Expect.  Tell family to anticipate waiting for new IV access.
• FYI: PICC cannot be repaired.  It will need to be replaced.

• May monitor advise to flush slowly to avoid fracture
• Home PN team may discuss with surgery re: elective repair/replacement
• FYI: internal wall of catheter broken, leading to aneurysm.

• As soon as possible, clean area, reaccess Port-a-Cath with new needle, flush with heparin.  (If unable to access Porta-Cath, see instructions below)

• Ask patient about any swelling, trauma to area.
• Refer to emergency department.
• Consider Xray for port migration.

• First flush with 10 ml normal saline.
• Try to draw back.
• If that doesn't work, deaccess and re-access Port-a-Cath.
• Try to draw back.
• If unsuccessful, instill  tPA for 2 hours and retry.

• Clamp catheter, replace with new tubing.
• Family should notify home infusion company.

• Flush with saline, then flush with heparin or connect to tubing.
• Check closely for catheter fracture
• Is there a back check valve in place (
• If this is first time going home, perhaps infusion rate is not high enough.
  • Stool Contamination to CVC
  • -Gather the following supplies: Saline Flushes, Heparin flush (if needed) Gauze, Multiple Alcohol Pads, sterile gloves, masks, and a new CVC cap
  • - Place gauze or towel under CVC and positive pressure cap. Do not disconnect any connected IVF/PN
  •  
  • - Use a 10ml Saline Flush to gently clean the exterior portion of CVC to remove visible stool
  • - Scrub CVC connection with alcohol protected by 2x2 gauze for at least 30 seconds. Repeat x1. If the alcohol has stool on it, discard and start with a new set up.
  • -Set up,3-4 alcohol pads on 3-4 sterile 2x2 gauze
  • Normal Saline flush
  • CVC cap (prime with Normal Saline leave flush attached)
  • Heparin Flush
  • Mask
  • Put on sterile gloves
  • Again scrub the CVC/ positive pressure cap junction for 30 seconds
  • Remove CVC cap
  • Scrub threads of CVC for at least 30 seconds
  • Connect new cap
  • Flush CVC
  • If there was a fluid running, discard current fluid and use a new bag
  • If there was not fluid running heparin flush the catheter
  • Watch patient closely for 24-48 hours for fever, lethargy, concerning clinical changes. Present to the ED immediately.
  • If patient is hemodynamically unstable, do not use CVC for parenteral nutrition.
  • If blood culture positive for bacteria, okay to run PN through CVC as long as hemodynamically stable.
  • If blood culture is positive for yeast, consider holding PN unless heroic measures for catheter salvage used.
  • If admitted after 1 pm, encourage family to bring HPN bag from home.  HPN bag must be sent to pharmacy to verify mixture matches most recent prescription and to affix bar code.  Floor nurses are not responsible for additions (eg.  H2 blocker, MVI).  The family is responsible for additions to the HPN bag from home.
  • Provide a copy of electronic HPN prescription.
  • Patient should use home supply of Omegaven.
  • Encourage team to communicate with HPN team during business hours.
  • Request copy of discharge summary, operative reports, laboratory studies.
  • Refer patient to emergency department
  • Call in Expect
  • Request the following labs: liver panel, triglycerides, electrolytes at baseline.  For patients receiving Omegaven, triglyceride level should be checked four hours after rapid infusion.
  • If patient receiving Omegaven, send email to Alexis Potemkin, OM study nurse coordinator
  1. Pause infusion. (hit “pause”)
  2. Disconnect tubing
  3. Re-prime tubing (hit “prime”)
  4. Resume infusion (hit resume)
  5. Reconnect tubing.
  6. If above does not work, see below.
  7. Switch to a back-up pump (problem with air sensor).
  8. Inform HPN team, who will inform home infusion company (potentially a manufacturing problem with tubing).
  1. “Upward occlusion?”  (between PN bag and pump)
     1. Check to see if tubing is pinched by door of pump
     2. Check to see if bag is tipped, so spike not underneath fluid
  2. “Downward occlusion?” (between pump and patient)
     1. Check to see clamp closed
     2. Check to see if there is anything in the way of tubing
     3. Disconnect tubing from CVC, check to make sure catheter flushes OK.  (If not flushing, see above “What if I cannot flush my catheter?”)