Mother and Child


In the 206 days since Vic died I have never missed her as much as now.

My UK daughter-in-law and her three girls are visiting. The poor little poppets have all had a gastric bug. The girls are amazing and I love them with every fibre in my body and they love me too. What struck me once again this week is that incredible bond between a mother and daughter. When a child is ill they want their Mommy. There is no substitute for a Mommy.

Dr Christiane Northrup, author of the book Mother-Daughter Wisdom (Hay House), says: “The mother-daughter relationship is the most powerful bond in the world, for better or for worse. It sets the stage for all other relationships.”

No other childhood experience is as compelling as a young girl’s relationship with her mother. Mothers impart on their daughters how she feels about being female, what she believes about her body, how she takes care of her health, and what she believes is possible in life.

Jennie Hannan, executive general manager of services at counselling provider Anglicare WA, agrees. “How a woman sees herself, how she is in her adult relationships with partners, and how she mothers her own children, is profoundly influenced by her relationship with her own mother,” she says.

When Vic was ill she wanted her Mommy. Last year, when she had her arm operation, she was so distraught in ICU that the staff asked me to stay with her around the clock. With each and every major surgery she ever had (excluding one knee operation), my face was the first she saw. Vic knew that I stayed outside the ICU until she was released into the ward. More often than not, I was not allowed to sit with her all the time but she knew I was there.

I am not exactly gifted in sewing or knitting… (It was the only subject I ever failed at school) yet I knitted Vic a massive blanket in 2007 sitting outside ICU and next to her hospital bed. I only ever knitted at hospital and I am a very slow knitter. If we had buried Vic I would have buried her wrapped in her blankie… My life ground to an absolute halt when Vic was in ICU or hospital.

Witnessing this incredible bond the past 2.5 weeks has brought back incredible memories of Vic sitting on my lap, her little arms curled around me and her head nestled into my neck. That incredible trust and reliance between us.

My daughter-in-law and I sit and chat into the early hours of the morning. She has a happy disposition. Her life revolves around her family. She has an easy laugh and great sense of humour. If ever I went into a Quiz Show and there was show business section I would want her next to my side. When she goes to bed she gives me a hug. I love this woman for her kindness and compassion.

I realised how much I have missed that companionship, our chats into the early hours of the morning. Somehow it truly made me realise that my child is dead and I am alone.

Jared, Vic’s eldest has come down with the girls’ gastric bug. His dad brought him home early because he wanted to be home…. He got straight into bed. I sat down next to him and asked him how he was feeling. I could hear the tears in his voice when he said “really ill…” I could hear the forlornness in his voice; his longing for his mother to be sitting on his bed.

Dear Mommy…                                                             Words could never explain what you mean to me…It always meant so much to me that no matter how bad you felt or how sick you were, you always went out of your way to do anything and everything you could for us… Always going out of your way to make everyone’s life easier especially mine…

You were always my hero… No matter how sick you were every morning you woke up and got dressed. Even if you didn’t do anything you always looked your best…

I love you so much mommy… You made such an impact on everyone’s life that you will never be forgotten…you will forever live in our memories as the bravest woman and best Mommy of all time…

No one will ever be able to replace you…

Jared

Jared is alone today. Jon-Daniel lit candles for Vic when he arrived home. Jon-Daniel is alone today.  How can such a tiny, sickly person leave such a horrific void in our lives? A mother and a child cannot be substituted or replaced. It is as simple as this.

Precious Vic, we miss you so much!!  We are all feeling miserable without you.  We miss that incredible bond we had with you.  We want you back at home.

Chaka’s Rock and bittersweet memories….


Chaka’s Rock is a quaint coastal town on the North Coast of Kwa Zulu Natal.

We have come to Chaka’s for the past 22 years.  Vic loved Chaka’s with a passion and always said that she started missing Chaka’s from the second we packed up until we set foot here the following year.

Vic and her boys 2005

Through every possible circumstance Vic made her way to Chaka’s – with the exception of 2012.  Last year she said “Mommy, I am not going to make it to Chaka’s this year…”

2007

2007

chakas jd

In 2007 Vic had 18 abdominal surgeries.  She developed septicaemia and contracted every superbug in the book.  She was on life support on more than one occasion.  Her kidneys and lungs failed.  Vic developed an intestinal fistula.  It was a high output fistula and she lost up to 7 litres of fecal matter through the fistula daily.  The poor poppet walked around with a machine that acted as a “catchment” for the fecal matter.  Vic was on TPN (Total Parental Nutrition) and not allowed to eat anything.  Her stomach had a gaping wound with fecal matter pouring out of a hole in the intestine.

Vic spent the majority of the year in hospital and reached a stage where she appeared to be like a “lamb being led to slaughter”.  It was such a concern to us that she appeared to have lost her will to live.

Vic at Chaka's Rock - getting ready to have TPN line changed.

Vic at Chaka’s Rock – getting ready to have TPN line changed.

Chaka 2007

Vic in the lounge of the chalet.

It was such a tough decision to make whether we should discharge Vic from hospital to make the trip or not.  The doctors had different views on whether we should go or not.  Two of them felt it would be emotionally uplifting for her to go and a third thought we were “absolutely nuts!”  I am so grateful that we decided to go ahead with our annual pilgrimage, as Vic was able to spend such precious time with us.  Even the bad weather worked in our favour and we spend wonderful days playing Bingo and Trivial Pursuit.

It was extremely difficult to manage Vic’s health in accommodation other than a hospital.  Changing the TPN was a sterile procedure.

On Friday morning, the 29th of June 2007, Vic collapsed was admitted to the ICU at the Albert Luthuli Hospital in Chaka’s Rock.  Vic was transferred back to the Donald Gordon Hospital by ambulance on the Saturday afternoon. 

In a “Get better soon” card that her boys wrote her after our little holiday they thanked her for the most wonderful holiday ever!  Certainly, we had had “better” holidays in our lives but the time that we spent together was so precious.

Vic was only released from the Intensive Care Unit of the Donald Gordon Hospital on the 23rd of July 2007.

IMG_1253

IMG_1136

In 2010 I only spent a weekend in Chaka’s with Vic and the boys as I had to fly to the Middle East on business.  .  Lee drove the boys back and Vic flew home.  This is an excerpt out of an email Vic sent me…

“Hi Mommy, boys are great… We had such a great evening last and day today… Jared had Tyron over to visit. We all miss Mommy already!!!! We really hope it goes well there!!! We are all holding thumbs and saying big prayers… Battling with the authorisation for the pain Infusion still. I think I broke another vertebrae on the flight back from Chaka’s. We had a bumpy landing and I am battling to breathe from the pain… I think it’s two above the last fracture.  Can’t believe how much I miss Mommy already.                                    We are all trying to think up a name for Gramps’ new puppy… J-D is still sulking, because I won’t carry her around like Gramp’s does. Can you believe it? Jared said that when we were all in Chaka’s, she didn’t need legs as Gramps’ just carries her everywhere. And I don’t know what she was eating at Moms’ but I know it wasn’t her food, she refuses to eat it, she was so spoilt Jared reckons she lived on sweets and Gramps’ food…                          I wish we were all still in Chaka’s, it was really great to spend the time with Mommy…

chaka 3

Vic in 2012…well, that is a different post….

Caregiver Isolation


Alberton-20120625-00559It happened without warning…

In 2002 I was on top of the world.  My career was at an all-time high, financially we were secure and I LOVED my job.  I was able to work long hours and spend time with my friends.  I was on 9 Church Committee’s and very involved with community work in the poor areas.

Then it happened…Vic had her blotched back surgery and our lives changed forever.  I spent 22 days in the waiting room outside the Intensive Care Unit.  My life ground to a halt.

We moved into a downward spiral of hospitals, doctor visits, x-rays, scans, 81 abdominal surgeries, pain, open wounds, hospital bugs, sepsis and wound dressings.  I felt over-whelmed and out of control.  Doctors and nurses prodding and touching my child.  To them she was a commodity.  But, to me, she was my life.

Slowly but surely my life changed…  I became fixated with finding a “solution” to my child’s devastating health problems.  After all, I am a Baby Boomer.  We don’t accept bad situations.  We find solutions.  We sort out problems.  I refused to accept the doctors’ prognosis as I did when she was a little girl.  I was told that Vic would not live to the age of 12 when she was diagnosed as a toddler…  I refused to accept it.  Vic not only outlived the prognosis but lived to complete school, get married and give birth to two beautiful boys.  The ventilators were turned off and Vic continued to breathe, live….

We went from one doctor to the next.  I spend hours every day of my life on the internet looking for solutions and advice; it became a coping mechanism.  I worked longer hours in-between surgeries.  Quite frankly, work became a crutch.  I spent less and less time with my family and friends…I suppose because I felt no-one understood my fear, my despair, my pain…

My fear, despair and pain became my constant companion.  My computer and the internet my trusted friend…

One day, about 7 years ago, Jared asked me “Oumie don’t you love your family?”

“Of course I love my family!  Why are you asking such a question?” I replied

“Because you are never home….”

I had to sit down and reassess my life.  Quite honestly the financial implications of keeping Vic alive and care for her was daunting.  I feared going home because I could not handle Vic’s pain….  I knew in my heart there was no cure.  The mere thought of Vic suffering for endless years were terrifying!  I could not bear to see the fear and helpless desperation in the boys’ eyes.

So contrary to what I have written before, and comments that have been left, I have not been the best mother.   There was a time that I ran away.  I was petrified of the thought that Vic would suffer for another 40 years…be dependent upon me for another 40 years… There were times that I thought to myself “There has to be more to life!”  I felt lost in the in-balance of my life.  No matter where I turned it was work and responsibility!

In 2009 my Dad came to live with us.  He suffered from Alzheimer’s.

Dad and I

Dad and I

Whilst I reached a maturity level where I realized that being a caregiver is a privilege, not a burden, our lives changed.

I started sleeping downstairs many years ago when Vic was so ill.  I was scared I would not hear her if I slept upstairs.  I slowly slipped into a habit of working late on my laptop and then falling asleep on the sofa.  This continued when my Dad lived with us.  I still sleep downstairs on the sofa – waiting for Vic shuffling footsteps down the passage, text messages saying “Can I have something for pain?” or the intercom screeching!  The intercom was the 911 call.

I slowly and inextricably slipped into depression.  My entire life was dominated by my fears for my child.  The caregiving demands steadily increased as the years passed and the situation deteriorated.  It became a dark and difficult period for the entire family.  We could no longer spontaneously decide to go to dinner, go away for a weekend or even a holiday.  Every activity demanded a great deal of planning.  We became more and more isolated as a family.

It is natural for family and friends to drift away when a loved one becomes ill. The longer the illness, the longer they stay away. By it’s very nature, caring giving is draining. It is far easier to stay home and rest than socialize outside the home.  Isolation can lead to loneliness, depression, and illness. It takes energy and effort to maintain friendships when one feels tired and discouraged.

My salvation was cyberspace.  I joined an Alzheimer support group, https://www.caring.com.  Without the support group I would never had coped with my dad’s descend into Alzheimer’s.  A year ago I started blogging on Vic’s final journey.  I have found a cyber-community with parents who also lost children, friends with a word of encouragement, a kind words.   I receive advice, support and information from a loving cyber-community.

I however realize that I need re-join life.  There are days that I just want to stay on my sofa with a blanket pulled over my head.  I fear that if I sleep in a bed I will never get out of it.  In the TV lounge there is always people.  Whether it be the boys, Danie or the housemaids.

Today I had tea with an old friend.  For almost 4 years I have not been able to see her.  She has a young son that I have never seen.  Our friendship was reduced to the odd phone call or text message.  Often she would phone and there would be a crisis with Vic.  I would say “I will phone you back” and never get around to it.  I isolated myself from friends.  I was so miserable and totally absorbed with Vic that no “outsider” could penetrate my “barrier”.

My life centred round my sick child and family.

Despite the trauma of Vic’s death and coming to terms with the horrible loss, my life has changed.  I have had tea with my new Magnolia friends and Christelle.  We go out to dinner on the spur of the moment; we have been on holiday and I spent 4 days at a Spa with my sister!  I have watched Jon-Daniel play hockey matches, started gym and started remodelling the house.  I have seen a psychiatrist and take antidepressants.  We have started Stepping Stone Hospice.

How amazing is this?

If the truth be known it is not amazing at all.  I am dying on the inside.  I cry uncontrollably – mostly when everyone has gone to bed.  If the boys were not living with us it would have been so different.  I KNOW I would still have been in bed.   I am consumed with longing for my child.  Last night I replayed 100’s of voicemail messages that Vic had left me….

“Love you Mommy…”

“Love you Baby Girl”

4027 days


Vic

Eleven years and ten days ago Vic had her first blotched back surgery that lead to 81 abdominal surgeries.  She lived another 4027 days with excruciating pain, indignity and misery because of the ego and arrogance of a neurosurgeon.  Her little body systematically being destroyed by the sepsis left behind by an idiot doctor.

Dr FS, you arrogant fool, you stole my daughter’s life, you stole a mother from two young boys, you stole her smile, her joy, her laughter, her marriage, her hope!  You gave her despair, pain, a mangled broken body, faeces running out of her intestines into a bag,  an open wound.

You coward, you would not face me in the passages of the Milpark ICU.  You denied me the truth.  You stole my child’s life!

You called my child a morphine addict.  You withheld opiates from her after surgery.  You SAID that the sepsis in the Pro-disc could be stopped with antibiotics…It was not necessary to remove and replace it…. 4027 days later it took her life…. Her little body riddled with infection, her body burning up with fever!  For 4027 days she suffered!

You condemned my child to 11 years of horrific suffering and misery.  Not a single day of her last 4027 days was she without pain.

I wish you saw her tears of pain whilst she was packing her little boys lunch boxes.  I wish you heard her 4-year old son say “Don’t worry Mommy.  I made my and my brothers beds because your back is sore”.  I wish you saw the despair in her sons eyes.  She was never able to give them a “normal” life.  You ensured that they spent their childhoods in their sick mother’s bedroom and not in the garden playing ball with her…

I still hear her saying “Mommy I am so sore even my ears ache…”

What do you hear?  The crisp sound of money? Certainly not my little girl’s screams’ of pain!

If only you said those magic words…”I am sorry….”  You arrogant fool the only words you uttered were “I refuse to accept that I am the cause of Vicky’s condition…”

Coward!  I hate you.  You have my daughter’s death on your conscience.  I hope you rot in hell!

https://tersiaburger.com/2012/10/19/the-albatross/

“It is close”…


Image

Tuesday 22.1.2013 – Tonight is the first night in a long time that I lay on my sofa, in my own TV lounge, watching Law & Order.  I kept listening for the sound of Vic’s little feet shuffling down the passage…It is the first time since Vic’s death that I truly experienced the “emptiness” of the house.

The house has been so busy.  In the days preceding Vic’s death the boys went to stay with friends and family.  Vic’s suffering was too horrible for them to witness.  I did not want them to remember life ebbing out of her.  On the 15th my brother arrived from the coast and my sister from a neighbouring city.  I was in such a dazed stupor that I don’t remember them arriving.  I fell asleep next to Vic with my head next to hers, and my hand on her heart whilst the minister was saying a prayer….

On Wednesday the 16th Leeann started staying with me.  Danie, my brother, Lee-Ann and I took turns on Thursday night staying awake with Vic.  The time still passed in an absolute maze of unreality.  I knew on the 16th that Vic would die by the weekend.

Vic was still able to communicate with her eyes. She blinked when I asked her a question and her answer were “yes”.

Thursday Dr Sue came to see Vic.

“It is close” Sue said.

Murky red urine dripped into the catheter bag….  Vic’s eyes no longer closed completely… Her eyes had “broken”… she was gasping for breath.

“We must increase the Buscopan” Sue said.

“I think I have heard a rattling sound once or twice” I said

“Yes” Sue said.  “I can hear it clearly through the stethoscope”

Sue increased the pain medication as well as the sedation.

We decided to let the boys come and say their goodbyes…  Someone, I am not sure who, went and fetched the boys from school.  The boys walked into their Mom’s room.  Their eyes wide and sad.  They lay with her and whispered soft words into her ears.  They softly kissed her and walked away.  It must of been the hardest thing they had ever done.

I send Danie out to go find me a new blood pressure measure that fits around the wrist and would not hurt her little arms every time I took her blood pressure.  (Sue had one…)  I became almost obsessive in trying to ascertain where she was in her journey.  Vic was very unstable – within minutes her blood pressure went from 150/123 to LO (too low to measure) on the machine.  Her pulse was racing at 160 beats a minute.

I lay next to her with my hand on her heart.  Her little heart was pounding against the palm of my hand.  Vic was fighting with every fibre in her body to stay alive.  I looked at my child and thought “If I have her admitted to the Donald Gordon ICU they may be able to save her…” but then I realized that it was futile.  Vic was slipping away and nobody could do anything in the world to change that. Vic was dying and I was helpless.  I could not save my child.

We need a miracle again….


Daniel and Vic 29-01-07

Sr Siza examined Vic today.  She phoned Dr Sue who will be in tomorrow morning.  She also brought a script with for Dalacin antibiotics.  The cellulitis has spread to all three the subcutaneous sites.

Siza expressed her concern at Vic’s decline…

Last Friday Danie, my husband, came and sat next to me and said “I know everyone says it will be better for Vic to die than live in this pain but I was thinking how hard it will be for us without her…”

That statement really shook me.  Up until now death has been a hypothetical issue… Doctors diagnoses and prognosis…predictions…  I have never really considered living without my child.

Last week Siza and I met with the CEO of Amcare, a large community project that provide community based feeding schemes, HIV/AIDS Counselling, Home-based care, skills development, ARV Clinic, women and children shelters.   We are hoping that they will “host” our Hospice at their premises.

The CEO knows Vicky and the boys.  Jared was confirmed in his church earlier this year.

I shared with them how difficult it was to get a terminally ill person into a Hospice Program and that 95% of the dying population die in pain.  Vernon (CEO) quietly listened to us and explained how difficult fundraising is.  Christians are tight with their money…

Vernon then shared the following with us.

“In 2007 I was driving home from a meeting when I felt this urgent need to see Vicky.  I knew she was in hospital as she was on the prayer list.  I drove to the Donald Gordon (Hospital) and was directed to the ICU.  The nurses welcomed me although it was way past visiting time.”

“Pray for her.  We are switching the machines off tomorrow morning…” they said.

I stood next to her bed, raised my arms and prayed that God would spare Vicky for her little boys.  I stood next to a dead person that night.  Two days later I heard that Vicky did not die when the machines were turned off…”

I just stared at him.  I was speechless…  I had no idea!   It was the first time I had ever heard the story!

In June 2007 Vic had developed ARDS (Acute Respiratory Distress Syndrome) after a series of operations trying to close up an abdominal fistula.  Her body was excreting up to 7 litres of faecal matter a day and she had every superbug the ICU could offer.  On the Tuesday Vic went into respiratory failure and was ventilated.  I was talking to her when the doctors rushed us out of ICU and put her onto the ventilator.  By the Thursday her kidneys and liver had started shutting down.

ARDS is a severe lung syndrome (not a disease) caused by a variety of direct and indirect issues. It is characterized by inflammation of the lung parenchyma leading to impaired gas exchange with concomitant systemic release of inflammatory mediators causing inflammation, hypoxemia and frequently resulting in multiple organ failure. This condition is often fatal, usually requiring mechanical and admission to an intensive care unit.   http://en.wikipedia.org/wiki/Acute_respiratory_distress_syndrome

My BFF, Gillian drove 350 kilometres to be with me.  On the Thursday there was absolutely no sign that Vic could or would recover.  Vic had a DNR and a living will that she had provided the hospital.

That evening one of the ICU doctors, Liam, hugged me and said “Mommy, Vic is tired.  You must let her go…”

Gill, Leeann (Vic’s friend) and I went home after visiting hour to talk to the boys.  They were already in bed when we arrived home.  We sat with them

Guys, you know how ill Mommy has been….Mommy’s lungs are not able to work on their own.  Mommy’s kidneys and liver is also not working that well anymore.  The doctors feel that Mommy will not be able to breathe without the machines and that Mommy has suffered too much.  They think it will be better for Mommy to be taken off the machines…”

Jared quietly started to cry.  Jon-Daniel was stoic.  Jared was 10 years old and Jon-Daniel 8 years old.

“What will happen with us Oumie” Jon-Daniel asked.

“Sweetie, Oumie and Oupie will ALWAYS be here for you.  This is your home.”

Jared cried himself to sleep.  Jon-Daniel just clung to me.  The three of us shared a bed that night.

The next morning early Gill, Lee and I set off to hospital.  When we arrived I said “I am not going into that hospital until I have prayed in the Chapel.”

The three of us prayed and it was with absolute certainty that I KNEW Vic would not die that day.

Family and friends drifted in and out of the waiting room the whole day.  My minister came and prayed for my child.  Everyone said goodbye.

That afternoon Danie and I were allowed to see Vic.  The “invasive” ventilator had been disconnected and she had a mask-like ventilator covering her face.  It was a grotesque sight.

Danie held her little hand and his tears dripped onto her arm.

Oh sweetie” he said, the sorrow and pain raw in his voice.

Vic opened her eyes and said “Daddy”….

Three days later Vic was discharged from ICU….. It was not her time.

Today I looked at her and fear struck at my heart.  My child is slowly slipping away.  Her little body is tired of the pain.  Her little organs are enlarged and diseased.  Her bones weak….

And the realisation hit home…. We need another miracle.

God please have mercy on my child.

Where to now?


IMG_7374

The subcutaneous driver is down.  By this morning it was obvious that Vic’s tissue was just not holding up. 

On Friday morning I removed and repositioned the driver.  Serum leaked out of the syringe hole for almost two days.  The area is inflamed, hot to the touch, swollen and painful.  Cellulitis has struck!  Yesterday evening I repositioned the driver again and this afternoon I removed it.  So I will now administer the 150mg of morphine and  the 60 ml Stemitil IM.  Vic’s derriere is black and blue and lumpy from the injections. 

Where to from here?  How are we going to control this poor child’s pain?  I can only think that they will have to fit a central line…  Will they do it?  She will have to go into theatre for that!  There is absolutely no way I would allow the procedure without sedation!  Central lines are very susceptible to infection and sepsis.  

Poor baby.  She is so ill.

Today I said to my BFF, Gillian, that it is almost as if, now the decision has been made regarding “her” Hospice, she is at peace.  I sat next to her and thought to myself “I wonder if she will make Christmas?”  But then I thought to myself “Wait a minute…This is Vic…She bounces back!”

Tomorrow her doctor will come and see her, she will go onto a course of antibiotics and bounce back again.  Then we will decide how to deal with her pain…

Central venous catheter   http://en.wikipedia.org/wiki/Central_venous_catheter

 

From Wikipedia, the free encyclopedia
Central venous catheter
Intervention
MeSH D002405

Central line equipment

CVC with three lumens

In medicine, a central venous catheter (“central line”, “CVC”, “central venous line” or “central venous access catheter”) is acatheter placed into a large vein in the neck (internal jugular vein), chest (subclavian vein or axillary vein) or groin (femoral vein). It is used to administer medication or fluids, obtain blood tests (specifically the “mixed venous oxygen saturation”), and directly obtain cardiovascular measurements such as the central venous pressure.

Contents

[hide]

Types

There are several types of central venous catheters:[1]

Non-tunneled vs. tunneled catheters

Non-tunneled catheters are fixed in place at the site of insertion, with the catheter and attachments protruding directly. Commonly used non-tunneled catheters include Quinton catheters.

Tunneled catheters are passed under the skin from the insertion site to a separate exit site, where the catheter and its attachments emerge from underneath the skin. The exit site is typically located in the chest, making the access ports less visible than if they were to directly protrude from the neck. Passing the catheter under the skin helps to prevent infection and provides stability. Commonly used tunneled catheters include Hickman catheters and Groshong catheters.

Implanted port

port is similar to a tunneled catheter but is left entirely under the skin. Medicines are injected through the skin into the catheter. Some implanted ports contain a small reservoir that can be refilled in the same way. After being filled, the reservoir slowly releases the medicine into the bloodstream. An implanted port is less obvious than a tunneled catheter and requires very little daily care. It has less impact on a person’s activities than a PICC line or a tunneled catheter. Surgically implanted infusion ports are placed below the clavicle (infraclavicular fossa), with the catheter threaded into the right atrium through large vein. Once implanted, the port is accessed via non-coring “Huber” needles inserted through the skin. The health care provider may need to use topical anesthetic prior to accessing port. Ports can be used for medications, chemotherapy, TPN, and blood. As compared to CVC or PICC catheters, ports are easy to maintain for home-based therapy.

Ports are typically used on patients requiring only occasional venous access over a long duration course of therapy. Since the port must be accessed using a needle, if venous access is required on a frequent basis a catheter having external access is more commonly used.

PICC line

A peripherally inserted central catheter, or PICC line (pronounced “pick”), is a central venous catheter inserted into a vein in the arm rather than a vein in the neck or chest.

Technical description

Triluminal catheter

Depending on its use, the catheter is monoluminal, biluminal or triluminal, dependent on the actual number of lumens (1, 2 and 3 respectively). Some catheters have 4 or 5 lumens, depending on the reason for their use.

The catheter is usually held in place by an adhesive dressing, suture, or staple which is covered by an occlusive dressing. Regular flushing with saline or a heparin-containing solution keeps the line patent and prevents thrombosis. Certain lines are impregnated with antibiotics, silver-containing substances (specifically silver sulfadiazine) and/or chlorhexidine to reduce infection risk.

Specific types of long-term central lines are the Hickman catheters, which require clamps to make sure the valve is closed, and Groshong catheters, which have a valve that opens as fluid is withdrawn or infused and remains closed when not in use. Hickman lines also have a “cuff” under the skin, to prevent bacterial migration[citation needed] and to cause tissue ingrowth into the device for long term securement.

Indications and uses

Indications for the use of central lines include:[2]

Central venous catheters usually remain in place for a longer period of time than other venous access devices, especially when the reason for their use is longstanding (such as total parenteral nutrition in a chronically ill patient). For such indications, a Hickman line, a PICC line or a portacath may be considered because of their smaller infection risk. Sterile technique is highly important here, as a line may serve as a porte d’entrée (place of entry) for pathogenic organisms, and the line itself may become infected with organisms such as Staphylococcus aureus and coagulase-negative Staphylococci.[citation needed]

Triple lumen in jugular vein

Chest x-ray with catheter in the right subclavian vein

The skin is cleaned, and local anesthetic applied if required. The location of the vein is then identified by landmarks or with the use of a small ultrasound device. A hollow needle is advanced through the skin until blood is aspirated; the color of the blood and the rate of its flow help distinguish it from arterial blood (suggesting that an artery has been accidentally punctured), although this method is inaccurate.[citation needed] Ultrasound probably now represents the gold standard for central venous access and skills, within North American and Europe, with landmark techniques are diminishing.[3][4]

The line is then inserted using the Seldinger technique: a blunt guidewire is passed through the needle, then the needle is removed. A dilating device may be passed over the guidewire to slightly enlarge the tract. Finally, the central line itself is then passed over the guidewire, which is then removed. All the lumens of the line are aspirated (to ensure that they are all positioned inside the vein) and flushed.[citation needed] A chest X-ray is typically performed afterwards to confirm that the line is positioned inside the superior vena cava and, in the case of insertion through the subclavian vein, that no pneumothorax was caused as a side effect. Vascular positioning systems can also be used to verify tip placement during insertion without the need to a chest X-ray, but this technique is not yet a standard of practice.

Videos are available demonstrating placement of a central venous catheter without[5] and with ultrasound guidance.[6]

Complications

Central line insertion may cause a number of complications. The benefit expected from their use therefore needs to outweigh the risk of those complications.

Pneumothorax

Pneumothorax (for central lines placed in the chest); the incidence is thought to be higher with subclavian vein catheterization. In catheterization of the internal jugular vein, the risk of pneumothorax can be minimized by the use of ultrasound guidance. For experienced clinicians, theincidence of pneumothorax is about 1.5-3.1%. Some official bodies, e.g. the National Institute for Health and Clinical Excellence (UK), recommend the routine use of ultrasonography to minimize complications.[7]

Central-Line Associated Bloodstream Infections (CLABSIs)

All catheters can introduce bacteria into the bloodstream, but CVCs are known for occasionally causing Staphylococcus aureus andStaphylococcus epidermidis sepsis. The problem of central line-associated bloodstream infections (CLABSI) has gained increasing attention in recent years. They cause a great deal of morbidity and deaths, and increase health care costs. Historically, a small number of CVC infections were considered an acceptable risk of placing central lines. However, the seminal work by Dr. Peter Pronovost at Johns Hopkins Hospital turned that perspective on its head. Additionally, the Institute for Healthcare Improvement (IHI) has done a tremendous amount of work in improving hospitals’ focus on central line-associated bloodstream infections (CLABSI), and is working to decrease the incidence of this particular complication among US hospitals.

The National Patient Safety Goals NPSGs and specifically NSPG 7.04 address how to decrease infections.[8] The NSPG 7.04 has 13 elements of performance to decrease CLABSIs.

The 13 Elements of Performance (EPs):

  • EP 1 & 2 deal with educating staff and patients about Central Vascular Catheters and their potential complications
  • EP 3 specifically directs facilities to implement policies and practices to reduce CLABSI
  • EP 4 & 5 are about how to perform surveillance for Central-Line Associated Bloodstream Infections (CLABSIs)
  • EP 6-13:

– Institute for Healthcare Improvement (IHI) bundle

  • 1. Hand Hygiene
  • 2. Full body drape
  • 3. Chlorhexidine gluconate skin anti-septic
  • 4. Selection of Optimal site for Central venus Catheter (CVC)
  • 5. Daily review of ongoing need for CVC

– Disinfection of intravenous access ports before use

National Patient Safety Goals require documentation of a checklist for CVC insertion and Disinfection of intravenous (IV) access ports before use (scrub the hub). Some literature has suggested the use of a safer vascular access route – such as intraosseous (IO) vascular access – when central lines are not absolutely necessary (such as when central lines are being placed solely for vascular access). Infection risks were initially thought to be less in jugular lines, but this only seems to be the case if the patient is obese.[9]

If a patient with a central line develops signs of infection, blood cultures are taken from both the catheter and from a vein elsewhere in the body. If the culture from the central line grows bacteria much earlier (>2 hours) than the other site, the line is the likely source of the infection. Quantitative blood culture is even more accurate, but this is not widely available.[10]

Generally, antibiotics are used, and occasionally the catheter will have to be removed. In the case of bacteremia from Staphylococcus aureus, removing the catheter without administering antibiotics is not adequate as 38% of such patients may still develop endocarditis.[11]

In a clinical practice guideline, the American Centers for Disease Control and Prevention recommends against routine culturing of central venous lines upon their removal.[12]The guideline makes a number of further recommendations to prevent line infections.[12]

To prevent infection, stringent cleaning of the catheter insertion site is advised. Povidone-iodine solution is often used for such cleaning, but chlorhexidine appears to be twice as effective as iodine.[13] Routine replacement of lines makes no difference in preventing infection.[14]

Thrombosis

CVCs are a risk factor for forming venous thrombosis[15] including upper extremity deep vein thrombosis.[16]

Other complications

Rarely, small amounts of air are sucked into the vein as a result of the negative Intra-thoracic pressure and insertion technique. Valved insertion devices can reduce this risk.[citation needed] If these air bubbles obstruct blood vessels, this is known as an air embolism.

Hemorrhage (bleeding) and formation of a hematoma (bruise) is slightly more common in jugular venous lines than in others.[9]

Arrhythmias may occur during the insertion process when the wire comes in contact with the endocardium. It typically resolved when the wire is pulled back.[citation needed]