Bye Bye Broviac

Manny has a central line called a broviac. It’s a small tube or straw-like device that goes inside a vein and delivers medicines near the heart.  A broviac central line catheter is made of silicone.  In his case, his is measured as a 4.2 which is about as thick as a fat spaghetti noodle inside. 

This broviac is his only source of nutrition.  Most kids eat by mouth.  Some eat by a tube in their stomachs.  A few “eat” only by IV.  It’s called Parentral Nutrition.  And if it’s the only thing you get, it’s called Total Parentral Nutrition or TPN. 

He needs to get his TPN 21 hours every day or his blood sugars go dangerously low.  During the 3 hours off, he gets other medicines in it … iron, heparin (clot preventer), ethanol (prevents bacterial growth), antibiotics, steroids, pain meds, blood, fluids, breathing meds, etc.  So basically it’s in use 24 hours a day. 

The catheter exits right at the skin in his chest.  The cuff like pieces are 3 of the repairs.  The one closest to his skin was the first one only 3 months after the line was placed.  The lowest (and cleanest) one was his 5th repair.  The discoloration on the older ones is from Iodine which is what we use to keep this area sterile and it's a staining dark red. 
This site is usually covered by a clear dressing.

These lines were designed for short term use.  They were designed for a medicine here and there.  They were NOT designed to be in basically 24 hour a day use with “caustic” substances. 

Some of those medicines I just mentioned are very hard on a line.  Stuff gets “stuck” to the insides of the walls of the catheter and then it makes it more difficult to get medicines in or blood out.  Periodically, he needs a medicine called TPA or Cathflo to help clear the sludge out of the line.  And in some cases, the buildup of gunk causes there to be so much pressure, nothing can get through and the line will break. 

In Manny’s case, this line was placed on February 7, 2012.  That makes the line over 2 years old.  It’s quite impressive how hard this little sucker has worked.  During that time, I’ve lost track of the number of times he’s needed TPA to clear the line.  And he’s had 6 breaks.  (Ironically, none of the breaks were at my hand. They all happened to be in the hands of a nurse.) 

His 6th break.  See the green scissor like device? It's a clamp called a Hemostat. It's what's there to prevent his line from bleeding.  Until we got that on, I had to pinch it as blood was pumping out with every heart beat.

During that time, he has also had NO line infections.  That’s incredible.  For a kid with intestinal failure, gi issues, the constant use of the line, the number of breaks, and other issues … this is amazing.  We contribute it to a couple of things.  One is impeccable line care.  I was taught by the best on how to care for the line and I (nicely) make sure everyone else who handles his line does the same.  And we use the Ethanol Lock Therapy (ELT).  This is a fairly newish procedure.  But basically .3 (that’s about 3 drops) of 70% Ethanol (a type of alcohol) goes into his line.  It stays there for about 2-4 hours.  We then withdraw it out of the line.  It’s a miracle!  But it’s also very, very hard on the line and makes the silicone weaker.  

Between all these factors, we are THRILLED that he has had this line in for over 25 months. 

But … now the line is so brittle and sensitive that a simple flush with saline broke the line.  This is after only 3 weeks ago, they cleaned it out with a medicine and a wire. 

So it’s time that we get a new line. 

What does that involve?                                                                                                                            

When Manny had his last broviac removed, it had only been in for 3 weeks and 2 days. So it was “easily” removed by a surgeon at the bed in ICU.  It took only a few minutes and left a very tiny scar.  (It got removed because it was infected and was making him sick.)

Main issues:

• This one has been in for so long… it might be complicated to get out.
• We have to get a new line in a vein.  The last time they put this one in, they said it was VERY tricky to get it in the vein. 
• He might not have any viable veins in his chest.  The only other options are in his legs.  (Needless to say, this is not a pleasant or easy option.)

So prior to the surgery, we will be doing a few tests.  Mostly to see if there are any veins in his chest that look like good options. 

The surgery plan will likely be:

• Get the old one out safely.
• Try to put the new one in the same vein.  (we know the vein works, why not try to use it?) They will attempt to put a wire in the vein to keep it open to basically “hold its place” and then put the new catheter in the vein.   This is option one for many reasons but mostly because it doesn’t “Use” another vein. 
• If that doesn’t work, the surgeon will attempt to put a new catheter in another vein in his chest.
• If that doesn’t work, he will find any vein he can get. 

This surgeon isn’t someone who has operated on Manny before but we are confident he is the man for the job. 

After surgery … he will be monitored in the hospital.  Not sure how long yet.  That will depend on how quickly Manny recovers and how difficult the surgery was. 

Then we hope the new line will be as good to us as this one was.