DEPARTMENTAL POLICY AND PROCEDURE
Program:
University of Michigan Cardiovascular Medicine – Pulmonary Hypertension Program
Procedure Title:
Guidelines for Hickman Catheter Infection in Patients on Intravenous Flolan™
(Epoprostenol)/Remodulin (Treprostinil) Veletri (Epoprostenol)
Procedure Written:
July 2011
Reviewed/ Revised: July 2011
Procedure Statement / Purpose: To provide guidelines for safe and timely management of infections
I.
Presence of Drainage, Redness or Pain Over Catheter Exit Site of Skin
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Obtain wound culture (even if there is no obvious drainage). Locate the catheter under the skin.
Run your finger down from the subclavian area towards the exit site in an attempt to “milk” some
drainage for culture.
Obtain blood culture and sensitivity through the catheter. ***See next page for instructions on drawing
sample from Hickman with Flolan/Remdoulin/Veletri infusing.*** If the patient has a double lumen
catheter, obtain blood cultures from both lumens and label culture bottles with the lumen site from
which they are obtained.
Obtain a CBC with WBC differential through the catheter.
Obtain one set of blood cultures through a peripheral vein and label it accordingly.
Institute dicloxacillin 500 mg four times a day orally until cultures come back. If patient has a
penicillin allergy, substitute with clindamycin 450 mg orally every 6 hours.
Instruct patient to obtain and record oral temperature three times a day.
FAX culture results to the Pulmonary Hypertension Program RN’s at (734) 763-7390.
For positive culture as follows
1. ID should be consulted for infections with s aureus (MSSA or MRSA) to help with duration
of therapy and further testing for possible endocarditis or embolic seeding.
2. ID involvement should also be considered with candidemia, enterococcus bacteremia, or
bacteremias that do not clear quickly, especially after line removal.
 Is this wound or blood
 If blood is positive – Need IVAB DC/PO x 10 days
 If site – PO Meds X 10 days
 If C-S, micrococcus, bacillus, most NR etc treat x 14 days
 Staphylococcus aureus and candida approximately treat x 14 days – check
with MD and ID
 If sustained bactermia (all S.aureus) need to r/o endocarditis. Candida needs
an opthy exam
 Catheter exit sit infections looks close to back to normal before stopping
meds.
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II.
Presence of Fever/Chills (With or Without Redness and/ or Drainage Over Exit Site of Skin)
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III.
Kefzol for all gram positive except MRSA/ vanco if pcn/cephalosporin
allergy
 Kefzol 2 grams 3x a day or nafcillin thru a pump (one patient action every 24
hours) both are more effective than vanco
 Kefzol for all susceptible staph infections. Other gram positive organisms
(like micrococcus or S. pneumonia, enterococcus) require different
treatments.
Obtain another set of blood cultures 48 hours after the last dose of the antibiotic.
Obtain wound culture (even if there is no obvious drainage). Locate the catheter under the skin.
Run your finger down from the subclavian area towards the exit site in an attempt to “milk” some
drainage for culture.
Obtain blood culture and sensitivity through the catheter. ***See next page for instructions on drawing
sample from Hickman with Flolan/Remodulin/Veletri infusing.*** If the patient has a double lumen
catheter, obtain blood cultures from both lumens and label culture bottles with the lumen site from
which they are obtained.
Obtain a CBC with WBC differential through the catheter.
Obtain one set of blood cultures through a peripheral vein and label it accordingly.
Place a PICC line and infuse Flolan/Remodulin/Veletri via PICC. Disconnect but DO NOT
FLUSH Hickman catheter.
Institute vancomycin 1 gm intravenously every 12 hours. Benadryl prophylaxis is to be instituted for
any patient with documented vancomycin sensitivity. If there is a history of gram negative
infections in the past, start gentamicin IVPB in combination with vancomycin until cultures come
back (gentamicin loading dose of 2 mg/kg IVPB and maintenance dosing of 1.5 mg/kg IVPB every
8 hours. Adjust dose as necessary for renal insufficiency.
Treat positive culture results for four weeks if uncomplicated Staph Aureus (with vancomycin, if
susceptible); two weeks of coverage if organism is Staph Epidermis. If culture does not isolate any
gram negative organism eliminate the gentamicin.
Antibiotics are to be infused through the central line (Hickman catheter). If the catheter has a
double lumen and both lumens are infected, antibiotic infusion should be alternated between the
two lumens.
Infuse the Flolan/Remodulin/Veletri through a PICC line, until the infection is cleared.
Repeat blood cultures (catheter and peripheral) 48 hours after the last dose of the antibiotic.
If cultures are negative, remove the PICC line and change Flolan/Remodulin/Veletri infusion to
Hickman catheter.
Repeated Systemic Infections with Hickman Catheters and/or the Presence of a Tunnel
Infection
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The catheter should be removed if the patient presents with a recurrent infection within two weeks
following antibiotic therapy and cultures isolate out the same organism, or if the patient presents
with an extensive tunnel infection as described by swelling of the subclavian area over the catheter,
redness, purulent drainage, warmth, and/or fever.
Replacement catheter should be a single lumen Hickman catheter.
Nurse clinicians will reinforce aseptic technique with patients.
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***Obtaining Blood Samples from a Hickman Catheter with Flolan Infusing***
- Only to be done by PH Nurse 
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Discontinue the Flolan/Remodulin/Veletri infusion, and place a sterile cap on the pump tubing.
Draw off 10 ml of blood and discard.
Draw off blood as needed for culture (10 ml per culture bottle/ culture bottle tops wiped with alcohol prep
pad/ inoculate the aerobic bottle first).
DO NOT flush the catheter with saline. Flushing the Flolan/Remodulin/Veletri line with saline could
potentially bolus the patient with Flolan/Remodulin and result in a fatal event.
Clean the catheter tip with an alcohol wipe first, and then directly connect the catheter back to the extension
tubing of the Flolan/Remodulin/Veletri infusion.
After the Flolan/Remodulin/Velteri infusion is reconnected, instruct the patient or patient’s family member
to “prime” the Hickman tubing with 0.75 ml of the Flolan/Remodulin/Veletri infusion…………….This is
done (while the pump is “off”) by pressing and holding the PRIME button on the CADD Legacy-1 pump.
After you see the word PRIME and three sets of dashes on the screen, release the PRIME button. Then
press and hold the PRIME button again for 7 out of the 10 beeps during the priming cycle. This will prime
approximately 0.75 ml of fluid into the catheter.
Ensure the pump is “on” and check the infusion.
MD Signature:
___________________________
Date: ____________
Val McLaughlin, MD
Medical Director, CVM Pulmonary Hypertension Program
Nurse Signature:
___________________________
Date: ____________
Janice Norville, MSN, MSBA, RN
Director of Clinical Operations – CVM – Special Programs
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