Training is available for nursing and medical staff who wish to access these lines for blood sampling, administration of medicines, routine flushing or maintenance, e.g. needleless connectors and dressing changes. Please contact your local centre for training. Do not access the line without training.
The use of central venous access devices for children and young people (CYP) undergoing treatment for cancer is almost universal and has greatly improved their quality of life. There are a number of different factors involved when choosing a line for each patient, for example, how intensive the treatment will be and the supportive therapy they are likely require. A CVAD makes the administration of drug and supportive therapy safer and easier. These lines will also enable us to take blood samples and perform other procedures with minimum trauma to the child or young person. The central line prevents needles being continually sited into veins.
Devices most commonly used within paediatric haematology/oncology
- Skin tunnelled catheters - Hickman™ or Broviac™ line (single or double lumen)
- Implanted port - Portacath™ (single or double lumen)
- PICC (peripherally inserted central catheter), which are generally used as a temporary line before inserting a permanent device.
Portacath™ and Hickman™ lines are always inserted into children and young people in theatre under general anaesthetic by a surgeon. PICCs are occasionally inserted in the ward / PICU, but usually this procedure is performed in theatre by a doctor or anaesthetist.
All devices are recommended to be removed as soon as possible to prevent risk of infection [6]. Skin tunnelled catheters and implanted ports are removed in theatre under a general anaesthetic.
Hickman™ Line
A Hickman™ line is tunnelled from the exit site on the chest wall, under the skin to the neck, where a small incision is made and the tip of the line is inserted into the superior vena cava with the tip usually sitting at the entrance of the right atrium. There is a Dacron cuff around the line which is designed to prevent dislodgement and form a barrier against infection through formation of a fibrous tissue around it. There may also be a stitch or stitches, supporting the line at the exit site, stitch(es) may be removed between 14 and 21 days post insertion. Sometimes dissolvable stitches are used.
Contact the Principal Treatment Centre (PTC) for advice as not all centres remove stiches.
Patients wear a transparent semi-permeable dressing over the exit site of their Hickman™ Line.[5] Many Centres use a BioPatch™ (a chlorhexidine impregnated disc) around the exit site before applying the transparent dressing.
When the exit site is clean and dry it should be cleaned and re-dressed weekly. The line requires flushing with sodium chloride and locked with Heparin Sodium once a week (when not in use) to ensure patency. Each PTC has their own guidelines so please refer to these for patient advice. Hickman™ lines are often used when more intensive therapy is required, or if a child or young person has needle phobia. Patients with Hickman™ lines are unable to go swimming and have to bathe with care – showers are more advisable.
When the line is not in use it may be secured in a special bag or with tape to prevent pulling and discomfort. Bags can be obtained from the patient’s treatment centre.
Portacath™
The Portacath™ is a totally implanted device which has a reservoir made up of titanium, stainless steel or plastic. The top of the reservoir, known as the septum, is the part that is closest to the skin’s surface and is made of self-sealing silicone. A catheter is connected to the reservoir and is fed under the skin to a vein in the neck. There will be a small incision in the neck to place this catheter into the vein and position it just above the heart.
To access the Portacath™ a special non-coring needle (e.g. Gripper™) is inserted through the skin into the port. Before inserting the gripper™ needle a local anaesthetic cream such as Emla™ or Ametop™ can be used. Once the Gripper™ needle is in place it will be secured with a transparent dressing such as IV3000™.
Although this can frighten children and young people at first, they soon get used to it. Play specialists are available in hospital to help prepare children and young people for this procedure. The needle can stay in place for one week before being changed and a clear dressing is used to cover and support the needle.
When the Portacath™ is not in use, no particular care is required and it only needs to be flushed monthly. When there is no gripper needle in the Portacath™ they may go swimming (if not neutropenic), bathe, etc, although contact sports should be avoided.
PICC (Peripherally inserted central catheter)
PICC lines are fine, flexible catheters, made from silicone rubber or polyurethane. The external tubing of a PICC line is narrow and is inserted through an introducer, similar to a cannula, into the cephalic, median cubital or basilic vein in the anticubital region of the arm. The line is inserted until the tip reaches the superior vena cava. The introducer is then removed and the line is secured with a suture and / or a STATLOCK® device and dressing.
Non-tunnelled lines are inserted usually into the internal jugular vein or femoral vein and are shorter in length.
Both PICC and non-tunnelled lines should be treated the same as other CVADs.
Source: Clinical Skills Management of Vascular Access Devices Pre-course handbook. Adapted with permission from NHS Lothian Employee and Education Development Team.[3]
Potential complications
There are a number of complications that can occur both during and as a result of the insertion of a CVAD. It is the nurse’s responsibility to closely monitor the patient for signs of these complications [1] [2]. The complications listed below are those that you may come across in the community once the line is established. Full details of all complications would be discussed on a CVAD course.
| Potential complication | The cause | The signs | The management |
| Air embolus | Caused by poor insertion technique, by a lumen being open to air or potentially if a line is accidentally disconnected from the CVC lumen. It is potentially life-threatening as it can lead to cardiac arrest and death [3] | Respiratory distress Sudden collapse Breathlessness Chest pain Tachycardia Hypotension. | Seek medical help Lie patient on left hand side and elevate foot of bed (to prevent air moving from right atrium into right ventricle then pulmonary circulation). Oxygen therapy Chest x-ray. |
| Infection | Caused by poor insertion technique and CVAD management | Redness Swelling at site Pain Pyrexia Infected exudates from exit site. | Prevention and patient / parent education key. Swab site for bacteriology. Blood samples should also be taken for culture and sensitivity - from the CVAD and peripheral. Treatment as indicated. Possible catheter removal if sepsis unresolved following antibiotic treatment. |
| CVAD Migration | Occurs when the catheter moves from its original position, for example, if catheter is accidentally pulled. It is the nurse’s role to check the position of the catheter at every use. Once in situ there should be adequate securement of the device, both at the site and also of the external sets, education of the patient and parent/carer to ensure that it is not pulled and report early if there are any changes to the length of the CVAD. | Can be asymptomatic. Partial or complete catheter occlusion. Reduced infusion rate. Signs of extravasation (pain, breathlessness) Swelling of the chest wall. “Ear gurgling” (described by patients when the CVAD has been positioned in the jugular vein). | During insertion the position can be rectified. Ultrasound of the jugular vein can indicate malposition in the vessel before an X-ray. X-ray to confirm position of the tip of the CVAD. Line removed. |
| CVAD Fracture | Due to a faulty VAD set or through ‘wear and tear.’ During insertion or as a result of the pinch off syndrome (when the catheter becomes trapped between the clavicle and the first rib) rubbing over time may cause the catheter to fracture and an embolism to occur. Not clamping at the correct position on the catheter. Nicking of the catheter when removing sutures. Over screwing of the cap on to the hub, or not allowing the cleaning agent time to dry and effectively gluing the cap onto the hub which may cause the hub to crack. The CVAD should be flushed and checked by the practitioner before insertion and the nurse should closely observe the catheter for leakage when it is in use. If there is any suspicion of a faulty CVAD, medical staff should be informed and the CVAD removed and replaced. Incident form completed and incident recorded in patient records.
| Catheter damage can occur at different points along the catheter: The catheter hub Internal fracture Above or below the catheter hub. | The position of the catheter fracture will determine if the catheter can be repaired or needs removing. Prevention is key when caring for CVADs. Use 10ml or large syringes. Avoid the use of small syringes wherever possible. Monitor catheters for cuts, leaks or tears. Check the dressing for moisture or leakage at the insertion site, during infusions. Educate the patient for signs. Immediate management is to clamp the catheter and assess the damage. Catheter repair can only be performed for external catheters. This should only be carried out by a skilled trained practitioner and in accordance with manufactures guidelines. |
| Thrombosis | A thrombosis is a clot of blood that can be present at the tip of a catheter or can surround the catheter. An SVC (superior vena cava) thrombus is caused when the catheter rubs against the wall of the SVC and this provokes thrombosis at the site or a fibrin sheath. | No blood return from the catheter. Reduce flow during infusions. Pain in the area. Oedema of the neck, chest and upper extremity. Tachycardia. Breathlessness. Cough. Discoloration of the limb. | Prevention: meticulous flushing with pulsatile positive pressure flush. Constant assessment of the function of the catheter. Venogram to diagnose Thrombolytic therapy (Urokinase). Oral anticoagulants. Catheter removal. |
| Catheter occlusion | There are two main types of occlusion: Persistent withdrawal occlusion (PWO) or total occlusion. PWO is when the catheter will flush but not bleed back preventing the practitioner from checking patency. Total occlusion is an inability to withdraw blood and infuse into the catheter. | No withdrawal of blood from the catheter. The catheter may, or may not, flush. | Prevention key: Correct flushing procedure Utilising a volumetric pump for infusion management; To ascertain the cause of the occlusion NB: Chemotherapy should NEVER be administered in a line with PWO until the line has been checked by x-ray or venogram for position or signs of a blood clot or fibrin sheath at the end of the line. Written confirmation should then be documented in the patient’s case notes to signify line is safe to use. If IV competent and competent in the management of central lines, follow the algorithm for PWO as per unit policy. |
Routine care of Central Venous Access Devices (CVAD) / Specific advice
Before caring for these lines, training must have been completed and CVAD competencies achieved. Local policy should be followed when providing routine care to any CVAD. Regardless of the type of CVAD used, the principles of care for the device remain the same [4]:
- To prevent infection adhering to principles of (Aseptic) Non Touch Technique (A) NTT [5,6]
- To maintain a patent device
- To prevent damage to the device and associated equipment.
Contact the Principal Treatment Centre for specific local guidelines on the care of central venous access devices.
Troubleshooting
| Potential problem | Action | Prevention |
| Accidental removal of central line | Apply pressure with sterile swab at exit and entry site. Inform patient’s treatment centre and advise patient to attend treatment centre. | Keep line in bag or tape onto body in a loop or S or Q shape to prevent accidental pulling. |
| Cut or break in line | Clamp line above break to prevent bleeding. Cover break with a sterile swab or plaster. Seek advice from Paediatric Oncology Outreach Nurse Specialist (POONS) or treatment centre. | Do not allow children to have scissors when line exposed. Clamp the line in a different place of the designated section every time. |
| Line will not accept flush | Seek advice from Paediatric Oncology Outreach Nurse Specialist (POONS) or PTC | Adhere to flushing advice |
References
[1] Hamilton (2006) Complications associated with venous access devices: part two. Nursing Standard 20 (27): 59
[2]Dougherty, L. (2006) Central Venous Access Devices, Care and Management. Blackwell Publishing. Oxford
[3]Source: Clinical Skills Management of Vascular Access Devices Pre-course handbook. Adapted with permission from NHS Lothian Employee and Education Development Team.
[4] Royal College of nursing (RCN) (2010) Standards for Infusion Therapy. The RCN IV Therapy Forum. www.rcn.org.uk
[5] www.his.org.uk/resources-guidelines epic3: National Evidence-Based Guidelines for Preventing HCAI in NHS Hospitals in England
[6]http://webarchive.nationalarchives.gov.uk/20120118164404/hcai.dh.gov.uk/whatdoido/high-impact-interventions/