Introduction
A cuffed tunnelled central venous catheter (CVC) is a soft, silicone tube inserted into a large vein in the neck or chest. The tip of the cuffed tunnelled CVC ends in a big vein close to the heart and can stay there for a long period. The other end of the cuffed tunnelled CVC sits outside of your child’s body.
The cuffed tunnelled CVC is used to give medicine or fluids directly to your child’s bloodstream and is inserted when your child:
- needs certain medications that can only be given through a cuffed tunnelled CVC
- has small or difficult veins
- needs to have parenteral nutrition – a method of providing nutrition through the veins
- is having treatment that will go for longer than 2 weeks.
The cuffed tunnelled CVC is also called a Hickman, a Broviac or a central line.
Before the procedure
The cuffed tunnelled CVC is inserted by a surgeon or an interventional radiologist while your child is under a general anaesthetic. General anaesthetic means your child will be asleep and will not feel any pain during the insertion.
Before the procedure, your child’s treating team will give you information including:
- when they need to stop eating and drinking
- what time to arrive at the hospital
- what to bring with you.
They will also answer any questions about the cuffed tunnelled CVC, how it is inserted, how to look after it and what to do if something goes wrong at home.
During the procedure
Generally, the steps for inserting the cuffed tunnelled CVC are as follows:
- the surgeon or radiologist makes 2 small cuts in the skin at the neck and on the chest
- the cuffed tunnelled CVC is inserted into the cut in the neck and passed under the skin until it comes out through the cut in the chest
- the cuts are stitched to close around the cuffed tunnelled CVC
- a dressing is placed over the cuffed tunnelled CVC
- an X-ray is done to check that the tip of the cuffed tunnelled CVC is in the right place, and the catheter will be repositioned if needed.
Only a small section of the catheter stays outside the body. It will have one or two openings, also called lumens. The lumens are where medicine, fluid and nutrition are passed through, and blood is taken from.
After the procedure
Your child may have some bleeding or oozing around the cuts in the neck and chest, but it should stop soon after the surgery.
If the surgeon uses dissolvable stitches, they will break down in the skin over time. If the surgeon used non-dissolvable stitches, they will be removed after 2-4 weeks.
Your child may have pain after the procedure that should improve after about a week. The doctor may inject some anaesthetic to numb the area and reduce pain. The hospital will tell you about pain relief medicine that can be used at home.
Let the doctor or nurse know as soon as possible if the cuffed tunnelled CVC is still painful after a week.
The cuffed tunnelled CVC is held in place by using:
- a small cuff that sits around the cuffed tunnelled CVC and sticks to tissue under the skin over 5-6 weeks.
- a clear dressing on the chest where the catheter is, with the outside of the catheter looped underneath. The dressings are changed every 7 days or sooner if wet, dirty, or not sticking to your child’s skin
- a securement device that supports the line and protects it from movement.
Your child will need to take care, particularly in the first 5-6 weeks, not to move or pull the cuffed tunnelled CVC so it does not come out.
Management
Returning to everyday activities
Once the cuffed tunnelled CVC has been inserted and healed, your child should be able to return to regular activities depending on their medical condition and treatment. Your child’s treating team will give you information and advice about any changes to lifestyle, activity, or sports.
Your child should not submerge their cuffed tunnelled CVC in water, for example, swimming or bathing.
Showers and baths are okay if your child has their cuffed tunnelled CVC covered with a taped plastic bag to stop it from getting wet.
Flushing and locking
Flushing is when a normal salt water or saline solution is pushed into the cuffed tunnelled CVC by a syringe. This helps to stop it from becoming blocked and is done after medication has been given.
Locking is when an anti-blood clotting and antibacterial solution is left in the cuffed tunnelled CVC. This is done when the cuffed tunnelled CVC does not need to be used for up to one week and stops an infection from happening and the line from becoming blocked.
Removing the cuffed tunnelled CVC
The cuffed tunnelled CVC is removed when:
- treatment finishes
- the line is no longer working well
- there is another problem.
A surgeon or an interventional radiologist removes the catheter while your child is under a general anaesthetic.
Common problems with the cuffed tunnelled CVC
While serious problems are rare, knowing about the risks is important.
Bleeding
There is a risk of bleeding or oozing around the cuts in the neck and chest after the cuffed tunnelled CVC is inserted. This usually stops quickly in the first day or two after the operation.
Very rarely, there can also be:
- a hemothorax – bleeding into the chest
- cardiac tamponade – bleeding around the heart.
Infection
Infection is always a risk when there are cuts or openings in the body, as germs can get inside. The hospital will ensure everything is clean and sterile, or free of germs, in the operating theatre when the cuffed tunnelled CVC is inserted.
Signs of infection include:
- redness
- pain
- heat
- swelling
- a temperature of over 38 degrees.
If your child shows signs of infection, take them to the nearest emergency department as soon as possible.
Infections are treated with antibiotics. Your child may need their cuffed tunnelled CVC removed or replaced if the infection is severe.
Damage to the catheter
It is important to check the outer tubes and lumens in your child’s cuffed tunnelled CVC for any damage or cracks.
Damage can cause the cuffed tunnelled CVC to leak, and you may see fluid or oozing under the dressing.
If this happens, clamp the line immediately and go to your nearest emergency department so it can be repaired or replaced.
Accidental removal and positioning
If the cuffed tunnelled CVC is moved or pulled out accidentally, you should:
- stop any medicine or fluid from running through the cuffed tunnelled CVC
- clamp the line
- apply pressure over the insertion cut in the neck and the exit cut in the chest
- call triple zero (000) for an ambulance
- call your child’s doctor while you wait for the ambulance to arrive.
You may be able to tell that the cuffed tunnelled CVC has moved if it becomes more difficult to take blood or give fluids. If this happens, tell your child’s doctor as soon as possible and follow their instructions.
Blockage
The cuffed tunnelled CVC should be flushed after every use and flushed and locked weekly if not used.
Blockage can be fixed by flushing. If this does not work, the cuffed tunnelled CVC must be replaced.
Air bubbles
Make sure no air bubbles are in the syringe when injecting into the cuffed tunnelled CVC. If there is a break or leak, clamp the line immediately to avoid air getting in.
Blood clots
Blood clots can develop in the vein around the cuffed tunnelled CVC. Blood clots should not cause any problems and can be dissolved with medication if they become too large or spread. If clots cannot be treated, the cuffed tunnelled CVC may need to be removed.
Serious complications
Serious complications are rare but can be life-threatening.
These can include:
- serious infection
- the cuffed tunnelled CVC damaging or puncturing the walls of the blood vessels or heart
- cardiac tamponade - fluid or blood collecting around the heart
- a hemothorax - fluid or blood collecting in the chest.
Your child may need further surgery to fix serious complications. Speak to your child’s doctor if you have any questions or concerns about complications from the cuffed tunnelled CVC.