Your doctor may have talked to you about using a device called a ‘cuffed tunnelled central venous catheter (CVC)’. You may have also heard of these referred to as a ‘Hickman’ or a ‘Broviac’ Central line. This factsheet explains how and why they’re used.
What is it and how is it inserted?
A ‘cuffed tunnelled central venous catheter’ is a soft silicon tube that is inserted into a large vein in the neck or chest. The tip of the catheter ends in a big vein close to the heart and can stay there for a long period of time so your child can receive intravenous medicine or fluids.
There will be two small incisions (cuts) made in the skin. The first at the neck, is where the catheter is inserted into a vein (entry site). The catheter is then passed under the skin and the second incision is made on the chest where the catheter comes out (exit site). The small incisions may be stitched closed with dissolvable stitches and a dressing is placed over the catheter. If non-dissolvable stitches are used, they will be removed after 2-4 weeks. Most of the catheter will not be visible; only a small section of the catheter remains outside the body and will have one or two openings or ‘lumens’. This is where the medicine is given or blood samples are taken.
The catheter is inserted by a surgeon or an interventional radiologist. Your child will be asleep for the procedure. This usually means having a general anaesthetic. The procedure is done in an operating theatre to reduce the risk of infection. An X-ray is done after the catheter has been inserted in the operating theatre to make sure the tip of the catheter is in the right place and is safe to use.
Why would my child need a cuffed tunnelled central venous catheter?
Cuffed tunnelled central venous catheters may be inserted for the following reasons:
- Certain medicines that cannot be given any other way
- Small/difficult veins making peripheral intravenous cannulas difficult to insert or maintain
- Parenteral nutrition - method of nutrition administered intravenously
- Other long term treatment
Potential problems with insertion
- There is a risk of bleeding or oozing around the insertion site in the neck and the exit site in the chest. This usually stops fairly quickly.
- The catheter may not be in the right place (when checked on the X-ray) and it may need to be repositioned.
Is it painful?
- Local anesthetic may be injected into the surrounding area to numb the area and reduce pain.
- Oral pain relief medicines may be needed for a short period after insertion, usually not for more than 4-5 days.
- For about a week after insertion, areas where the catheter is inserted will be little sore. Once these have healed, your child should not feel any pain. If the catheter is still painful after a week please inform the medical staff.
How is this catheter kept in place?
- There is a cuff around the catheter that sits under the skin. Once the tissue under the skin grows over the cuff it helps to hold the catheter in place and prevents it from falling out. This usually takes 5-6 weeks and the catheter is at a greater risk of being accidentally pulled out during this time. This means that extra care must be taken to avoid pulling on the line until the site is completely healed.
- A clear dressing is also applied to the chest where the catheter is and the catheter outside the body is looped underneath the clear dressing. This helps in preventing the catheter from being accidentally pulled out. The dressings are changed every 7 days or sooner if they are wet, dirty or not sticking to your child’s skin.
- A securement device may be used to help support the line and protect it from movement if it is pulled accidentally. This is used for the first month, but can be used long term if needed.
- There may also be a stitch. If it is a non-dissolvable stich, it will be removed 2-4 weeks after the CVC is inserted.
Are there any changes to my child’s everyday activities because of the catheter?
- Your child will be able to resume most activities including day care and school once the catheter has been inserted and the area has healed. This depends on your child’s medical condition and treatment. Please ask your child’s medical team for advice.
- It is recommended that your child’s catheter is not submerged in water, for example swimming or bathing are to be avoided. However your child is able to sit in a bath or have a shower as long as the catheter is covered with a plastic taped bag to prevent it getting wet.
- If your child currently plays a contact sport, please speak to the doctor for further advice.
What is ‘flushing’ and ‘locking’?
‘Flushing’ of the catheter occurs when a normal saline (salt water) solution is injected into the line to prevent it from blocking. This is typically done after medicines have been given.
‘Locking’ refers to when a solution made out of anti-blood clotting agent (heparin or citrate) and sometimes an added antibacterial agent (taurolidine/Taurolock) is left in the line when it is not being used. This is typically done when the catheter does not need to be used for some time, which can be up to one week.
How is it removed?
The catheter is removed when it is no longer needed - that is, when treatment is finished, or if it is not working well, or there is another problem. The catheter is removed by a surgeon or an interventional radiologist in the operating theatre. Your child will need a general anesthetic.
Possible problems
Serious problems are very rare and most of the time this type of catheter is the best choice for your child, with the benefits outweighing the risks. However, it is important to know the risks involved before you consent to the procedure.
Bleeding
- Like most operations, there is a risk of bleeding during the insertion.
- There is a risk of bleeding or oozing around the insertion site in the neck and the exit site in the chest. This usually stops fairly quickly in the first day or two after the operation.
- Very rarely there can be bleeding into the chest (a haemothorax) or bleeding around the heart (cardiac tamponade- see below
Infection
- As with any procedure there is a risk of infection. We try to reduce the risk by making sure everything is clean and sterile in the operating theatre.
- Signs to look for include redness, pain, heat and swelling over the site where the catheter is inserted.
- If your child has a fever or is not feeling well, you will need to take them to your closest Emergency Department especially if they have a temperature of 38oC or more. The catheter may be the possible source of infection and they may need antibiotics.
- Sometimes it is possible to clear the infection with the antibiotics. However if the infection remains the catheter may need to be removed. If another catheter is needed, we may need to wait until the infection is completely cleared before inserting a new catheter.
Damage to the catheter
The part of the catheter outside the body may become damaged with a split or crack causing it to leak.
- You may notice some fluid ooze from the catheter or under the dressing.
- If this happens, the catheter can sometimes be repaired. Otherwise it will need to be removed and a new one put in.
- If you notice any damage or leaking, the line must be clamped immediately (between the exit site and the damage) and you should take your child to your nearest Emergency Department
Accidental removal and positioning
The catheter may move or be pulled out by mistake.
- If this happens, pressure should be applied over the insertion site in the neck and also the exit site in the chest and medical staff informed immediately. If at home call 000.
- Any fluid or medicine running through the catheter should be stopped and the catheter should be clamped.
- Changes in position may be indicated by difficulty taking blood or giving fluids. If we are concerned about this, further investigations may be needed. An X-ray may need to be taken to check the catheter’s position.
Blockage
A more common complication is blockage of the catheter.
- This happens if blood or medicine gets stuck in the catheter.
- To prevent blockages the catheter will either have fluid running through it or it must be locked. All lumens (channels) of the catheter must be flushed and locked every week if it is not used, to stop them from becoming blocked.
- A blocked catheter can sometimes be fixed by flushing with an anti-clotting medicine. Sometimes the catheter is too blocked and needs to be replaced.
Air bubbles
There is a small risk of air bubbles entering the catheter.
- We make sure that there is no air in the syringes used to inject into the catheter.
- If there is a break or a leak in the catheter it is important to clamp it immediately to prevent air from entering.
Blood clots
A blood clot could develop around the catheter in the vein. There is always a little bit of clotting but this rarely causes problems. If the clot is large or spreading, medicine may be needed to dissolve the clot and the catheter may need to be removed.
Very rarely there can be serious complications. These can be life-threatening.
- The catheter could damage or puncture the walls of blood vessels or of the heart. Fluid from the line, or blood could collect around the heart (this is called cardiac tamponade) or in the chest (this is called haemothorax). If either of these things happen, emergency treatment to drain the fluid or blood and fix the hole may be needed.
- A serious infection or blood clot could develop.
Before you consent to your child having a cuffed tunnelled central venous catheter, it is important to discuss these possible problems with your child’s doctor. The doctor will also explain any other risks and benefits of having the catheter.
Please feel free to talk to your team doctor about any concerns you have. Being informed will help you make the best choice for your child.
Questions
Write down any questions or concerns you would like to discuss your doctor/nurse.
