Central Line Placement and Removal

What is a central line?

A central line is a catheter (a thin tube) that is placed in a vein for long-term use. It can be placed in the neck, but may also be placed in the groin or chest. When a catheter is intended for long-term use, it is usually “tunneled” under the skin. Some catheters have an attached cuff that allows tissue and skin to grow around it, giving the line more stability, other catheters are placed completely beneath the skin The two most common type of lines place by a pediatric surgeon include a Port-a-Cath and a Broviac (Hickman or Leonard) catheter. The choice of catheter depends upon the frequency of and type of use, size of patient, and other factors that will be discussed by your doctors.

Port –A- Cath:
consists of a reservoir compartment (the portal) that has a silicone bubble for needle insertion (the septum), with an attached plastic tube (the catheter). The device is surgically inserted under the skin in the chest and can be felt as a bump under the skin. It requires no special maintenance and is completely internal so swimming and bathing are allowed. The catheter runs from the port and is surgically inserted into a vein (usually the jugular vein or subclavian vein) and follows the course of the vein into the superior vena cava, the major vein entering the heart. This position allows infused agents to be spread throughout the body quickly and efficiently. Additionally, because the vein is at is widest here, agents like TPN (total parenteral nutrition), and chemotherapy drugs mix efficiently with blood and do not damage the vein.

The port can be repeatedly accessed using a special needle which goes through the skin into the reservoir of the port. Prior to “accessing” the port, the skin overlying it is anesthetized with a desensitizing cream. When the port is not accessed, a small amount of heparin is instilled into the reservoir to keep the blood from clotting the line. This should happen once a month if the line is not in frequent use.

Broviac:
The internal portion of the Broviac and Hickman catheters are identical to the Port-a-Catheter. They both allow a soft special type of rubber (silicone) catheter to be placed in your child without the need for repeated placement of intravenous catheters in the extremities. Identical to a port, a Broviac catheter is placed directly into a central vein, usually in the neck, upper chest or groin. The catheter tip is positioned in the superior vena cave, the largest vein in the body, just above the heart. The catheter is then tunneled under the skin and brought out on the chest or thigh away from the site where it enters the vein. This placement diminishes the chance of bacteria from gaining access to the central portion of the catheter. Finally, Broviac catheters contain a dacron"cuff" which is buried under the skin. Your child's tissues will grow into this "cuff" and allow the catheter to become more stable, which will reduce the chance of it becoming pulled out.  The cuff also helps to decrease the migration of bacteria from the skin along the catheter. In between uses, a small amount of heparin is instilled into the catheter to keep the blood from clotting the line. Unlike a port, broviac catheters need to be flushed daily. Because a portion of the catheter is external, swimming and bathing (soaking) are not allowed while the catheter is in place.

What is it used for?

Tunneled central lines are used when we need access to a vein over a long period of time (anywhere from two weeks to several months). Some medications cannot be given through regular IV lines and require frequent, painful needle insertions. A tunneled central line is a more comfortable way for the patient to receive medications such as chemotherapy or nutrition and fluids, and also allows the medical team to obtain blood samples without placing a new IV.

What will happen in the hospital?

The procedure itself will take about an hour in the operating room. The surgeon will insert the catheter into a vein, usually in the neck or chest, and thread it into the large vein that carries blood into the heart. This will be done under fluoroscopy (x-ray) so that the position of the catheter is visualized during placement. Your child may have an x-ray in the recovery room to confirm placement once the line is inserted in order to allow the line to be used.

When will my child be discharged?

Your child will most likely be discharged the same day if it is an outpatient procedure once they are fully awake after the anesthesia. On occasion, depending on your child’s diagnosis, the primary team may choose to admit your child for the initiation of therapy.

What should I look out for after the operation? Hospitalization?

After the tunneled central line is inserted, your child will be able to resume most activities, including day care and school. Your child should not be lifting anything greater than ten pounds for one week. After that time, the port-a-catheter has no restrictions, but swimming or bathing are restricted with Broviac lines because they are external. Children with Broviac catheters should be discouraged from activities such as contact sports and rough playing which may inadvertently pull line and lead to damage or loss of the catheter. Broviac catheters will require sterile dressing changes which will be taught to you by specialized practitioners in the hospital. Your role in changing dressings may vary according to hospital policies and visiting nurse services. A Port-a-cath requires no special dressing if it is not accessed, once the primary dressing placed during the procedure is removed.

When can I remove the bandages?

Your child will have two bandages, one over the insertion site (usually at the neck), and one over the catheter at the exit site or at the site of implantation of the Port-a-Cath (typically on the upper chest). After one week, you may remove part of the bandage at the insertion site. Take off the gauze and the clear bandage. The steri-strips (white strips) should not be removed. They should fall off on their own within two weeks. The bandage over the catheter must remain clean and dry at all times. It should be changed once a week. The bandage may be changed at appointments or family members may change it at home if they have been trained to do so. Do not remove the bandage if you have not been trained.

When can my child bathe after the catheter is placed?

Your child should not take a shower or bathe until instructed to remove the bandage at the insertion site. After that, your child may shower or bathe with the catheter-site bandage in place. If showering, your child should face away from the spray so water does not hit the catheter directly. If taking a bath, keep the bandage above the water. The clear tape is water resistant not water proof.

How is a central line removed?

Most frequently, removal of Port-a-Caths are performed with general anesthesia with the additional administration of local  numbing medicine.  Broviac catheters can be removed either in the operating room or at the bedside. Options pertaining to Broviac removal will be discussed with you by a doctor or nurse practitioner.

When can I remove the bandage after the catheter is removed?

The bandage must stay in place for one week. Then you may remove the gauze and clear bandage. The white steri-strips should not be removed. It is safe for the incision to be open to air while the steri-strips are falling off. If the steri-strips haven’t fallen off after ten days, you may remove them. Once the incision has healed and the steri-strips have fallen off, there is no need to place any type of dressing or covering over the site.

When can my child bathe or shower after the tunneled central line is removed?

Your child shouldn’t take a shower or bath for 48 hours, until you have removed the gauze and clear tape unless specifically allowed by your doctor. After that baths and showers are OK. If showering, your child should face away from the spray so water does not hit the site directly. If taking a bath, your child should keep the site above the water. Once the steri-strips have fallen off your child may shower or bathe as usual.

Additional Option for Central Line Access - What is a PICC line?

A PICC line (Peripherally Inserted Central Catheter) is a special IV that is placed in your child’s vein that helps give your body medicine, fluids and nutrition. PICC lines last longer than standard peripheral intravenous devices and are usually placed in your arm above the elbow. Your child will be able to move your arm and play, and will allow for less blood draws and new IV’s. The priniciple difference between a standard IV catheter and a PICC line is the length of the catheter. The PICC line is much longer and is able to travel to the large veins of the chest.  These veins are able to support the presence of an IV for a very long time.

Why does my child need a PICC?

It is used when your child needs IV medicines or fluids for a long period of time (greater than a week but usually less than one month). Your child may have a PICC line only during the hospital stay or he or she may go home with the PICC line in place depending on how the duration of their need for therapy.

What will happen in the hospital/how is the PICC line placed?

A specially trained doctor or nurse will place your PICC line either at the bedside or in interventional radiology. Depending on your child’s age, he/she may receive some light sedation to allow him/her to relax and stay still during the procedure. The nurse or doctor will insert the line in a sterile setting.  Your child’s skin will be cleaned with a sterile soap and the area will be covered with a sterile cloth. After the procedure your child may get an X-Ray to make sure the PICC is in the right place.

What will be my child's recovery?

There is very little recovery time when a PICC is placed. Depending on if your child gets medication they may be a little sleepy, but should wake up soon after. If no sedation is given, recovery is immediate. After the procedure, Tylenol or Motrin may be given for mild soreness if needed.

How will my child's PICC be cared for while in the hospital?

The nurses caring for you will change the dressing over the PICC after the first 24 hours, and every 7 days or when needed according to hospital policy. The dressing helps to keep the area clean and dry. The PICC may not go under water, so baths need to be avoided. Showers are allowed if the PICC can be kept covered. Sponge baths can be given. If the dressing looks wet, it must be changed to prevent infection. If the PICC is not connected to an IV bag, the nurses will flush it with heparin, a special medicine to prevent it from clotting. How often and what type of medicine depends on the type of catheter they have inserted. If your child is getting medicines, then it will need to be flushed after the medicine has been given.

What should I look for after the procedure? What if my child goes home with the PICC line?

If your child goes home with a PICC line you will be taught to do some of the care. This includes administering heparin to prevent clotting and the other medicines your child needs (for example; antibiotics). A nurse from a home care agency will come to the hospital to teach you what you need to know. They will do all of the dressing changes at home. Some patients may have their dressing changed during a clinic visit. The nurses from the hospital will go over the teaching to be sure you are comfortable with everything you need to do. If you notice the line cannot be flushed, or if there is any redness or swelling at the site, you should contact your visiting nurse agency or doctor.