Thursday, December 8, 2016

Central Line Placement Without Sedation

An additional medical 'accessory,' like a central line, is an intimidating thought. The processes involved prompt a plethora of questions. To avoid disease progression associated with anesthetics, my central lines are placed without drugs. Being fully conscious for my PICC and Hickman placements allow for much insight on the procedures. Hopefully documenting my experiences can clarify any unknowns that accompany line placement, post-surgery, and removal. 


The Procedure(s)

Over the years, quite a few central lines have been placed into my body. They have consisted of PICC lines and two separate Bard Power Hickmans in my chest.  

PICC(s)

PICCs lines are inserted into the patient's arm. They are designed for shorter term use. Every PICC I have had was done bedside without sedation and no lidocaine. There is the option for patients to accept twilight sedatives (i.e. versed, fentanyl) and numbing (i.e. lidocaine). 

First, the nurse lays a sterile drape on top of the body and arm once disinfected with alcohol. There is a clear window to view the spot on the arm where the line will be placed. Using ultrasound, the nurse locates the vein. If ultrasound is necessary again, sterile jelly and sterile plastic covering the ultrasound wand is used. Using a sterile marker, the nurse marks the arm for insertion. They stick a needle in with a guide wire until it reaches the proper spot in the vein. The catheter is positioned over the guide wire to slide the line in place. Surrounding skin is sliced with a scalpel to fit the catheter. An x-ray confirms correct positioning.

The needle is equivalent to a glorified IV poke. Once in the vein, tugging sensations are felt from the guide wire. It has sometimes caused pain if it gets caught near the shoulder area in its travels. The painful portion of the procedure is slicing the skin and the initial force of jamming the catheter over the wire. On a 1 to 10 scale, I would rate it a 4. 
EDS TIP: If you have Ehlers Danlos Syndrome, ensure that the arm or shoulder is in a normal range of motion. The chances of the wire getting caught in the shoulder area are increased if the arm is hyper-extended. 
Bard Power Hickman(s)

My first Hickman was surgically placed while under general anesthesia for other procedures. This is how it is commonly done. However, the second hickman was placed completely awake with only lidocaine in interventional radiology. I was awake for the entire placement from the set up to stitching the line. It is somewhat similar to the above PICC line insertion. 

Alcohol and betadine disinfect the area. A sterile drape is set on top of my body. It covered my head so I could not actually visualize what was being done. There was a cutout over the area the line will go, as well as where the nurse uses ultrasound to locate the appropriate veins in the same manner as the PICC. 

The radiologist injected lidocaine into multiple areas - the neck and chest. This is the portion of the procedure I had feared the most. The neck is a delicate area, seeming as if it would immensely hurt. The initial stick was like a large IV. My fears were unnecessary because it was hardly painful. Numbing eventually took effect for the remainder of the placement. Uncomfortable sensations of pulling and tugging were the extent of the 'pain,' if you would term it as such. Two incisions were made, which I did not feel either. And a metal tool was inserted into those incisions to place the catheter. The radiologist stitched the wings down. The interesting fact is that the entire procedure of putting the line in takes about fifteen minutes. Setting up consumes the majority of the time. It was quick and easy! 

The next day, the stitches for my line were in the incorrect place. They had to be removed and the line restitched. This was without anesthesia of any kind or lidocaine because the lidocaine had caused a huge reaction. The area was extremely tender/bruised, but the pain was not nearly what I expected. The stitching with no numbing was a sharp, short-lived pain that was significantly better than the alternative reactions. 

Post Surgery 

PICC(s)

Pain from the PICC line procedure is very minimal in my experience. The incision is the bothersome part, bleeding for a few hours to days. It compares to a large cut. For a couple of days, the arm is sore. Certain positions cause nerve pain; however, this does not stem from the placement. 

Bard Power Hickman(s)

The pain after placement is what I would describe as being very similar to a pulled muscle. The pain extends from the neck into the chest/shoulder areas, depending on line location. The soreness was the worst the second day. It endured, while decreasing, for another week. Sleeping on the specific side the line is on remained slightly uncomfortable. The incision site was also tender. It burned like a cut and was sensitive for a few weeks. My main tip is to do engage in strenuous activity or heavy lifting. Unlike the PICC, there is no lingering pain when the line is removed. 

Removal

PICC(s)

Removing a PICC is nothing. With my first PICC, I was anxious about its removal though. The nurse peels off the dressing, places gauze over site, and slides the PICC line out of the vein. It bleeds minimally. There is some discomfort around the incision site at the beginning. There is no pain for the rest of the process. In my experience, I often got intermittent phantom PICC pain when the line was no longer in. It was confined to the incision area on the skin and similar to a nerve pain. 

Bard Power Hickman(s)

Pulling out a Hickman line differs drastically from the PICC. The nurse literally yanks the cuff (where the skin heals around the line) out of the body. It was not painless, but the discomfort is not lasting. Below is a video of the removal! 


Experiences vary patient to patient, as do pain thresholds. What I feel may differ from what another feels. But these types of procedures are rarely as scary as they seem!