Friday, April 21, 2017

Types of Central Line Access

You are inpatient at the hospital. The pump screams “occlusion” with movement of your arm, which makes even browsing the web on your laptop a game of acrobatics. The intense treatment begins to burn your tiny veins. After the second IV in your mid-arm goes, the nurse plots the next spot of attack as her eyes scan your wrist. You await the reprieve of discharge, a relief.


But then you learn that some patients do not have the opportunity to abandon all IV treatments at the hospital—you just never thought it would be you. Thankfully, enduring intravenous therapies at home do not entail dealing with finicky, painful, and unreliable IVs. There are numerous lines that are better suited.

What line is best? Ports, PICC lines, Hickmans, Broviac—the terminology is initially overwhelming. With clarification, it will not be!


PICC Lines

A PICC line is a small, IV catheter inserted into the middle upper arm and leads to the main artery (superior vena cava) in the heart. They are best used for short term, like when access is required less than a year.


Pros -

  • Easier insertion that does not require surgery or anesthesia

The procedure is done beside or in interventional radiology. Lidocaine or twilight anesthesia (Fentanyl and Versed combination) is usually offered, but can be declined.

Read Central Line Placement Without Sedation for insight on PICC line insertion.

  • One cut for insertion

The one cut is where the catheter is inserted into the arm.

  • Minimal scarring following removal

Scarring from PICC lines are hardly noticeable. The scars are discreet in the location on the upper arm. The above link covers removal too.


Cons -

  • Prone to clotting

The catheter is narrower than the other options.

  • Slightly higher infection risk

This is because the catheter is not tunneled, meaning it does contain a cuff to secure the line in place. Instead, there is a direct access into the vein without the cuff as a barrier to prevent infection

  • Less independence

Without the use of extensions, it is not simple to maintain line care without the help of another person to sterilely connect and administer the IV therapies.

  • Must be flushed daily when not in use

Even if intravenous therapies are not done daily, tunneled catheters must be locked off (flushed with saline/and or heparin and then clamped) daily. The frequency (anywhere from once to 3-4x) is determined on the length of time not in use and if heparin-locked.

Read The Secret Weapon To No Heparin.

  • Requires Heparin Locks (IF NOT POWER PICC)

Flushing and clamping the line with Heparin acts to prevent clots in the line. This is common in the older styles. The Bard Power PICC does not have clamps and heparin use is not as imperative.



Tunneled Lines

Tunneled lines are inserted into the chest, leading into the artery (superior vena cava) in the heart to deliver intravenous medications necessary for long term. They are tunneled under the skin with a cuff. The cuff is an antibacterial barrier that holds the line in place. There are multiple types of these lines.   

The most common types of tunneled lines are a HICKMAN or a BROVIAC. The Broviac line is the pediatric version of a hickman. The general pros/cons are universal. 

Pros -

  • Less infection risk

The cuffs decrease infection risk. They provide a barrier between the line site and the vein. Bacteria must travel further past the cuff to cause infection, rather than going straight into the vein like in the case of a PICC line. The material of the cuff also decreases infection risk because it is soaked in antibacterial.

  • Independence With Chest Placement

Having the line on the chest, instead of the arm, allows for increased independence to administer IV therapies without the aid of a nurse, family member, etc

  • Decrease Clot Risk

The thicker catheter is less likely to get clogged from blood, thicker infusions, etc.

  • Long term

They are designed to remain in the chest for long term. They do not have to be replaced unless there is a problem (breaks, infection, etc.).


Cons -

  • Surgical Procedure

Placement for tunneled lines is surgery and it does require anesthesia, whether it is twilight anesthetic, general, or only a local (i.e. lidocaine). Two incisions are made, one in the site and the other near the collarbone or jugular.  

My hickman placed with lidocaine only. The following day, it was unstitched and restitched with nothing.

Central Line Placement Without Sedation briefs the surgery of Hickman (and PICC) placement and features a video of Hickman removal.

  • Reactions to cuff

There is the chance of reacting to the materials in the cuff because some are soaked in antibacterial and/or antibiotic. The materials are dependent on the brand and type line. If you have known sensitivities, it is practical to consult a medical professional prior to placement.

  • Require Heparin locks

If sensitive, this can definitely be a negative. Heparin is ideal for line care to prevent clots in hickman and broviac tunneled lines.

Read The Secret Weapon To No Heparin to learn about how to avoid Heparin without a groshong line.

  • Must be flushed daily when not in use

Even if intravenous therapies are not done daily, tunneled catheters must be locked off (flushed with saline/and or heparin and then clamped) daily. The frequency (anywhere from once to 3-4x) is determined on the length of time not in use and if heparin-locked.

A GROSHONG catheter is like a Hickman or broviac because it is a tunneled catheter.  The pros and cons are also similar. 

The TWO differences are that a groshong catheter or any line with a groshong tip DOES NOT require heparin for maintenance or clamping of the line. Routine flushing with saline locks are sufficient for preventing line clots. There is an option for a Bard PowerPort to come with a groshong catheter [see link here] if tunneled lines are not your preference and Heparin locking is an issue.



Ports

A port is an access device that is lies under the skin and must be accessed with a needle to infuse IV therapies into the catheter leading to the heart (superior vena cava) to infuse long term intravenous therapies. It is normally in the chest, but can be placed in locations under the breast or arm. It is common amongst cancer patients. 

[ x ]
Downloadable information can be retrieved here

Pros -

  • Deaccess for normalcy / Cosmetically pleasing

When not in use, the needle is pulled out of the port and all that remains is a “bump” under the skin. There is no visible catheter if not accessed with the needle. This is convenient to shower or swim when it is dangerous for the line to get wet. It is also perfect if there is a special occasion where the patient does not desire to have the port shown.

  • Very long term 

Ports can stay in for years.

  • Flushed monthly when not in use

If IV access is not needed for a prolonged length of time, the port only has to be flushed and heparin locked once a month to ensure the line is patent.


Cons -

  • Bigger surgery

Like tunneled lines, two incisions are necessary. One of those incisions is larger because the port is a contraption under the skin.

  • Infection risk controversial

One component of a port is the reservoir. The controversy is that the port is a higher infection risk in comparison to other lines because that reservoir can become a breeding area for bacteria, especially in the case of treatments like TPN (Total Parenteral Nutrition) where lipids or thicker infusions are trapped in the port’s reservoir with a high dextrose content to attract bacteria.  

Read about My Experience On Total Parenteral Nutrition (TPN) With Mast Cell Disease.

Skin bacteria can be another concern with a port, as it requires frequent needle sticks for accessing. Excessive puncture of the skin has potential to cause infection. With that being said, ports are not optimal for constant, daily access with the needle in 24/7/365. That does not mean that it cannot be done though.

Contrary to the above belief, one could say that the ability to deaccess for tasks like showering, swimming, etc. while the port is completely closed under the skin decreases infection risk.

Risk is dependent on how often the patient is accessed, for how long, what treatments they are undergoing, and many additional factors.

  • Additional materials to react to

Aside from plastics in the port body, as well as the silicone for reservoir, ports also contain a variety of metals in the body. The type depends on the brand of port being placed

  • Pain

Ports require the skin to be punctured with a needle. This is a painful process for some patients that is contingent on tolerance, scarring, etc.


Other

PICC in Chest 

There are instances where Mast Cell Disease causes it to be difficult to tolerate plastic materials that compose the lines or the antibacterial in the cuff of tunneled catheters. If the patient does well with their temporary PICC line, there is an option to place a PICC line into the chest to decrease the chances of reacting.   [see picture here]  

Essentially, it is like a Hickman or Broviac without the tunneled cuff to hold it in place. It has the cons of a PICC line because there is not cuff and the catheter is narrower, and the cons of a Hickman/broviac/groshong in needing two incisions for placement, but the pros of independence in placement location. 

Single, Double, or Triple Lumen? 

The discussed line options come with the choice of single, double, or a triple lumen. A lumen is the tube on the line leading into the central catheter. They are "entrances" with a hub to connect to the infusions. 

A single lumen is one tube. Bi-fuse extensions can be put on the end of single lumen lines to run multiple infusions. 


 A double lumen is two tubes and a triple is three. Infection risk increases with additional lumens.


The lumen amount depends on the amount of medications or infusions ran through the line, as well as capability. Medications are not always compatible to have contact. Multiple lumens make running incompatible medications safe without pausing, disconnecting, and reconnecting with a single lumen.

The type of line is dependent on the individual patient, their preferences, and their needs. There are numerous factors. A line is a heavy decision. It is nice to be informed and study experiences, but overall you choose what works for YOU! Below are just a few basics to consider.

Do you have Mast Cell Disease or a related condition? Do you also have a central line and receive or wish to receive IV therapies? Join the Facebook group IV Therapies For Mast Cell Disease + Related Conditions






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