Tunnelled central venous line

Also known as a Broviac, or Hickman line, or often by the child as a ‘wiggly’. These are skin-tunnelled silastic catheters which are inserted, under general anaesthetic, into the subclavian or internal jugular vein (Fig. 13.1). These lines can be single, double or triple lumen with each lumen having an external clamp. The type inserted depends upon the clinical requirements of the patient.

Figure 13.1 Position of central venous line.

The Groshong catheter is a similar type of line, but it has an internal valve to prevent the backflow of blood, so does not require an external clamp.

Note: 10 mL or larger syringes are recommended, particularly when confirming patency.

Implanted port

Also known as a Port-a-Cath, Vascuport or TIVAD (totally implantable venous access device). This is a silastic catheter, inserted into the subclavian or internal jugular vein, which is attached to a metal or plastic chamber sealed at the top with a septum of self-sealing silicone. The port (chamber) is positioned under the skin on the chest wall. Access to this system is via straight or angled Huber non-coring needles through the septum of the port (Fig. 13.2).

Figure 13.2 (A) A port in situ. (B) Cross-section of a port.

Note: Always use 10 mL or larger syringes with the ports as recommended by the manufacturers.

Non-tunnelled long line

This is a short-term venous access device more commonly used in the intensive care or high-dependency setting. These lines are not skin-tunnelled and can be inserted under local anaesthetic. They are usually held in place with skin sutures. These lines can have a single, double or triple lumen. Peripherally inserted central catheters (PICC lines) are included in this category of central venous lines.

Note: 10 mL or larger syringes are recommended with PICC lines.

The type of line used for a particular child will depend upon various factors:

This is usually decided by the medical consultants in charge of the individual child’s care and is often also dependent upon the treatment protocol. Full details of the line inserted, i.e. make, model and size, should be documented in the child’s medical notes. This assists staff to obtain the correct repair kit in the event of a line break. Table 13.1 gives examples of conditions and the type of line used for each condition.

Preparation of the child and family for the insertion of any central line is essential (McInally 2005). This includes information from medical and nursing staff, plus preparatory work by the hospital play specialist if available. After discussion with the child and family, it may be useful to introduce them to another child with the same type of line.

Central venous lines can be in situ for months or even years, often in children who are immunocompromised (Cesaro et al 2004, Ewenstein et al 2004, McIntosh 2003, McInally 2005, Valentino et al 2004). As they provide direct access to the child’s central venous system, the major risk is of infection either to the exit site or the line itself with the potential for septicaemia. For this reason alone, strict aseptic non-touch procedures need to be maintained when accessing all types of central line (NICE 2003, Pratt et al 2007).

Many children will go home with these lines in situ so they and their families need to follow the same procedures and be knowledgeable about potential problems and how to deal with them (McInally 2005, Pratt et al 2007). Community nursing staff may also be involved in their care.