Guy s, King s and St Thomas Cancer Centre The Cancer Outpatient Clinic Central venous catheter: Skin tunnelled line

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1 Guy s, King s and St Thomas Cancer Centre The Cancer Outpatient Clinic Central venous catheter: Skin tunnelled line This information leaflet aims to help answer some of the questions you may have about your skin tunnelled line. If you have any other questions or concerns, please do not hesitate to speak to the doctor or nurse caring for you. A skin tunnelled line is a long, hollow tube inserted in one of the veins of the neck or under the collar bone. You might hear it referred to as a line, central line, tunnelled line or hickman. It has openings on both ends and the space inside the line is called a lumen. A line can have one, two or three lumens. The lumens can be found at one end of the line, while the other end, which is the tip, will sit in a big vein located just outside your heart. The lumens have clamps and bungs on them which will remain closed when not in use. These lumens will allow different drugs and infusions to be given at the same time without causing any interactions between the medications. The line is held in place by a small cuff around the central line which can be felt under the skin near the exit site (where the line comes out of your body). This information leaflet will explain why you need a line, what to do before you come in for the procedure and how to care for it when you are at home. Why should I have a skin tunnelled line? Some drug treatments, like chemotherapy, need to be given directly into a vein to allow the drug to travel around the blood stream. Certain chemotherapy drugs can cause irritation and discomfort to veins (particularly in your arms) so giving treatments through a central line can reduce irritation and make sure your treatment is given safely. As a central line is also used to take blood samples, the line can reduce the need to use needles which can make your arms sore when blood tests are taken over a period of time. Page 1 of 7

2 A central line may be used for: taking a blood sample giving medication giving blood or blood products, like platelets giving chemotherapy intravenous feeding bone marrow transplantation photopheresis (a treatment where blood is drawn out from the body and treated with light before being returned to the body). Are there any risks? Serious problems are rare while a central line is being put in and most of the time it goes smoothly. However, as with most procedures, there are some risks involved. The doctor/nurse putting in your central line will explain these to you. The most common risks are: Infection. All surgical procedures have a risk of infection. Infections can also occur any time after the central line is in place. Clot or thrombus. Sometimes a clot of blood can form around the central line. This is most common when the line has been in place for some time. Often, it is the nurse who notices a clot because the central line becomes difficult to get blood from. Some people may also notice that their shoulder or arm gets painful and swollen. Accidental puncture of the lung. Rarely (less than 1 in 100 chance), the lung can be scratched or punctured. This is called a pneumothorax and can cause air to leak into the chest. This risk is also increased when skin tunnelled lines are placed in a vein under the collarbone. Signs of a pneumothorax include: o Breathlessness after the central line is inserted o Sharp pain at the back of your shoulder Pneumothorax can be detected early by scanning the chest with an ultrasound probe and having a chest x-ray after the procedure. Usually you will be treated straight away, but if the pneumothorax is small, treatment it is not always necessary. However, we will always monitor you closely. The end of the catheter is not in the correct position. After your central line has been put in you will have an x-ray to make sure it is in the right place. If it is not, we will adjust the line to the correct position. Accidental puncture of the artery. The vein the central line is put into lies beside an artery. Occasionally, the artery is punctured. If this happens, the procedure is stopped and pressure is placed over the artery. This may cause temporary bleeding or bruising. What preparation do I need before a central line is put in? Most skin tunnelled lines are put in as a day case procedure (this means that you will not have to stay in hospital overnight.) Your doctor/nurse will tell you what time you should come into hospital to have your line inserted. You may want to bring a family member or friend as you might be sedated during the procedure. 2 of 7

3 Sedation Some patients may prefer to have some conscious sedation during the line insertion. This involves giving you a sedative through a cannula which can make you feel relaxed. This medication will not make you sleep during the insertion but will help reduce fear and anxiety. If you are having sedation, you can have light food and have something to drink before the procedure. You also need a responsible adult as an escort to take you home and look after you for the next 12 hours. A member of your hospital team will talk to you about whether intravenous sedation is a good option for you at least 24 hours before your line is put in. Giving your consent (permission) The staff caring for you may need to ask your permission to perform a particular treatment or investigation. You will be asked to sign a consent form that says you have agreed to have a skin tunnelled line. If there is anything you do not understand or you need more time to think about it, please tell the staff caring for you. Remember, it is your decision. You can change your mind at any time, even if you have signed the consent form. Let staff know immediately if you change your mind. Your wishes will be respected at all times. If you would like to read our consent policy, please tell a member of staff. What happens during the line insertion? The skin tunnelled line is inserted by a specially trained doctor or nurse. A local anaesthetic is used to numb the area where the line enters the body. You may be given sedation to help you relax during the procedure. (Image courtesy of Vygon Pharmaceuticals) A small opening is made on the skin near to the collarbone or neck to help find the correct vein. This is called the insertion site. The exit site is where the line comes out of the chest, which can be on your right or left side. After the line has been put in you will have a chest x-ray to make sure it is in the right place. You will have stitches on the skin, holding the line in place. These will be covered by a clear dressing. The dressing is waterproof and needs to be changed at least once a week. 3 of 7

4 Will I feel any pain? You may have some bruising and be a little sore for a few days. Some patients take a mild painkiller to ease this (make sure you follow the instructions on the packet). Once the bruising has gone the skin tunnelled line should be painless. What happens after the procedure? The local anaesthetic will wear off after you have returned to the day unit or ward. It is normal to feel some discomfort and you will be given painkillers to ease this. There may also be some blood on the dressing and bruising. This is all normal. The stitches close to your collarbone or neck will be removed after about seven days and the exit site stitch will be removed after about 21 days. The dressings can be changed after 24 hours. Who will care for my skin tunnelled line? While in hospital your skin tunnelled line will be looked after by nursing staff. This involves: cleaning the exit site and applying a new dressing at least once a week flushing the line every week to prevent blockages when it is not being used checking the skin tunnelled line and the area it enters your chest every day for problems with the tubing or exit site. Before you leave hospital you will be shown how to care for your line, including how to flush your line to prevent blockages when it is not being used. You will also be given enough cleansing wipes, dressing packs, dressings and saline filled syringes for you to use until your next hospital appointment. If you need a district nurse to flush your line, we will arrange this before you go home. If you have any problems at home, please ring us using the numbers at the end of this leaflet. Caring for your skin tunnelled line at home Showering. Use a transparent dressing as this will usually keep the exit site dry during a shower. Having a bath. Bath water is not as clean as shower water so if you have a bath, please make sure to keep the exit site out of the water. Sports. Sports like tennis, golf or strenuous gym exercises should be avoided. There is a risk your skin tunnelled line could become dislodged due to a lot of upper body movement. Your doctor/nurse can advise you about other sports which are acceptable. Caring for the exit site To prevent infection your line must be kept clean and dry at the exit site and also at the end where the bung is attached. While the stitches are in place you should change the dressing once a week, or more frequently if the dressing becomes soiled, loose or wet. Nurses on the day unit or ward can teach you, a family member or friend how to change the dressing and give you anything you need. 4 of 7

5 Alternatively, we can arrange for a district nurse to change the dressing for you. Once the stitches are removed, you do not need to have a dressing. Keeping the skin tunnelled line working If your line is not always being used, the plastic clamp must stay closed. Remember to check it is closed every day and that the bung on the end is securely attached. Flushing your line regularly will also help to prevent it becoming blocked. We recommend your line is flushed once a week. The bungs at the end of your line should be changed at the same time (weekly). The day unit or ward nurses can teach you, a family member or friend how to flush your line. Alternatively, we can arrange a district nurse to do this. If you experience a cold and shivery attack during or after flushing your line, contact the hospital immediately. This could be due to an infection in the line. The line is in a large vein close to your heart so it is important to treat any infection as soon as possible. You should also contact the hospital straight away if: you experience pain, redness or swelling in your arm or neck on the same side of the body as your line the cuff or line has moved you feel breathless your skin tunnelled line becomes damaged or develops a leak. How to flush your line Your hospital nurse should already have shown you or the person flushing your line (for example a family member or friend) how it is done safely and correctly. The person should feel happy and comfortable and be familiar with the equipment given to you by the hospital. Instructions These instructions are a prompt or reminder of the steps the hospital nurse showed you. They are based on flushing a double lumen skin tunnelled line. You will have been provided with all the equipment needed from the hospital. 1. Gather together the following items. o Two pre-filled saline syringes o ChloraPrep -3mL or ChloraPrep antiseptic wipes o Two bungs o Dressing pack o Gloves 2. Find a clear area, for example, a table or desk and make sure the surface is clean. 3. Wash hands thoroughly with soap and water. Dry your hands. 4. Open the dressing pack. The dressing pack is sterile, so try to unwrap it by touching the outside only. Peel open the syringe packaging and bungs, and drop onto the open dressing pack. If needed, open additional wipes and drop on dressing pack. 5 of 7

6 5. Wash hands thoroughly with soap and water and dry them. 6. Put on gloves. 7. Remove old bung and put on new bung. Do this to all lumens. 8. Clean end of new bung with the ChloraPrep wipe. Discard the wipe. 9. Attach syringe and inject contents slowly. Do this for all lumens. 10. Clamp lumens immediately after flushing. If you are feeling resistance or finding difficulty injecting the fluid, stop immediately. Do not force any fluid in to the line. This could damage your line. If you have any problems, call the hospital. How is the skin tunnelled line removed when it is no longer needed? The line is removed by releasing the cuff which holds it in place under the skin. A local anaesthetic is given to numb the area around the cuff. A small cut is made to release the cuff and the line is removed. Frequently asked questions Who puts the line in? Where is the central line? How long can it stay in? Can I bath and shower? Will it leave any scars when removed? Can I swim with it? Do I need to have the dressing changed? Does it need to be flushed? A specialist nurse or a doctor in a dedicated procedure room or interventional radiology It exits the body from the upper chest wall Many months Yes but you should not submerge your chest or the tip of the line in the bath Yes No Yes once a week until healed Yes once a week 6 of 7

7 Useful contact numbers Guy s Haematology Day Unit t: Haematology Clinic t: Guy s Chemotherapy Day Unit t: St Thomas Chemotherapy Day Unit t: Samaritan Ward (24 hours) t: Hedley Atkins Ward (24 hours) t: Advanced Nurse Practitioner for Central Access Devices t: Macmillan Cancer Support t: w: www. macmillan.org.uk Dimbleby Cancer Care is the cancer support service for Guy s and St Thomas. They have drop-in information centres, and also offer complementary therapies, psychological support and benefits advice. Drop-in information centres are located at Guy s in Oncology Outpatients (Ground floor, Tabard Annexe) and at St Thomas on the Lower Ground Floor, Lambeth Wing. t: e: RichardDimblebyCentre@gstt.nhs.uk Guy s and St Thomas hospitals offer a range of cancer-related information leaflets for patients and carers, available at PALS To make comments or raise concerns about the Trust s services, please contact our Patient Advice and Liaison Service (PALS). Ask a member of staff to direct you to PALS or: t: at St Thomas t: at Guy s e: pals@gstt.nhs.uk Language support services If you need an interpreter or information about the care you are receiving in the language or format of your choice, please get in touch using the following contact details: t: fax: e: languagesupport@gstt.nhs.uk Knowledge & Information Centre (KIC) For more information about health conditions, support groups and local services, or to search the internet and send s, please visit the KIC on the Ground Floor, North Wing, St Thomas Hospital. t: of 7 Leaflet number: 2840/VER2 Date published: November 2012 Review date: November Guy s and St Thomas NHS Foundation Trust