Advanced Lines

Authors: Alexandra Cottrell, Claire Fitzgerald / Editors: Charlotte Davies, Liz Herrieven / Codes: / Published: 25/02/2020

“Pre-alert: 18-year-old with bleeding from a hickman line. Currently haemodynamically stable, but still bleeding.”

We’re great at getting access in the ED – we’ve got our ultrasound to help and when that doesn’t work (despite utilising all the tricks in January’s blog), we might insert a central line (only takes 30 seconds, right?), or an intraosseous device. But occasionally, our patients turn up with indwelling IV access and encourage us to use them. Or occasionally, we can’t get any alternative access, but our patients won’t let us use their indwelling devices. There are a few problems with these lines – how do we know which they are? Can we use them? What do we lock them with? Obviously each trust will have its own policy – here’s some collective knowledge!

What sort of problems do lines have? Well, all lines may get infected; it is possible for thromboses to form in the vein, usually at the tip of the line; if not appropriately managed, air can get in the line causing an air embolus; and lines can get broken or cut.

Blocked Lines

One of the biggest problems is blocked lines – lines may be blocked by residual drug, parenteral nutrition or clotted blood. When a line is blocked, the problem is sometimes resolved by a change in the patient’s position (lying down, raising an arm, coughing or sitting up). As long as a line is flushed once a week in the community (every shift whilst an inpatient) it can be safely used. Ports need to be flushed once a month.


Infected Lines

Infection is another big risk – beware of rigors within half an hour of the line being used, local signs of infection (ie erythema at site, oozing, pain out of proportion) or systemic indicators of infection such as tachycardia, fever or hypotension. You should take a blood sample from the line for culture but be sure to take a peripheral sample from the opposite arm, at the same time. Leave the line in place if in doubt about whether it’s infected. An “antibiotic line lock” might be another option if it’s a PICC line (maybe for post-ED care, but worth knowing either way). The antibiotic and time length would be guided by micro advice pending culture results, but basically it’s pushing 2mls of antibiotic into the line, clamping it (and thereby creating positive pressure), and leaving it.

Bleeding Lines

Back to the 18 year old though: if it’s bleeding from the line, find out when was it put in. Are they still haemodynamically stable? If they are, fine. If not, give treatment as for many other bleeds – consider platelets, packed red cells, vitamin K and/or tranexamic acid (TXA).

If it appears to be a more straightforward bleed from around the site, a topical TXA dressing (sterile gauze soaked in TXA, under a tegaderm), or any absorbable dressing (e.g. alginate) would be a good first step. It goes without saying that anything involving direct contact with the site should be sterile. Dressing changes must be aseptic non touch technique (ANTT).

I’d like to put a copy of this on every hospital ward ? pic.twitter.com/F3tToVqEv9

Dave Naumann (@davidnnaumann) June 1, 2018

Incidentally, if it’s a Hickmann line, they are likely to be an oncology patient (or on parenteral nutrition) therefore check platelets, FBC and clotting to assess if that’s why they’re bleeding.

For anyone presenting with an alternative access device, get a full history of the line along with your usual clerking. Be sure to ask:

• What line is it? (!)
  
• When was it put in?
  
• Measurements of the line, particularly if the patient thinks it’s migrated
  
• Any trauma to the line?
  
• Any historical issues with the line? Is today’s issue something which has come up before? (e.g. some are always ‘sluggish’)

 

 

 

 

 

 

 

 

 

N.B. These patients are generally very familiar with their lines and will be able to answer the above questions reliably. They will be very protective of their line and potentially very wary of someone unknowingly damaging it.

As a rule of thumb, most Hickmann, PICC, Tesio lines and ports are safe to use if:

• Regularly used
• Not obviously blocked
• Good history
• Presenting complaint is not line related
• No obvious signs of infection
• If the patient is unconscious or unable to provide history, then following a chest XR to check positioning: Hickmans, PICCs and ports should sit in the distal SVC or cavoatrial junction
• A functioning line should be easy to aspirate and easy to flush

If aspiration isn’t possible e.g. due to patient or line position, or fibrin sheath (patients generally won’t know if they have one of these), flush 5-10mls of normal saline (in a 10ml syringe so the pressure’s not too high) using a stop-start technique.

Tesios may have anticoagulant line locks therefore it’s important to always aspirate these lines before use no matter what. They should be easy to aspirate as they’re frequently used so aspirate-DISCARD!-flush.

If a clot causes the blockage, gentle irrigation and aspiration can usually dislodge this with a 10ml syringe half-filled with heparinised saline. How you make heparinised saline is line dependent; the heparin lock amount is determined by the line length, so can be between 5000-2500u heparin for the longest lines; generally for a heparin lock in a tesio line = 5000units/1ml so 2ml for each lumen.

This may take a few minutes but be patient. Under no circumstances should an attempt be made to force fluid through the line. If irrigation fails, thrombolytic agents may be used – 2ml urokinase is the most common. Use 10,000 units diluted to 2mls with saline and put it into a line lock to help with sluggish picc lines for 30mins+. Anecdotally the longer you leave it the better the results (which isn’t fully understood as the urokinase would have become inactive after 2 hours or so). Each line has different priming volumes these may be documented on the side of the line. Generally, PICC = 0.5 mL, skin tunnelled catheter = 1 mL, port = 3 mL. Use this volume + 1.5ml.

Is advised that only specifically trained nursing or medical staff should perform this procedure. A 10ml syringe must be used to reduce the risk of damaging the catheter. If the clot cannot be aspirated, seek specialist advice and repeat the procedure leaving the Urokinase in place overnight. Your oncology nurses are likely to know more about this than you – if in doubt, ask!

We’ll stop here and consider the different common lines – be aware that a midline is basically a long cannula but looks like a PICC as they’re both placed in the upper biceps. Midlines also usually won’t have an orange Securacath (see photo) which are more commonly found on PICCs. Patient history is key. You can’t usually take blood from a midline, because of its cannula-like ways, and it’s often vein dependent too.

Image from bmjopen.bmj.com

As a rule, if the line meets the safe to use rules, blood can be drawn from them (hooray!) and they can be used to give drugs/fluid/blood products. To be clear, that includes PICCs, Hickmanns and ports. ANTT must be strictly observed when drawing blood off. You should then discard 10mls to clear the flush, take your samples, then flush with 10mls normal saline (using a start-stop technique).

Accessing a Portacath (port):

A good history is essential – again patients are often protective of their device and so, if able, will be able to give a sound history. Ports can only be accessed by needles specific to their size. Your patient may have these themselves, and will bring them to hospital if able.

Port needles relate to the depth of the port and where it’s placed, therefore should only be accessed using specialist equipment and training. If these are available and it’s flushing etc, these can be used for blood samples, medication, fluid and so on.

There’s a short video from the don’t forget the bubbles team here.

Types of Line

PICC lines

PICC Line: Image courtesy of Wikipedia

PICC lines are Peripherally Inserted Central Catheters that are inserted into one of the large veins of the arm near the bend of the elbow. It is then threaded into the vein until the tip of the line sits at the lower wall of the Superior Vena Cava. They’re inserted under radiology guidance, and can easily be removed. PICCs can be either open ended or valved. A non-valved catheter will have a clamp in situ which will need to be closed when not in use. PICCs can have single or dual lumens and each lumen is separate along the full length of the line – these 2 lumens should be treated as two separate catheters when flushing.

Hickman lines

Hickman lines are central venous catheters that are long, hollow tubes made from silicone tubing. They are tunnelled under the skin of the chest into a vein. The tip of the tube sits in either the internal jugular vein (and on occasion, the subclavian vein), before it enters the heart. The other end of the line hangs out of the body in the anterior chest wall. They are inserted under radiology guidance and removed by specialists. You can identify them as they are found on the chest wall and you can palpate the line tunnelling under the skin. They shouldn’t be removed except by those trained in their use there is a cuff that anchors the line which involves cutting down to clamp the cuff and closing with sutures (in Trendelenberg position, whilst applying pressure to the internal jugular).

Midlines

PICC vs Midline from Wikipedia

Midlines are short term peripheral access devices, known as a “long cannula”. The tip of the cannula is situated in the axillary vein. They are indicated for treatments lasting for up to four weeks. They do not require x-raying prior to use and have a decreased risk of extravasation. They are used mainly for intravenous antibiotic use, although slow fluids can also be infused. They can also be used to take samples for blood tests and blood cultures.

They are inserted under ultrasound guidance, with a similar technique to cannulation. They should also be removed in a similar way to cannulas.

They look like PICC lines.

Portacaths

Portcath: from FLIKR

Portacath: Wikipedia

Portacaths are totally implantable venous access devices used for long term medication administration. A Portacath consists of two parts, a tunnelled line and an injection port. These are connected together underneath the skin. The tunnelled central venous catheter is a long, thin, hollow tube. One end of the tube (the distal end) sits just near the entrance to the heart. The other end connects to an implantable port that sits just under the skin, usually on the upper chest. The port is about the size of a 10 pence coin and is about 1 cm thick. A Portacath is the most discrete form of long term access as the entire device remains under the skin. They can be left in place for months or years.

“Accessing” them is easy if you have the right access needles and are trained. Sometimes patients will bring their own needles, and some can access their own device ready for you.

More issues with long term venous access lines:

Catheter migration: If a patient presents saying they think their line has migrated a chest x-ray is the most appropriate action at this time before the line can be used (usual locations: PICC, Hickmann and Portacaths should all be in the SVC, Tesios should be in the SVC with a visible distance between the two lumens – midlines do not need XR, if they’ve migrated they won’t be flushable – otherwise it has tissued).

Leakage from the catheter: The catheter could be damaged. Stop any medication and organise a linogram to determine blockages or fractures in the internal part of the line. Check the external length (which sits on the chest wall) for fractures visible to the eye. If the leakage is from an obvious split in the external part of the line, clamp above the damage immediately. Hickmans and Tesios can be repaired using a repair kit and must be done by a trained professional. PICCs will need to be removed and replaced.

Thrombosis: This might present as pain and swelling, often across the chest and neck, tracking down the tunnelled part of the line or at the exit site. An ultrasound doppler needs to be arranged ASAP. Consider starting the patient on low molecular weight heparin if there are no other contraindications (contact pharmacy for advice if needed). Lines can be used despite the presence of a clot, but this decision would require senior medical input.

After you’ve finished accessing a line?

The line should then be locked most people use heparinised saline 500 international units heparin in 5 mL 0.9% sodium chloride.

Heparinised saline is infrequently kept in the ED. Your local friendly ICU will often have heparin.

How to remove an intravascular device

Central lines have a risk of air embolus during removal, so the patient should be lying flat with the head of the bed tilted down (Trendelenburg position) and holding his/her breath during the removal to maintain a high intra-thoracic pressure. You should clean the site, then gently remove the device. The site should then be covered with a sterile air occlusive dressing.

PICCs and Midlines do not have the same risks of embolus, so should be removed in the same way as you’d remove a cannula.

Hickman lines should be removed by experienced staff only.

There’s a summary of different lines here.

Oh, and the bleeding hickman line? The ambulance crew solved that problem they found a “cap” and thought it looked like it should be attached. They re-attached it, and the bleeding stopped. Funny that. What would we have done if it didn’t? This is likely to be a non-compressible haemorrhage, so early consultation with the thoracic team with a view to thoracotomy was our plan b!

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