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What is a central line?
A central line is a special soft plastic type of intravenous (IV) catheter that can remain in the body for a longer period of time than a typical peripheral intravenous (PIV) catheter placed for shorter periods in the hands, arms, feet, or sometimes, the scalp. The central line is a means of giving IV medications, fluids, nutrition and taking blood samples without having to endure multiple needle sticks. The tip of the central line usually resides near or at the junction of a large vein and the heart. In this area of very rapid blood flow, fluids and medications are rapidly transported and distributed to and throughout the body. A particular advantage of the C-line over a PIV is that it is much less likely to infiltrate (come out of or erode through) the vein and, therefore, in the absence of complications, does not have to be replaced and can be left until no further access to the blood stream is required. Another advantage is that the C-line is usually placed in a spot that leaves the arms and legs free and does not interfere with the motion and function of these extremities.
Why might a child need a central line?
There are many reasons. After a time in the hospital, there may be few, if any remaining sites for PIV placement. These tinier veins can be “used up” by prior IVs or your child may be a difficult IV access problem.
In some children, a prolonged course of IV treatment may be anticipated and a C-line may be recommended even before peripheral sites have been depleted. Examples of this include: (1) various infections which may need weeks (or more) of IV antibiotics; (2) numerous intestinal conditions which leave the child unable to eat, requiring IV access for intravenous nutrition or total parenteral nutrition (TPN); (3) numerous malignant (cancerous) conditions in which vascular access is required long-term for administration of chemotherapy; (4) repeated hospitalizations for acute exacerbations of chronic conditions in children with difficult IV access problems; (5) various other disease (such as hemophilia) in which IV medications and/or blood or blood products may be intermittently required for months or years; (6) any condition for which your doctor believes that long-term vascular access is required for effective delivery of IV treatment
What are the different types of central lines available?
While all C-lines have the above features, there are several different types available, each with their own advantages and disadvantages. The specific type utilized in your child will be determined by a combination of factors, including your child’s diagnosis, surgeon preference, anticipated duration of IV therapy and whether treatment at home will require IV therapy. Some of the different choices available include:
A Broviac catheter is a soft silicone central line that has only one lumen (or inner pathway). It is generally utilized for infants or smaller children, although it is available in several different sizes (or lumen diameters). It is generally used for infants and smaller children who have smaller veins, but it may also be appropriate for older children if only one lumen will be required for treatment. It is generally placed by a pediatric surgeon, usually in the operating room. This catheter can be placed at various sites including the neck, upper chest and groin areas. The end of the catheter exits the body and can be accessed with no discomfort or pain to your child. To stabilize the catheter and also minimize the potential for infection, this catheter is tunneled through some subcutaneous (under the skin) fat before it enters the vein and travels toward the heart. The catheter has a Dacron cuff in the subcutaneous portion which attaches by scar formation to surrounding tissue soon after placement which further anchors the device and decreases the likelihood of inadvertent or accidental removal. In the absence of complications, this catheter may remain in place for weeks or months (and sometimes years) until it is ready to be removed.Generally, these catheters are placed by a pediatric surgeon.
A Hickman catheter is identical to the Broviac catheter except it has 2 lumens (a double lumen catheter). This catheter looks like the letter “Y” since the two separate lumens connect to a single catheter (even though the 2 lumens remain separated inside the joined portion of the catheter. This allows the delivery of two fluids and/or medications through the catheter, occasional simultaneously. With this catheter, an ongoing infusion (such as TPN [see above] or another treatment) does not have to be interrupted to begin a second IV medication or perform a phlebotomy (drawing blood for testing). This catheter is usually placed in older children or patients who require chemotherapy for various malignancies.
Portacath (or Mediport)
A Portacath is a central line in which all of the components are subcutaneous (beneath the skin). This device has a reservoir which usually resides on the chest wall and allows easy access with a special non-coring (Huber) needle. The reservoir is connected to a catheter much like the Broviac or Hickman catheter (see above) which tunnels under the skin, into the vein and toward the heart. The reservoir is raised, thus it is easy to see and feel, thus needle placement is easy and precise. The skin can be prepared with special anesthetic cream to minimize discomfort during needle placement; however, after a number of “sticks”, fibrous (scar) tissue will form around nerve endings and accessing the port reservoir will be progressively less painful. The advantage to this system is that there is much less chance of inadvertent or accidental removal of the catheter than with the external varieties; also, the infection rate (see Complications) is lower because there is no skin opening which would allow bacteria to enter. A disadvantage is that removal of a Portacath does require a return trip to the operating room since it is entirely beneath the skin. Portacaths are placed on the majority of, but not all, oncology (cancer) patients. These devices are also placed by a pediatric surgeon.
A PICC (Peripherally Inserted Central Catheter) is a long, straight catheter which enters the body from a peripheral site (such as the arm [most common] or leg) just like a normal peripheral IV (PIV) but travels up the entire vein of the extremity and ends in the chest near the heart or in a major vein within the abdomen. These catheters may be placed by a pediatric surgeon, an interventional radiologist or specially trained nurses. They are most commonly utilized when total time of required IV access is more than two or three weeks. They avoid some of the possible complications of other central lines because the needles used to place them pass into a small vein in an extremity rather than into a large vein near major organs (such as the lung). A PICC line can easily be removed in an office or at the child’s home.
Non-tunneled Central Lines
A non-tunneled central line is generally placed on hospitalized patients who may need secure intravenous access for shorter periods of time, but they are not appropriate for very long-term utilization or after hospitalization treatment at home. These are places in several locations such as the neck, chest or groin and enter directly into the vein without tunneling through tissue under the skin.
How are central lines placed?
The placement of the line is usually done under general anesthesia in the operating room. This will allow sterile conditions and the greatest precision. On occasion, the line can be placed under sedation in the hospital on the Pediatric Floor or Pediatric Intensive Care Unit (PICU). If your child is to go home with a C-line, you (and your child, if he or she is old enough and can understand) will be taught how to take care of the line. It is important to know how to flush the line daily to keep it from clotting and how to change the cap and dressing once a week. This will be explained and shown to you by nursing staff and, possibly, home-health nursing services.
Are there complications of central lines?
Yes, there are potential complications of C-lines, both in their placement and in the course of their existence in the body. To place a catheter into the chest, a needle is placed into the subclavian vein located beneath the clavicle (collar bone). This can result in bleeding (on very rare occasions, severe/life-threatening) or pneumothorax (collapsed lung) since the vein is located very close to the lung. This latter complication may require a tube thoracostomy (placement of a chest tube) to evacuate the air compressing and collapsing the lung.
Infection is a possible complication of central lines. In general, the longer a line is in place within the bloodstream the greater the likelihood of an infection. This infection may be apparent on the skin or may be on the internal portion of the catheter within the bloodstream. Infection may occur due to introduction of bacteria from the skin at the site the catheter enters the body. Also, it may travel to the catheter within the bloodstream from infection elsewhere, thus “seeding” the catheter which then may become an independent source of infection itself. Antibiotic treatment may eradicate these infections; however, in instances where the infection can not be eliminated, some consideration may have to be given to removal (explantation) of the catheter, even if intravenous access is still required for your child’s medical condition. In those cases, after removal, a peripheral IV is usually placed and a second central line is considered when the infection clears.
Thrombosis (clotting) may occur within or outside of the catheter. These devices are designed to react minimally with the blood, but foreign bodies of any kind within the bloodstream have the potential to generate clots. These, in many cases, are much easier to prevent than they are to treat. If a catheter does clot, flow through it can be impaired or blocked completely. Several medications are available which may lyse (dissolve) the clot and restore patency (free-flow) through the catheter but, if these fail, catheter removal will be required.
When will my child’s C-line be removed?
Generally, a central line is removed when all of your child’s treating physicians feel that it is no longer needed and vascular access is not required. These physicians will probably involve a team of doctors, including surgeons, infectious disease specialists, oncologists, gastroenterologists and others. Because of the difficulty, risk and potential complications associated with the placement and use of a C-line, it is better to have the line and not need it than to need it and not have it due to premature removal. Therefore, it is best to remove these devices when there is a reasonable expectation that a further C-line will not be required.
Pediatric General Surgery
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