Skin Tunnelled Lines

  • Reference Number: HEY-612/2017
  • Departments: Nutrition Support

Introduction

This leaflet has been produced to give you general information about your procedure.  Most of your questions should be answered by this leaflet. It is not intended to replace the discussion between you and your doctor, but may act as a starting point for discussion.   If after reading it you have any concerns or require further explanation, please discuss this with a member of the healthcare team caring for you.

What is a skin tunnelled line?

A skin tunnelled line is a long, hollow tube inserted into one of the veins in the neck or under the collar bone. You might hear it referred to as a ‘line’, ‘skin 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 or two lumens. The lumens can be found at one end of the line, while the other end which is the tip will sit in a large vein located just outside your heart. The lumens have clamps and bungs on them which will remain closed when not in use. 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 do I need a skin tunnelled line?

A skin tunnelled line allows you to receive Parenteral Nutrition (PN) or Intravenous Fluids (IVF) that could cause damage if given through one of the smaller veins in your arms and will prevent you having other lines placed for your ongoing treatment.

Can there be any complications or risks?

Serious problems are rare while a skin tunnelled 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 putting in your skin tunnelled 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 skin tunnelled line is in place.

Clot or thrombus

Sometimes a clot of blood can form around the skin tunnelled 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.

Patients identified for Home Parenteral Nutrition or Home Intravenous Fluids to refer to the Patient Manual, Training guide and the Home Parenteral Nutrition Trouble shooting guidance for further information.

Accidental puncture of the lung

This is rare but the lung can be scratched or punctured. This can cause air to leak into the chest. This is called a pneumothorax.

Signs of a pneumothorax include:

  • Breathlessness after the skin tunnelled line is inserted.
  • 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 skin tunnelled 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 skin tunnelled 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.

How do I prepare for the skin tunnelled line?

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.

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.

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.

What will happen?

The skin tunnelled line is inserted by a specially trained doctor. 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. 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. Insertion site sutures to be removed 7 days post insertion and exit site sutures to be removed 21 days post insertion. This will be covered by a clear dressing. These will be changed at least once a week.

Should I feel 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 will happen after the procedure?

The local anesthetic 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 dressings will be changed after a 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, you will go through a training package with your nurse. If you are unable to care for the line, we will organise a healthcare team of registered nurses to look after your line. If you have any problems at home, please ring us using the numbers at the end of this leaflet.

Caring of 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

Bathwater is not as clean as shower water so if you have a bath please make sure to keep the exit site and the end of the line 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. Also swimming is not advised with a tunnel line as you would not be able to keep the exit site or end of line out of water and could increase the risk of infection. Your doctor/nurse can advise you about other sports which are acceptable.

Exit site

To prevent infection your skin tunnelled line must be kept clean and dry at the exit site you should change the dressing once a week or more frequently if the dressing becomes soiled, loose or wet.

Keeping the skin tunnelled line working

If your skin tunnelled 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 with normal saline. You will be trained how to complete this or if you are unable to care for your line the homecare team will complete this for you. The bungs at the end of your line should be changed at the same time (weekly).

Possible problems

You should contact your nurse Monday to Friday between 7:00am – 4:00pm or Ward 11 at Castle Hill Hospital after 4 pm and at weekends for any of the possible problems.

Infection:

It is possible for an infection to develop inside the line or in the area where it goes into the vein.

If you notice any swelling, or redness, along the vein above the insertion site.

Leaking of Parenteral Nutrition (PN), Blood or Fluid:

If you notice any leaking from the line it may be a hole that has developed in the line.

Line Blocked/infusion stops:

Your infusion of Parenteral nutrition (PN) or Intravenous Fluid (IVF) will not flow through the line, or you are unable to flush using normal pressure.
Report any difficulties flushing your line to your nurse.

The line breaks or you accidently cut the line:

You notice a cut or tear in the line. Contact your nurse who will arrange a repair or replacement of your tunnelled line.

Air in the Tunnelled line entering the bloodstream:

You may suddenly have difficulty breathing, experience chest pain, dizziness or confusion. Stop the infusion and immediately clamp the catheter.

  • Contact the emergency services
  • If possible lie down with your head lower than your hips and feet until assistance arrives.

Should you require further advice on the issues contained in this leaflet, please do not hesitate to contact the Nutrition Nurses via switchboard – (01482) 875875 Bleep 771 CHH or 640 HRI, or direct on the mobile phone number 07827 937025.

After 4pm and Weekends/Bank Holidays please contact Ward 11 CHH on (01482) 623011.

General Advice and Consent

Most of your questions should have been answered by this leaflet, but remember that this is only a starting point for discussion with the healthcare team.

Consent to treatment

Before any doctor, nurse or therapist examines or treats you, they must seek your consent or permission. In order to make a decision, you need to have information from health professionals about the treatment or investigation which is being offered to you. You should always ask them more questions if you do not understand or if you want more information.

The information you receive should be about your condition, the alternatives available to you, and whether it carries risks as well as the benefits. What is important is that your consent is genuine or valid. That means:

  • you must be able to give your consent
  • you must be given enough information to enable you to make a decision
  • you must be acting under your own free will and not under the strong influence of another person

Information about you

We collect and use your information to provide you with care and treatment. As part of your care, information about you will be shared between members of a healthcare team, some of whom you may not meet. Your information may also be used to help train staff, to check the quality of our care, to manage and plan the health service, and to help with research. Wherever possible we use anonymous data.

We may pass on relevant information to other health organisations that provide you with care. All information is treated as strictly confidential and is not given to anyone who does not need it. If you have any concerns please ask your doctor, or the person caring for you.

Under the General Data Protection Regulation and the Data Protection Act 2018 we are responsible for maintaining the confidentiality of any information we hold about you. For further information visit the following page: Confidential Information about You.

If you or your carer needs information about your health and wellbeing and about your care and treatment in a different format, such as large print, braille or audio, due to disability, impairment or sensory loss, please advise a member of staff and this can be arranged.