Central-Line and PICC Troubleshooting

A central line, also called a central venous catheter, is a thin tube placed in a large vein so that its tip ends near the heart. It lets chemotherapy, fluids, antibiotics and feeds go in, and blood come out, without a fresh needle each time.

Three kinds turn up in cancer care. A PICC goes into a large vein of the arm above the bend of the elbow and threads toward the heart. It can stay in for weeks or months. A tunnelled line, such as a Hickman, enters through a small cut near the collarbone and runs under the skin to an exit site on the chest. An implanted port sits entirely under the skin, usually on the chest, and is used by pushing a special needle through the skin into it.

Each lumen, meaning each separate channel inside the line, may have its own flushing rule. Write down what you have: the type, how many lumens, and the flush plan for each.

Call emergency services (911 in the US, 999 or 112 in the UK) if:

• You suddenly become breathless, your chest hurts or feels tight, you cough, or you feel faint or confused during or just after using the line. See the air section below and act on it while help is coming.
• Blood is spurting or pouring from the line or the exit site.
• Your temperature is 38.0 °C / 100.4 °F or higher, and you feel shivery, shaky or unwell with it. The CDC uses 100.4 °F, the NCI uses 100.5 °F. Use the lower number. Fever with a line is treated as a bloodstream infection until proven otherwise.
• The line is cut, split, cracked or leaking. Clamp it first, then go in.

Call your line team or oncology unit the same day if:

• The skin at the exit site is red, sore, hot, swollen, or leaking yellow or green fluid.
• The arm, hand, shoulder, chest or neck on the side of the line swells, aches, or looks red or purple.
• You cannot flush the line, or the flush meets resistance. Never push harder.
• You cannot draw blood back when you usually can.
• The line looks longer outside the skin than it used to, or the stitch or fixing device has let go.
• The dressing is wet, loose, or dirty and you cannot replace it.

A central line runs from the outside world straight into a big vein. Bacteria that get in do not stay local. About 5 percent of people with a central line in hospital develop a bloodstream infection from it, and between 12 and 25 percent of those infections are fatal.

What it looks like at home is usually simple: fever, chills, and red, sore skin around the line. Sometimes the only sign is shaking and feeling dreadful within minutes of a flush, because the flush pushed bacteria off the inside of the line and into the blood. That is not a coincidence, and it is worth saying out loud on the phone.

Do not treat a fever with acetaminophen and go to bed. NCI says to talk with your doctor or nurse before taking medicine — "even aspirin, acetaminophen (such as Tylenol), or ibuprofen (such as Advil)" — for a fever, because those medicines "can lower a fever but may also mask or hide signs of a more serious problem."

Air pulled into a central vein can lodge in the heart and lungs. This is an air embolism, and it is the reason caps stay on and clamps stay closed. StatPearls puts it this way: "Volumes of 50 to 100 mL can trigger hemodynamic instability, with 300 mL being usually fatal." Air gets in when a cap comes off, a connection pulls apart, a line splits, or the tubing is left open while someone takes a deep breath sitting upright.

Signs are sudden: breathlessness, chest pain, coughing, wheezing, a racing heart, low blood pressure, blue lips, confusion, or collapse.

If you think air has entered:

1. Clamp the line at once, or pinch it closed against the skin.
2. Lie the person down on their left side with the head lower than the feet, if it is safe to do so. This traps air in the right side of the heart instead of letting it move on.
3. Call emergency services. Say the words "central line" and "possible air embolism".
4. If home oxygen is already prescribed and set up, use it. High-flow oxygen helps the body absorb the air.

Macmillan's instruction is specific, and it is worth learning before you need it. Try to clamp or tie the line just above the break, so the damage is sealed off from where the line enters your body. Then contact the hospital straight away.

"Above the break" means on the body side of the split, between the split and your skin. That single move stops both bleeding out and air going in. Keep a smooth-jawed clamp taped to the dressing or in your bag so it is never more than a second away. Do not use the line again, do not try to tape it up, and do not flush it to test it.

Blockage usually comes from a clot, from drug crystals, or from a kink under the dressing. Occasionally the tip has moved.

If your team has trained you to flush at home, follow the sequence they taught you and then stop. Do not force it. Forcing can rupture the line or push a clot into the circulation. Their sequence may include easing an obvious kink or shifting your position before one gentle attempt; use their version, not a general one, because it depends on your line. If it still will not go, or you were never trained to flush, leave the line alone and call.

StatPearls notes that once non-clot causes have been excluded, clinics can try to clear a blockage with alteplase or another clot-dissolving drug left to sit inside the lumen.

A line irritates the vein it sits in, and clots can form around it. The sign is swelling on the same side as the line: a puffy hand, a tight arm, a fuller neck, or veins standing out across the chest. Report it the same day. Treatment is usually a blood thinner, and the line often stays in.

• Wash your hands with soap and water before touching anything to do with the line. CDC says to scrub for at least 20 seconds.
• Wipe the end cap with an alcohol or chlorhexidine wipe every time, before every connection.
• Keep the dressing dry and intact. Change it about once a week, and sooner if it is loose, wet or dirty. Gauze dressings need changing more often, around every 2 days.
• Cover the site for showers. Do not soak it in a bath.
• Follow your own flush schedule. Macmillan says a central line or PICC that is not in active use is usually flushed once a week, but schedules differ by line and by unit, so use the one your team wrote for you.
• Avoid tugging: no heavy bags on that shoulder, no sleeping on the line, and keep the tubing looped and taped.
• Keep the exit site out of the way of scissors, razors and pets' claws.

• CDC — About Central Line-associated Bloodstream Infections
• NCBI Bookshelf (StatPearls) — Care of a Central Line
• NCBI Bookshelf (StatPearls) — Central Line Management
• NCBI Bookshelf (StatPearls) — Venous Gas Embolism
• MedlinePlus — Peripherally inserted central catheter: flushing
• MedlinePlus — Peripherally inserted central catheter: dressing change
• MedlinePlus — Central venous catheters: ports
• Macmillan Cancer Support — Central lines
• Macmillan Cancer Support — PICC lines
• CDC — Watch Out for Fever (Preventing Infections in Cancer Patients)
• National Cancer Institute — Infection and Neutropenia During Cancer Treatment
• CDC — About Handwashing