How we clean and manage my son's central line to keep him safe from infection.
My son has a single Hickman line. For the uninitiated, a Hickman line is a type of central line. It is essentially a plastic tube, placed by a surgeon, into the chest for delivering chemo drugs, fluids, and transfusions. It goes through the skin and into the superior vena cava, so the drugs go right into the heart and are pumped through the body. This keeps the chemo drugs from sitting in one spot too long where they can do even more damage to the body.
The exposed end of the Hickman, the lumen, has three key pieces, the clamp, the Cap, and, well another cap--I'll call this one the blue cap. The clamp does exactly that, clamps the end so that when you change the caps there is still some barrier between the heart and the outside world.
The Cap screws onto the end of the lumen and is where the drugs are delivered. It has a silicone plunger like piece inside of it that pushes up when a syringe or other delivery device are screwed into the Cap as another barrier. The Cap needs to be changed once a week, generally this is done at the oncologist's office, because they need to replace it every time they draw blood (which is at least once a week). Finally, we have the blue cap.
The blue cap is exactly what it sounds like, a cap that screws into larger, longer Cap to protect the end. The inside of the blue cap has a sponge saturated with alcohol to assist in keeping the opening of the Cap clean. The blue cap needs to be changed every time The Cap is accessed, which is at least once a day when when the Heparin flush is administered at home. The Heparin is diluted with saline, and is used to keep clots from developing in the line.
A Hickman is a direct line from the outside world to the heart, so it is important to keep the line and site (location where the tube enters the skin) very clean. The dressing has to be changed once a week, and the site has to be thoroughly cleaned with Cloraprep. This is the best time to really look at the site and make sure there are no significant changes or signs of infection, like swelling, bleeding or and pus or discharge. (If there is call your oncologist's office immediately.) After the Cloraprep dries a bandage goes over the site. Then we wipe the line down with alcohol to clean it.
If your child has a central line, it is also important to bathe them everyday. (A short aside: Now, I am sure a lot of people are like, "Well, isn't that normal?" Yes, but stop and think about the times when your baby skips a nap and then crashes 2 hours before bedtime. Imagine having to wake them up to bathe them, when normally you would probably skip that one night. Not fun.) That means sponge baths, since you cannot get the site wet. (We use hibiclens in the hospital and occasionally at home too.) In my experience sponge baths take a considerably longer time including set up and tear down.
In an adult a Hickman can get caught on stuff like clothing, doors,or random objects and get pulled out of the skin. Now, I want you to imagine what could happen with a baby who is learning about their own body, learning to roll over, crawl, stand, and walk. I'll wait.
So yeah, scary, right?
I have heard stories from nurses about babies and toddlers ripping them out, chewing holes in the plastic, siblings or playmates pulling them out, parents accidentally cutting or yanking the line... Ugh. Apparently this type of thing is so common that we got a primer on what to do when each of these things happened. (Apply pressure to site, secure the line above the hole, and call the hospital immediately--in case you were wondering.)
So how do you try to avoid this? With tape (lots of tape) and ingenuity. I think every parent develops their own strategy when it comes to securing the Hickman. I am a taper, out of necessity. Our Little Buddha is a grabber. My husband and I have often had to grab the line out of my son's hand to keep him from pulling on the lumen or sucking on the end of the caps. There are a few products out there like the Hickman Hider, a pretty cool tube-top like design with a pocket for the lumen, which I think would work great for some kids. We live in Hawaii, where it is pretty warm most of the year, Little Buddha runs hot, and he tends to grab at the actual dressing and site as much as the ends, so not a great option for us.
He has a long line, so we pull the clamp down low, so it is accessible for draws, flushes, and chemo, then coil the line twice. I use a long thin piece of tape wrapped around the line, just above the clamp to secure it on top of the bandage that covers the site. Then I use two pieces of tape to secure the coil to the bandage. Then I cut a slit in a third piece and slide it up from the bottom, under the line, to cover the bottom of the dressing. Then over all of this two more large pieces, slightly larger than the bandage, are placed to secure everything and protect the bandage covering the site. If the bandage were to get dirty or come loose, the chances of infection increase, so I try my best to create as much of a seal as possible.
At the end of all of this, just the clamp and caps and the small amount of line they cover is exposed. I sewed a small pocket onto two icords I knitted and we slip this exposed portion into the pocket and tie the icords behind his back to keep it from dangling and rubbing against his skin too much. I am still trying to work on something that would require less tape and a more secure fit.
The only problem with the tape is that it irritates Buddha's skin, as well as the solvents they have given us to try to dissolve the adhesive to make the tape easier to remove.Hypafix tape works best, but it still causes occasional welts and irritation. This is one of the most frustrating things about taking care of a sick child, hurting them. I hate that he cries when we change his dressing, both from the discomfort of removing tape and the stinging of the cleaner over his already irritated skin, and just from having to be held down so that he doesn't pull at his exposed line. I usually end up in tears myself by the time we are done with the 15-20 minute operation. Then he spends the rest of the night scratching at the site and dressing area because of the irritation. It breaks my heart.
Since it is very important to keep the line and dressing clean we also carry an emergency kit I put together. It includes everything we need to patch or replace the dressing: gloves, Cloraprep swabs, bandages, pre-cut hypafix tape, alcohol wipes, blue caps, a face mask and replacement Cap. I packed it all in a Ziploc freezer bag and it stays in the diaper bag. Luckily we have only had to patch his site while we were out, frankly the idea of being forced to change it outside home or the hospital scares me to death.
So this is how our family deals with the Hickman, but I am constantly looking for new, better ways. If anyone knows of a better, or different way please share! You can write in the comments, or email me at firstname.lastname@example.org, it would be very much appreciated.