External catheter

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The external catheter is a long, flexible tube with one end in the right atrium of the heart and the other end outside the skin of the chest. The tube tunnels under the skin of the chest, enters a large vein near the collarbone, and threads inside the vein to the heart (see Figure 8-1). Because chemotherapy drugs, transfusions, and IV fluids are put in the end of the tube hanging outside the body, the child feels no pain. Blood for complete blood counts (CBC) or chemistry tests can also be drawn from the end of the catheter. With daily care, the external catheter can be left in place for years.

External catheters are usually put in under general anesthesia. Once the child is anesthetized, the surgeon makes two small incisions. One incision is near the collarbone over the spot where the catheter will enter the vein, the other is the area on the chest where the catheter exits the body. To prevent the catheter from slipping out, it is stitched to the skin where it comes out of the chest. There is a Dacron cuff around the catheter right above the exit site (under the skin) into which body tissue grows. This further anchors the catheter and helps prevent infection. After healing is complete, normal activities can resume.

Figure 8-1. External catheter

Daily care

The external catheter requires careful maintenance to prevent infection or the formation of clots. The site where the catheter exits the body must be cleaned frequently (schedules range from every other day to weekly) and a fresh, sterile dressing needs to be applied and taped in place. Some pediatric oncology centers also place a small antibiotic-impregnated disk around the catheter at the exit site. The site should be checked for redness, swelling, or drainage.

To prevent clots, parents or older children are taught to flush the line with a heparin solution. Different institutions use different schedules for how often the line should be flushed. Nurses at the hospital instruct parents and children in catheter care, and plenty of practice should be provided until both parent and child are comfortable with the entire procedure. At discharge, home nursing visits are sometimes arranged to provide further help.

We were very grateful for Matthew's Hickman line. Like a lot of children, he was terribly afraid of needles. The maintenance that was necessary to keep his line working properly became second nature to me. After his diagnosis, and again after his relapse, he had a Hickman implanted. In total, he had his external catheter for more than four years.

Risks

The major complications of using the external catheter are infections—either in the blood or at the insertion site—and the formation of clots in the line or the blood vessel where the catheter is placed. Rare complications are kinking of the catheter, catheter dislodgement, or breakage of the external segment of the catheter.

Infections

Even with the best care, infections are common in children with external lines. Children who have low blood counts for long periods of time are at risk for developing infections. The need for frequent flushing of the external line also increases the chance for bacteria to enter the catheter. Most infections are caused by the childs own bacteria that move from where they belong (skin, mouth, gastrointestinal tract) and enter the bloodstream. The most common organism is a bacterium called staphylo-coccus epidermidis, which lives on the skin, though a host of other organisms can cause infections in children receiving chemotherapy.

If your child develops a fever over 101° F (38.5° C), redness or swelling at the insertion site, or pain in the catheter area, infection is suspected. To determine if bacteria are present, blood will be drawn from the catheter to culture (grow in a laboratory for 24 to 48 hours). Treatment will start whenever there is a suspected infection and will end if the culture comes back negative. If the culture is positive, treatment usually continues for ten to fourteen days. Treatment with antibiotics is usually effective, though certain organisms are capable of causing a bacterial film to grow on the catheter that is impossible to eradicate, thus necessitating removal of the catheter.

When my daughter had a line infection, I wanted to use the antibiotic pump at home. It was hard, though. It took two hours per dose, three doses per day, for fourteen days. I would get up at 5 A.M. to hook her up, so that she would sleep through the first dose. The second dose I would give while she watched a tape in the early afternoon. Then I would hook her up at bedtime so she would sleep through it. I had to wait up to flush and disconnect, so I was very tired by the end of the two weeks.

We used the IV infusion ball when Joseph needed a three-hour Vancomycin infusion so he didn't have to sit chained to a pump. The IV infusion ball is cool because if you have a sweatshirt with front pockets, you can make a tiny hole in the back of the sweatshirt to put the tubing through and stash the ball in the pocket so you can go about your business while your IV is infusing and no one has to know a thing! It's handy for pain meds, too. He even used it at school, as long as I was there with him. An awesome invention—brilliantly simple. Here's the website that describes it: http://www.i-flowcorp.com/3_PRODUCTS/ index.html.

Some physicians require that the child be hospitalized for antibiotic treatment, while others allow the child to receive treatment at home. If the infection does not respond to treatment, the catheter may have to be removed.

Clots

Even with excellent daily care, some external catheters develop blockages and/or clots. If the catheter becomes blocked with a blood clot, it will be flushed with a drug capable of dissolving the clot. Examples of such drugs are activase, urokinase, and streptokinase. The agents are given in the clinic or hospital, and usually the child is required to remain nearby for one to two hours, depending on the institutional protocol. If the catheter is blocked by solidified medications (precipitate), a diluted hydrochloric acid solution may be used to dissolve the blockage. This is a rare occurrence, but may be caused by simultaneous administration of incompatible drugs or long-term administration of intravenous nutrition solutions.

We had no choice of catheter in 1985, and Judd received the Hickman line from Dr. Hickman himself. We had very little trouble with it until the last six months of the three-year protocol. It was found that Judd had a very large blood clot on the end of the line in his heart, possibly due to being too slow in flushing the line. With only one treatment to go, we had the line removed.

Two months before the end of Kristin's treatment, her line plugged up. We tried several maneuvers at home unsuccessfully. We had to bring her in for the IV team to work on it. I think the bumpy ride to the hospital loosened it because they were able to dislodge the clot just by flushing it with saline.

Kinks

Rarely, a kink develops in the catheter due to a sharp angle where the catheter enters the neck vein. In such cases, the fluids may go in the catheter but it is hard to get blood out. Parents and nurses are often able to work around this problem by experimenting with different positions for the child when the blood is drawn. Another method is to teach the child a Valsalva maneuver, such as bearing down as if to have a bowel movement, taking a deep breath, coughing, or laughing.

Catheter breakage

Breaks in the line do happen, but they are very rare. If the break or rupture of the line inside the body occurs when the line is not in use, only heparin will leak into surrounding tissues. If the break occurs when corrosive chemotherapy drugs are flowing through the catheter, they may leak and cause damage to surrounding tissue. The risk of an internal line leaking is far lower than the chance of leakage from an IV in a vein of the hand or arm.

Breaks in the external portion of the catheter may also occur. If this occurs, clamp the line between the point of breakage and the chest wall, cover the break in the line with a sterile gauze pad, and notify the physician immediately. In most cases, the line can be successfully repaired. Many institutions send a catheter repair kit home with parents.

I think it is important for parents to obtain clamps from the treating institution to carry with them. The preschool or school the child attends should also have one, in case something happens to the external line above the clamps that exist on the catheter Younger children should wear a snug tank top that helps hold the catheter in place. Pinning it to the shirt is not the best solution for active or younger kids.

Other factors to consider

The proper care and maintenance of an external catheter requires motivation and organization. The site needs to be cleaned and dressed frequently, and heparin must be injected using sterile technique. The dressing must be secured to the skin with an adhering dressing. If your child is very tape sensitive (cries whenever tape is removed or skin reddens and breaks out), the external line may not be the best choice.

One of my most difficult times was learning to change the dressing for Ben's catheter I am totally freaked out by syringes, and anything like that, and here we were given a ten-minute demonstration in the hospital and an instruction book and that was it. I was petrified of doing something wrong to hurt my son. My husband tried, but he does not have very good balance, and he could not get the sterile gloves on without contaminating them. I went into panic mode the first week home from the hospital. I felt like the most inadequate mother in the whole world. Since neither of us could do what had to be done, my husband called a home health agency and they sent a nurse.

Kathy was the most wonderful person on earth. She told me that even though she had been a nurse for twenty years, she didn't think she could change the dressing on her own child, and she perfectly understood my fears. She had me watch her over and over again until I was comfortable enough to do it with her watching, and then finally on my own. She also talked to our insurance company numerous times to explain why she had to change the dressing instead of the family, and they ended up paying for her services! It was totally amazing. In addition, she helped my mental mood immensely; always telling me how good Ben was doing and sharing stories with me. I could tell her anything and she always understood. After I no longer needed her, she still stopped by about once a month to see how Ben was doing. She was my guardian angel.

The external line is a constant reminder of cancer treatment and causes changes in body image. Both parent and child need to be comfortable with the idea of seeing and handling a tube that emerges from the chest. It is noticeable under lightweight clothing and bathing suits, but not under heavier clothing like sweaters or coats. If a younger sibling might pull or yank on the catheter, the Hickman or Broviac might not be the appropriate choice.

On the other hand, the reason external lines are chosen so frequently is that there are no needles and no pain. This is a very important consideration for young children or for any person who is frightened of needles and/or pain. Some treatment protocols require double lumen access and the external catheter is the only appropriate option. Finally, children who require long-term continuous venous access or children for whom a bone marrow transplant is planned require external venous catheters.

We didn't get a choice when Morgan needed a stem cell transplant. They needed to put in two Broviac lines to accommodate all of the meds, fluids, and TPN she needed for the procedure. I remember seeing six bags hanging up at once. I did the dressing changes, and we didn't have any trouble with the lines throughout the recuperation.

An external catheter may require restrictions regarding swimming, use of hot tubs, and sometimes bathing and showering, though care protocols vary by institution.

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