hey friends!! I'm back with another blog post, but this one is a bit more informational than my normal ones! as you can tell by the title, this is about the whole central line placement/recovery/day-to-day process. I've been asked numerous times for advice so I thought I'd write it all down and put it out there! I've had a line since February 2022 and it's been almost complication free, so I wanted to share some advice and the inside scoop on the process. if you don't know, a central line is used when frequent or repeated venous access is necessary. Central lines can be used for nutrition, hydration, medications, chemotherapy, or blood draws.
after you and your dr decide it's time to place a line, research is the next step. your team must decide what kind of line is best (PICC, port, and tunneled lines: Hickman, Broviac, Groshong), where to place it, use and frequency, and the estimated duration of needing the line. you might start with a PICC line before moving to a more permanent line or it may be used in an urgent placement. if your line is used for TPN (intravenous nutrition), a PICC or tunneled line will be chosen as many hospitals have protocols against using a port for TPN. ports contain a "chamber" that can harbor sugars and lipids and allow bacteria to grow. each of these lines can be "power" compatible meaning MRI/CT contrast can be pushed through them.
a PICC line is typically used for frequent use (daily to almost daily) and short-term (some sources say up to 3-18 months). PICCs are placed in the upper arm and can be placed bedside or in interventional radiology. they can split into 1, 2, or 3 tubes so that different medications can run separately.
a port is typically used for intermittent use (weekly to monthly or less) and long-term (up to 5-10 years). a port is accessed with a special bent needle and is unusable when the needle is removed, hence intermittent use. when deaccessed, there is just a small bump under the skin and no dressing is needed, otherwise, the needle is covered with a sterile dressing.
when not in use, a port must be accessed and flushed with saline and heparin, once a month, to prevent clots from forming and keep the line patent. a port is placed in the upper chest, arm, thigh, or abdomen and is placed by a general surgeon or interventional radiologist. ports can be single or double-lumen.
a tunneled line is used for frequent use (daily to almost daily) and long-term (up to a few years). these lines are placed in the upper chest and placed by interventional radiology. PICCs and tunneled lines are always "accessed" and always require a dressing to keep them sterile. these lines can have a single, double, or triple lumen (so multiple things can run). tunneled lines can have a cuff (a small felt-like piece of material that circles the line). Skin will grow around the cuff to help hold the line in place. The cuff also acts as a barrier to decrease the chance of infection.
home health/infusion pharmacy or an infusion center is the next hurdle. coordinating home health (nursing) and an infusion pharmacy (for supplies and medications) can be very difficult. there are many supply shortages as well as nursing shortages which prevent patients from finding an available company. even infusion centers are having to turn patients away. one additional thing to note for iv hydration specifically is the difference between an infusion pump vs gravity drip. a pump is used when gravity is unfeasible due to specific run times, mobility, personal preference, and type of central line. TPN and many medications are unable to be run via gravity as a specific rate is needed. some central lines are highly positional and will not allow gravity infusion or the tubing is too small. for example, my port is an 8 french so gravity runs quite slow, but the needle gauge also plays into effect. many patients have home health for dressing changes and port accessing if they are not able to/ don't feel comfortable learning themselves, but typically connect and run their own medications.
PICC line placement is relatively simple. the skin is numbed and a needle is inserted into a vein in your arm. this is done under fluoroscopy. then the line will be threaded over the guidewire and up your arm then into the large vein at the top of your heart, secured, and dressed! thats it!
for tunneled lines and ports
I absolutely recommend having interventional radiology place your line! I had a general surgeon originally and wish I had gone with IR. they place them every day and are much more specialized. also if you prefer conscious sedation, IR is more prepared for that. general surgeons usually prefer general anesthesia (which I also prefer), but IR can typically get an anesthesiologist so you can have general anesthesia, if necessary.
typically sedation/anesthesia is given and then they use ultrasound to find a good vein to use. once it's picked, they numb the puncture site (where they go into the vein) and the insertion site (where the line goes in) and begin placing the line. this article explains the process super well!! port placements have a few more steps as the dr creates a "pocket" where the port sits.
ask about specific placement and where they hope to place it! advocate for it to not be too low or in a lot of muscle cause it’ll be harder to access or use, so you want it more medial away from straps! mine is in the literal perfect spot, away from straps not too high or too low. they are typically placed in the internal jugular vein or subclavian so there isn't a whole lot of flexibility. scar tissue from previous lines also plays into effect. if you have adhesive allergies let the team know so they can use a more tolerable dressing/cleaner. wearing a loose shirt is helpful since it may be painful to get a normal shirt back on after placement.
after placement, stretch and move your neck as much as possible! moving helps prevent stiffness!! ice is also amazing!!! your arm on that side might also be hard to move. my biggest tip is to keep stretching and stay ahead of the pain! pain medication isn't typically prescribed for line placement since it's a simple procedure. it kinda feels like a 2 pound weight on your chest at first and sharp pain then it bruises and the swelling slowly goes down. my main cause of the pain was from my boobs pulling the skin over my port and stretching the sore incision, so I wore a strapless bra until my incision was more healed. I also had issues with my incision splitting open over and over. if you have EDS, they can do a second layer of stitches to prevent that! for tunneled lines, usually, the stitches are removed once the cuff heals but if you have EDS, the stitches can be left in. if you had a port placed, and you’re using it right away, have them access it during placement!
so here is the "fun" part. I love to customize my supplies/line and make it as personal as possible! a few examples are supply organization, cute tape for your dressing, a backpack or pole, and port shirts. organizing my supplies is literally my favorite day of the week! I love to put it all away and restock my supplies to be ready for the week of infusions. I use IKEA Alex drawers and containers to organize. my overflow supplies are in a dresser drawer and contain supplies I'm allergic to/don't use. tubie tape is my absolute favorite!!! I use it on the top of my dressing to reinforce the dressing and make it a bit cuter:)
there are lots of Etsy shops that sell it as well as other online shops! my favorite is threads of kindness co !! another helpful product is griplocs! they are sticky on one side then have a velcro flap to secure your tubing in. I'm unfortunately allergic to them now but they are super helpful in preventing any accidental pulls.
you will need either an infusion backpack or an IV pole for your infusions. I have both but no longer use my pole since my bags come with the air removed so I just toss it and my pump in a backpack.
I got some floral garland and lights for my pole to make it less sterile looking. I have also customized my backpack with my monogram, new zipper pulls, and a tubie clip for my tubing!
a bit less fun, but showering with a line can be quite difficult! PICC lines can be protected by a special sleeve that protects it from the water. tunneled lines and accessed ports are a bit harder to cover, due to their location. your infusion company may send your aquaguard/showerguard which is a sticky plastic dressing that goes over your sterile dressing to keep it dry. I am too nervous to try aquaguard so I just body shower chest down!
I don't own any specific port shirts (shirt with a diagonal zipper to see your line) but if you are going to an infusion center or inpatient, they may be helpful for your team! in the winter, I use 1/4 zip-ups for accessing but otherwise, I just slip my shirt off to access and normal T-shirts work. some people prefer crop tanks or low-cut shirts to have their line more accessible. PICC line sleeves are used to protect your line and can be fun to pick out patterns/colors! port pillows are used to protect your port from the pressure of the seatbelt. the seatbelts used to both my port but now I don't even notice! I haven’t used any kind of numbing cream for access because it’s not bad at all but definitely an option! a neck pillow is good too because your neck will feel so weak.
so if you have allergies or sensitive skin, dressings, cleaners, biopatches, and skin prep may be difficult to coordinate. there are tons of dressing options, 3 cleaner options, 3 different "biopatch" options, and a few skin prep types. most dressing change kits include a simple Tegaderm dressing, CHG, and skin prep. I am unfortunately allergic to Tegaderm so we use IV3000 and I use an iodine/alcohol kit since I'm also allergic to CHG. my skin rips off with adhesives so I have to use skin prep/barrier as well as adhesive remover when deaccessing. I can still tolerate a biopatch at the insertion site but will switch to a silver patch if issues occur. some dressings also contain CHG such as certain Tegaderms, iv clear, and sorbaview shield.
that's it!! I hope this was super helpful and answers any questions you may have! much love!!