Most of you will have seen the transparent dressing on my upper chest, and the white plastic line underneath it. This is my Hickman line.
What is a Hickman Line?
In technical terms, it’s a tunnelled central line.
Central because the tip of the line sits either just in, or just above my heart (that’s pretty central, no?). To get the line to that spot, it was inserted into a vein in my neck and just gently pushed through the vein until it arrived at my heart. All roads lead to Rome; all veins lead to the heart (with one exception, in case my pedantic medic friends are reading this).
If the line had been left like this, it would be just a ‘normal’ central line.
This is a ‘normal’ central line
These are used in hospitals all the time (usually in intensive care units). However, because the line comes out of the skin right next to the vein, it provides a direct route for infection to get into the bloodstream. This is a Bad Thing.
To reduce the risk of infection, long-term lines like mine are ‘tunnelled’ under the skin so that the exit point is a long way from the vein. Hickman lines (a brand name) have a cuff around the line that sits in the tunnel, usually an inch or two away from the exit site. This is designed to encourage the skin to heal around the cuff inside the tunnel, providing another barrier to infection, and anchoring the line firmly in place.
Hickman lines can have one, two or three lumens (separate lines with a plastic outer coating). My line has two lumens: one is reserved for IV nutrition and the other one is used for my normal daily medications and fluids.
Why do I have a Hickman line?
If you were paying attention, you might notice that I just answered that, but there’s a more detailed answer. Because my stomach and intestines are too stretchy, they don’t work very efficiently to break up food and move it through the GI tract, absorbing nutrients along the way. We know that I absorb some oral medications extremely erratically, because there are blood tests to check absorption. We also suspect that I don’t absorb other medications, fluids or nutrients from food. Because I have severe autonomic dysfunction (dysautonomia), my body needs about 3 litres of fluids per day, but I can take in less than 1 litre orally, of which some is not absorbed. In this hot weather, I’m running 3 litres of fluids per day through my Hickman line.
In hospital, it is commonplace to use peripheral cannulae (peripheral being the opposite of central), usually in the hands or arms. In the year or two prior to getting my Hickman line, I had literally hundreds of these peripheral cannulae placed, and hundreds more unsuccessful attempts. My veins are very small, and very fragile, like the rest of my skin. If someone is skillful or lucky enough to get a cannula into one of my veins, it’s almost certain to fail within 24 hours (the policy at my local hospital is to change them every five days routinely, or more often if necessary). After trying all the usual places, I ended up with IV lines in places as unusual as my fingers and feet.
Some of the medications that I need are very irritant to veins, so must be administered into a large vein, i.e. via a central line, to avoid causing local damage. This includes TPN – the IV nutrition that I am likely to need at home at some point. I had an appointment with one of the specialists at the Intestinal Failure Unit at St Mark’s Hospital (one of only two such units in the country), which lasted for over two hours, discussing my medical history and possible treatment options. All my doctors seem to be agreed that I will need TPN at some point, as my GI tract will continue to deteriorate. The Intestinal Failure specialist was in favour of a trial of TPN sooner rather than later, despite the fact that I’ve managed to gain back much of the weight that I lost when things went really pear-shaped back in 2012, but my local nutrition specialist would like to delay TPN as long as possible, as there are so many risks associated with it, and once started, it’s likely that I’ll be on TPN for the rest of my life.
Finally, I need to be able to use this line and care for it at home. There are very long lines (called PICC lines), which are inserted into a vein, usually in the arm, and are then threaded up the vein to the heart, under x-ray guidance. The main problem with PICC lines, from my point of view, is that if the line is in one of my arms, I can’t take care of it myself. PICC lines are also more likely to come out than Hickman lines and don’t have the cuff that protects against infection.
What could go wrong?
There are lots of reasons not to make the decision to have a Hickman line too lightly. There are a number of potentially serious complications:
- Infections – any ‘foreign’ object within the body is a playground for bacteria, and a playground that leads straight into the bloodstream is a big risk. Having IV nutrition into a Hickman line increases the infection risk, because TPN is sugary, and bacteria just loooove sugar! I’ve had a number of episodes of TPN, always in hospital, and usually for around two weeks, but I’ve only had one infection. Bloodstream infections can be really serious, leading to organ failure or even death. I was lucky that the bacteria that got into my bloodstream was sensitive to the usual antibiotics, and that I got the appropriate treatment quickly enough to prevent serious damage to any of my organs, and that the bacteria was sensitive enough to antibiotics that I was able to keep my line (with certain types of bacteria, the line has to be removed, as the bacteria can form a ‘biofilm’ within or around the line, which allows them to ‘hide’ from antibiotics).
- Blood clots – foreign objects, again, provide a point where the blood flow slows down, and if the walls of the blood vessel get damaged, e.g. by the line rubbing against them, chemicals can be released that encourage the formation of blood clots. These clots can cling to the walls of the Hickman line, where they can grow and grow, and then float off around the body. The size of the clot will determine where it gets stuck – big clots stick in big blood vessels; little clots stick in little blood vessels. Mostly, large clots cause more problems than small ones, but if the clot lodges in the lungs, heart or brain, they can cause really serious problems. I’ve been lucky not to have any clots so far, but I’m not on TPN, which is a significant risk factor for clots
- Damage to the line – some lines can migrate out altogether, especially those that don’t have the cuff around them, but even if the line stays put, it can degrade over time. I lost my first Hickman line due to degradation of the plastic of one of the lumens, allowing a large hole to form. I was very glad to have the second lumen, so that I could still receive the medications and fluids that I need at home, in the month or so that I had to wait for the line to be replaced
Oh dear… Look at that hole!
Who looks after the line?
The short answer to that is that I do. I get supplies from a number of places, including my local hospital, clinical commissioning group, district nurses and on prescription from my GP. Most people would have district nurses come in to change their dressing, and possibly also to administer medications. The district nurses did come out to watch me change my dressing the first few times when I left hospital, but they couldn’t tell me when they would arrive, beyond ‘Tuesday’, which I found frustrating, and which would have been even more frustrating if I’d needed the nurses to come out to give antibiotics or other medications up to four times daily.
I’m lucky that my line was placed at a hospital where they have an IV team committed to patient safety, and that they were supportive of my wishes to take care of the line myself. It’s not just being obsessive (though it is mostly that), but every person who touches my line is a potential carrier of infection. I can’t check everything, such as the handwashing technique of my local nurses, or whether they have pushed their hair out of their face with sterile gloves. If I take care of the line, I know exactly the standard of care that I receive, every time my line is accessed. If something goes wrong, the blame lies squarely in my court.
I hope that answers your questions, but feel free to ask questions in the comments, or by email. I’m always happy to share…