2. HICKMAN CATHETER

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2. HICKMAN CATHETER
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Acknowledgements
This project is an initiative of Nurse
Education Workforce Strategy Gippsland Content
supplied by Gippsland Oncology Nurses Group
(GONG)- an initiative of Gippsland Region
Integrated Cancer Services (GRICS) Special
thanks Anny Byrne (Gippsland Regional
Integrated Cancer Services) Anne Maree Day (West
Gippsland HealthCare Group) Dianne Fahy (Nurse
Education Workforce Strategy) Anne Johnson
(Latrobe Regional Hospital) Linda Langskaill
(Central Gippsland Health Service) Melanie Regan
(Gippsland Regional Integrated Cancer
Services) See other sources and references at
the end of this presentation. Further reading is
encouraged to complement these tutorials.
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Scope of Tutorial

• What is a Hickman Catheter?
• List the advantages and disadvantages
• What care should be provided when changing a
  cap/bung?
• What is the strength of heparin lock used for a
  Hickman catheter?
• Describe how to flush in a pulsatile manner
• What is the minimum size syringe used when
  accessing a Hickman Catheter?
• List the essentials for documentation
• What are the main complications with a Hickman
  Catheter and how to troubleshoot them?

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Hickman Catheter - Description

• A Hickman Catheter is a tunnelled Central Venous
  Catheter. The tip of the Hickman Catheter
  resides in the Superior Vena Cava. The remaining
  lumen is tunnelled under the skin and exits the
  chest or abdominal wall. A cuff attached to the
  lumen adheres to the skin and tissues close to
  the exit site, which anchors the catheter.
• A Hickman catheter can consist of single, double
  or triple lumens.
• A Hickman catheter is used for intermediate and
  long term therapies usually in the haematology
  setting.

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Hickman Catheter

• ADVANTAGES
• Large bore lumens
• Pain free when accessed
• Single, double or triple lumens for multiple
  infusions

• DISADVANTAGES
• High maintenance
• Altered body image
• Theatre for insertion / removal
• Increased risk of infection

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Confirmation of placement

• Every time the Hickman Catheter is accessed, the
  nurse is responsible for confirming correct
  placement by
• Aspiration of blood
• Ability to easily infuse solutions
• Normal appearance of site and patients chest
• Written x-ray report confirming correct placement
  of Hickman Catheter available in patient record
• If unable to confirm correct placement refer to
  the troubleshooting section of the GONG Cancer
  Care Guidelines Hickman Catheter Management
  (see Resources)

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Principles of Care
Non Positive Pressure Bung

• Clamps are ESSENTIAL on Hickman catheters
• Must be left open when a positive pressure bung
  is in use
• Must be closed if a non-positive pressure bung is
  in use
• Must be closed when the system is opened i.e.
  cap/bung removed

Positive Pressure Bung
Note Above is a sample of one type of bung
currently available
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Accessing

• A clean technique is required for accessing a
  closed system through a cap/bung
• Aspirate for blood return to check patency and
  position
• Flush with 10 ml normal saline in a pulsatile
  manner when position confirmed
• Connect to IV line
• Recommended clean technique clean gloves and
  clean with 3 alcohol swabs and allow to air dry
  before proceeding to access a closed system

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Syringe Size

• Syringes no smaller than 10 ml to be used
• Smaller syringes increase the pressure in the
  catheter wall and increase the risk of rupture of
  the catheter

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Catheter Removal

• Only to be performed by a doctor in a hospital
  setting

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Flushing

• Flush with Normal Saline 10 ml in a pulsatile
  (stop/start) manner that is, push then pause the
  plunger of 10ml syringe continuously in short
  bursts until syringe empty
• On accessing the Hickman Catheter to determine
  patency
• Before and after drug administration
• After blood sampling
• Weekly, when not in use

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Heparin Lock

• Weak heparin lock (heparinization) 50u/s in 5ml
  is all that is required
• After each use, and weekly, when a non-positive
  pressure bung is in use
• Remember never use a syringe smaller than a
  10ml

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Cap / Bung Description
Non Positive Pressure Bung

• The positive pressure bung maintains a positive
  pressure in the line to prevent back flow of
  blood into the end of the catheter.
• A positive pressure bung should be used with a
  Hickman Catheter. If a positive pressure bung is
  unavailable then use a non positive pressure bung
  and weak heparinization is required.

Positive Pressure Bung
Note Above is a sample of one type of bung
currently available
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Changing a Cap / Bung

• Aseptic technique required using a sterile tray
  and sterile gloves
• Positive pressure cap/bung should always be
  insitu and must be changed at least every 7 days
• Clamp line before removing cap/bung

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Changing a dressing

• Always use an aseptic technique
• Initial dressing should be changed 24 hours post
  insertion
• Dressing should be changed every 7 days or
  earlier if necessary
• Dressing usually not required 21 days post
  insertion
• Entry site may be left uncovered when healed

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Changing an IV Line

• A clean technique is required when the system is
  closed ie. bung is in place
• Continuous IV infusion line is changed every 72
  hours
• For intermittent IV infusion, change line with
  each infusion
• Change IV TPN/Lipid line every 24 hours
• Blood product infusion sets changed to an IV
  infusion set on completion of the blood product
  infusion
• Recommended clean technique clean gloves and
  clean with 3 alcohol swabs and allow to air dry
  before proceeding to access a closed system

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Taking Blood

• Perform initial flush to determine patency
  (except for blood cultures)
• Discard the first 5ml of blood withdrawn before
  collecting sample
• When taking blood cultures do not perform initial
  flush to determine patency, do not discard a
  sample. Retain initial sample for blood culture
• Flush Hickman Catheter, in a pulsatile manner,
  with 20ml of Normal Saline after blood sampling
  and continue with treatment as ordered and / or
  heparinization if required

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Documentation

• Clear, consistent documentation is essential
• after each treatment or shift. This should
  include
• Ability to confirm placement
• Medications and flushes administered
• Strength of heparinization (if used)
• Type of bung/cap used
• Dressing change
• Signs and symptoms of infection or thrombosis
• Troubleshooting
• Written x-ray report confirming correct
  placement at time of insertion should be
  available in patient documentation

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Complications

• Blockage of lumens
• Infection at insertion site or in catheter
• Thrombosis
• Damage to exposed catheter

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1. Blockage of lumen

• Difficulty flushing and/or aspirating blood
• Ensure any clamps are open
• Change position of patient
• Change cap or bung

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2. Infection

• Redness, discharge, tenderness, heat, patient
  feels unwell, pain and swelling at Hickman
  Catheter site may be symptoms of infection
• If signs of infection are present do not access
  Hickman Catheter and consult physician
• Septic shower may occur immediately after
  flushing due to infection in the line. There may
  be an absence of obvious infection at entry site,
  however the patient will experience rigors and
  generally feel unwell. Consult physician

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3. Thrombosis

• Do not access Hickman Catheter and consult
  physician

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4. Damage to exposed catheter

• Check catheter every time it is accessed for
• Perishing, splitting, damage and if the cap is
  firmly in place
• Refer to physician if integrity is compromised
• This is more common in children

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Resources

• GONG Cancer Care Guidelines have been accepted
  to guide the management of all patients with a
  CVAD in Gippsland and are available at each
  Gippsland Health Service.Also available on-line
  at www.gha.net.au/grics

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GONG Products

• www.gha.net.au/grics