Top Tips for Paediatric Oncology Lines

Are you involved in the care of paediatric Hickman, port or PICC lines in young people? Lines, particularly those for oncology patients can sometimes leave nursing and medical staff all tangled up. Thanks to the Royal London Hospital Paediatric Oncology team, Ana Waddington and Amanda Ullman we are happy to share some handy top tips to improve line care:

1. Use aseptic non touch technique (ANTT) when accessing Oncology patients central venous lines 
2. Clamping sequence is important, to prevent back-flow of blood up the device. But, the sequence (including positive vs neutral pressure) depends on the needleless connector that you use. Always check the manufacturer’s recommendations.
3. Securing your line:  Always have at least one securement device (e.g., sutures, clasp, reinforced dressing) to keep the central line in the correct place – and two is even better
4. Flushing: Flushing the central line with 0.9% sodium chloride after administration of viscous fluids is vital to prevent occlusion. 
5. When accessing a totally implanted device (e.g., Port-a-CathTM):
   • Consider local anaesthetic prior to insertion (e.g., LMX, Ametop, Emla)
   • Pinch the edges of the port-a-cath to secure the location to insert your needle
   • Insert at 90 angle until you feel the needle hit the back
   • Don’t force it- you may cause some injury to the port chamber
   • Try repositioning yourself and the patient to an angle that feels more comfortable
   • If under the armpit, try lifting the patient’s arm to stretch the skin
   • Try not to go where there is bruising, adjust the skin
6. There are 2 types of occlusion – withdrawal occlusion and total occlusion
   • Withdrawal occlusion – flush gently with 0.9% Sodium chloride, get patient to look up and away from their line as they maybe causing an internal kink, change their position, if unsuccessful then can use Urokinase/Alteplase
   • Total occlusion – Change bionector, take dressing down to check for external kinks, get patient to look up and away from their line as they maybe causing an internal kink, change their position, if unsuccessful then can use Urokinase/Alteplase
7. No matter what the presentation (e.g., injection vs aspirate occlusion) always think through the possible causes, while problem-solving:
   • Consider mechanical occlusion: e.g., do you have malfunctioning needleless connectors? Are there external kinks? Plus [really importantly] is the tip position central? 
   • Consider infusate occlusion: i.e. have you just administered medications that may have precipitated? If so, talk to your pharmacist about how to dissolve.
   • Then think about thrombotic occlusion, and consider administering thrombolytic agents, like urokinase. If this doesn’t work, consider imaging e.g., lineogram
8. Do not use prefilled syringes to flush off a PICC, as these are Luer lock not Luer slip syringes and they cause the PICCs to block
9. Do not put heparin into a PICC line, they are to be flushed with 0.9% sodium chloride
10.  If you run into trouble and are not sure what to do- make sure that you seek help with senior staff of your team, check your hospital policy/guidelines and the manufacturer instructions to solve the problem together.

For your convenience, the top tips are summarised in an A4 poster format (infographic by Grace Leo):