What is a Hickman Catheter?
Hickman catheters were originally described by Hickman and colleagues in 1979. Since that time this catheter has been adapted to a wide range of uses in sizes for both pediatric and adult uses. These catheters can have single, double or triple lumens. They are usually manufactured from
soft silicon rubber or PVC.
These long narrow tube that are commonly made of silicon are inserted into a large vein in the neck or chest, so that one end of the tube sits inside the vein usually in the superior vena cava (SVC) or the right atrium of the heart or the junction of the two structures. The other end of a hickman catheter is tunneled on the chest and exits the tunnel on the chest. (The picture above is of a Hickman Catheter with two end holes/lumens)
Hickman catheter is part of a subclass of central venous catheters which are tunneled, since a segment of the catheter is tunneled under the skin before exiting the chest. (Other tunneled catheters which are used for other objectives include broviac catheters which have smaller lumens and a lower profile and permacaths which are larger bore and more commonly used for dialysis).
Like nearly all tunneled catheters (Broviac catheters, permacaths…) Hickman catheters are characterized by a Dacron cuff which is a cotton like material that is on the catheter and is positioned within the tunneled portion near the chest exit site and provides an anchorage in a subcutaneous tract as subcutaneous tissue tends to grow into the interstices of the cuff. The cuff may also act as a microbial barrier although this is in debate
Approximately two weeks after a hickman catheter has been placed this dacron cuff is incorporated into the body theoretically helping protect the catheter from infection and keeping the line stable in its place (even without a retention suture).
Considerations of types of catheters to be placed
Choosing among a peripherally inserted central catheter (PICC) or a tunneled central venous catheter eg, Hickman catheter, Groshong catheter, or implanted infusion port should be individualized and depend upon duration of need for parenteral nutrition, local expertise, ability of the facility or individual to take care of the device, and presence of other risk factors for catheter-related blood stream infections (CRBSI; eg previous sepsis with CVC in place). The American Society for Parenteral and Enteral Nutrition (ASPEN) has issued clinical guidelines to describe best practices in the selection and care of central venous access devices for the infusion of home parenteral nutrition in adult patients. In the absence of guidelines specific to the critically ill, similar principles can be used when selecting CVADs for hospitalized critically ill patients in whom parenteral nutrition is indicated. ASPEN guidelines use an arbitrary cutoff of 30 days to distinguish short-term from long-term parenteral use.
●In general, patients in whom short-term administration of parenteral nutrition is desirable or intended that parenteral nutrition be delivered through a PICC. Alternatively, while not preferable, parenteral nutrition may be administered through a subclavian, internal jugular, or femoral central venous catheter if parenteral nutrition is only needed for very short periods (eg, a few days) or if a PICC is not feasible or reasonable. Tradition teaches that the femoral site is least desirable due to an increased risk of infection
●For long term administration of parenteral nutrition, A.S.P.E.N. guidelines indicated a preference for a tunneled central venous catheters. However, the rationale for this choice is based upon expert opinion and observational studies that suggest infection rates may be lower with tunneled catheters rather than randomized trials that validate this finding.
●When possible, a single lumen central venous catheter should be used for the infusion of parenteral nutrition. If a multiple lumen central venous catheter is used it should have one port/channel dedicated solely for the infusion of parenteral nutrition. In addition, catheter manipulations should be minimized. These precautions may decrease the infectious complications associated with parenteral nutrition. For patients who have an existing central venous catheter, a new central venous catheter is not typically required unless there has been septicemia during the life of the existing line.
Indications for placement of Hickman Catheters
- Hickman’s line is used in cases where the treatment continues over a couple of weeks and this catheter is often used for total parenteral nutrition (TPN).
- Other uses include plasmapheresis and apheresis, A route for taking blood samples frequently without puncturing the peripheral veins repeatedly, Administration of drugs and fluids during a long-term treatment
- Hickman’s catheters due to their flexibility provides with a greater freedom of movement and are often considered more comfortable for patients compared to stiffer catheters.
Hickman Catheter insertion and removal
The Hickman catheter is inserted under local anesthesia by a radiologist or a surgeon, with your oxygen levels, heart rate and blood pressure being constantly monitored. Patients often receive lidocaine as a local anesthetic which numbs the site of insertion in the neck and the tract to be formed under the skin on the chest. Some facilities use Fentanyl IV and Versed for moderate sedation but this procedure is performed with patients sedated but awake.
Once venous anatomy (right neck internal jugular preferred) is mapped out with ultrasound local anesthetic is applied and a small incision is made at the base of the neck. A needle is inserted and used to access the internal jugular vein (although other options for venous access exist). A small wire is passed through the needle into the vein. This wire is then upsized to a stiffer wire over a transitional catheter and then the tract from the jugular vein access at the base of the neck is serially dilated until a sheath is placed
The Hickman line is tunneled under the skin on the chest up to the venotomy at the base of the neck. The catheter is then cut to the desired length and inserted into the jugular vein and subsequently into the superior vena cava or the right atrium. Once positioning of the catheter tip is confirmed with fluoroscopy (X-Rays) the catheter is sutured to the chest at the exit site to keep the catheter in place while the cuff grows into the tissues under the skin. The vein puncture site at the base of the neck is either sutured closed with absorbable sutures (Some physicians place non-absorbable sutures which they have to later remove) or dermabond (Skin glue) and steri strips (skin adhesive). Finally a small dressing is put over each of the sites (insertion and exit).
Hickman catheter removal
Because of the cuff that is tunneled under the skin by near the exit site these catheter cuff grows into the subcutaneous tissues. Because the cuff adheres to the bodies tissues under the skin tract overlying skin, the hickman catheter removal will require a procedure. The dressing is removed and the hickman catheter exit site is prepped with chloraprep or other similar cleaning liquid and draped in the usual sterile manner. subsequently local anesthetic is given/injected around the catheter exit site and around the cuff. The area of catheter exit from the chest is numb, the cuff is loosened from the underlying tissues with a hemostat or scissors. Once the cuff is free to move, your line is releases easily.
Complications of hickman catheters
Before a hickman’s catheter is inserted, make sure you discuss the procedure in detail with your interventionalist and also learn about its risks and benefits. The following are a couple of risks associated with the catheter placement;
- Bacterial infection – this is usually a delayed complication but can occur at any time after placement of a hickman catheter
- Pneumothorax – although a serious complication this is an uncommon issue which can occur if the lung apex is punctured during venous access. Ultrasound availability and usage has decreased this complication significantly.
- Bleeding – is an uncommon complication that can occur during or immediately after catheter placement. bleeding which can take the form of a pericardial bleed (bleeding around the heart as a result of rupture of a vein) or bleeding from an arterial rather than venous puncture are thankfully uncommon and can become even less common if ultrasound guidance is used for venous access.
- Thrombosis – aka clotting of catheters can occur usually some time after catheter placement
- Fibrin sheath formation – a Fibrin sheath is a fiberous like matrix that grows around a catheter that has been in place for extended periods of time. clinically this usually manifests in a catheter that can be flushed but cannot be aspirated. It usually requires catheter replacement and angioplasty (ballooning) of the fibrin sheath to break it up
These risks have low chances and if proper protocol is followed, care is taken and the case is handled by a professional, then occurrence of such complications is rare.