What is the standard operating procedure (SOP) for inserting and maintaining a Hickman line in pediatric patients?

Standard Operating Procedure for Hickman Line in Pediatric Patients

Catheter Selection and Indications

For pediatric patients requiring prolonged parenteral nutrition or long-term venous access, tunneled cuffed Hickman catheters (or Broviac catheters) are the recommended devices. 1

• Tunneled Hickman/Broviac catheters should be used for long-term PN and home PN in children 1
• For hospitalized children requiring prolonged PN, either PICC or tunneled CVC are appropriate 1
• Catheter sizes range from 2.7F to 10F with 1-3 lumens, depending on patient size and needs 2
• Use single-lumen catheters whenever possible to minimize infection risk 1
• If multi-lumen catheters are necessary, dedicate one lumen exclusively to PN 1
• Silicone or polyurethane materials are preferred for long-term use 1

Pre-Insertion Preparation

Patient Assessment

• Verify no infection at proposed insertion site (absolute contraindication) 3
• Assess for distorted anatomy or known venous thrombosis at insertion site 3
• Check coagulation parameters: proceed if platelet count >50 × 10⁹/L, aPTT <1.3 times normal, INR <1.8 1
• Evaluate for previous radiation to insertion area or presence of tracheostomy (relative contraindications for internal jugular approach) 3

Equipment and Personnel

• Designate trained personnel specifically for catheter insertion and maintenance 1
• Ensure availability of ultrasound guidance equipment 2
• Prepare full range of pediatric-specific equipment including narrower guidewires (0.021" vs 0.032" for adults) 1
• Stock catheters sized 2.7F-10F with appropriate number of lumens 1

Insertion Technique

Site Selection

• Internal jugular vein is the preferred site for pediatric Hickman insertion 2
• In pediatric patients, upper or lower extremities or scalp (in neonates) can be used 1
• Femoral vein is acceptable in children when superior vena cava access is not possible, as complication rates are not higher than jugular/subclavian sites 1
• Avoid subclavian site in patients with advanced kidney disease or severe respiratory compromise 3

Insertion Protocol

• Use ultrasound guidance for all internal jugular vein cannulations 2
• Apply maximal sterile barrier precautions during insertion 1, 3
• Most pediatric procedures require general anesthesia (except PICCs) 1
• Use chlorhexidine for skin antisepsis, but exercise caution with 2% concentration in premature infants due to risk of skin burns 1
• Avoid excessive quantities and pooling of chlorhexidine solution 1
• Position catheter tip between lower third of superior vena cava and upper third of right atrium 1
• Confirm tip position with X-ray imaging (standard for pediatric patients) 1
• Use contrast if needed for visualization of fine catheters 1

Technical Considerations

• Guidewires in pediatric patients are narrower and prone to kinking during dilator advancement 1
• Less curved guidewire tips are preferable in narrow veins 1
• Verify guidewire removal at procedure completion 4
• Secure catheter without sutures when possible (use sutureless devices) 1

Post-Insertion Management

Catheter Care and Maintenance

• Dedicate the catheter exclusively to PN administration when possible 1
• Avoid blood sampling, transfusions, and central venous pressure monitoring through the PN lumen 1
• For routine monitoring in long-term PN patients, blood sampling via CVC is acceptable if full aseptic protocol is followed 1
• Cap all stopcocks when not in use 1

Dressing Management

• Use sterile gauze with tape or transparent semi-permeable polyurethane dressing 1
• Sterile gauze dressing is preferable if catheter site is bleeding or oozing 1
• Replace gauze dressings every 2 days; transparent dressings every 7 days 1
• Change dressing immediately if it becomes damp, loosened, or soiled 1
• For well-healed tunneled catheters, dressing is not required to prevent dislodgement, but useful in children to keep catheter looped and covered 1
• Consider chlorhexidine-impregnated sponge dressing in patients >2 months with short-term catheters at high infection risk 1

Daily Monitoring

• Evaluate catheter insertion site daily by palpation through dressing 1
• Inspect visually if transparent dressing is used 1
• Remove opaque dressings only if patient shows signs of infection (local tenderness, erythema, warmth) 1
• Do not apply prophylactic topical antimicrobial ointment to insertion site 1

Infection Prevention

• Do not administer prophylactic systemic or intranasal antimicrobials 1
• Do not use antimicrobial-coated CVCs for long-term PN in children 1
• Admix all parenteral fluids in pharmacy using laminar-flow hood and aseptic technique 1
• Use single-dose vials when possible; never combine leftover contents of single-use vials 1
• Access system using aseptic technique with appropriate antiseptic 1

Activity Restrictions

• Children with well-healed tunneled catheters may swim if water-resistant dressing covers entire catheter 1
• Immediately after swimming: clean and disinfect exit site, change dressing 1

Catheter Removal Indications

Remove Catheter If:

• Patient develops signs of phlebitis (warmth, tenderness, erythema, palpable venous cord) 1
• Catheter malfunctions 1
• Candida species fungemia occurs 5
• Bacillus species bacteremia occurs 5
• Bacteremia persists >48 hours after appropriate antibiotics 5
• Tunnel infection develops 5
• Catheter-associated thrombosis occurs 5

Conservative Management Appropriate For:

• Most bacteremias and exit site infections can be treated with antibiotics and local care without catheter removal 6, 5
• 89% of septicemia episodes (including fungemia and multiple organism infections) resolve with treatment without catheter removal in pediatric oncology patients 6

Complications and Management

Expected Complication Rates

• Perioperative complications occur in approximately 2.4% of cases 2
• Catheter-related sepsis rate: 3.16 per 1000 catheter days 2
• Exit site infections: common but manageable with local care and antibiotics 5
• Inadvertent dislodgement: 22% of catheters 7

Common Pitfalls to Avoid

• Failing to use ultrasound guidance when available significantly increases mechanical complications 3
• Using multi-lumen catheters when single-lumen would suffice increases infection risk 1
• Removing catheters prematurely for infections that can be treated conservatively 6, 5
• Inadequate training of personnel performing insertion and maintenance 1, 3

Quality Improvement Measures

• Implement multimodal protocols ("bundles") standardizing insertion and maintenance practices 1
• Provide regular training and education for healthcare staff 1
• Conduct regular audits of catheter-related practices 1
• Concentrate vascular access procedures to a specialist team to optimize learning curve 2
• Monitor catheter-related bloodstream infection rates per 1000 catheter-days 1