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Tunnelled central line (Hickman)

A long-term central line tunnelled under the chest skin, usually for chemo or TPN. The default assumption in a febrile patient is that the line is infected - but prove it and don't reflexively remove it.

Adult & paediatricVascular access & dialysisGuideline

Also called: Hickman, Hickman line, tunnelled CVC, tunnelled central venous catheter, Broviac, Groshong, skin-tunnelled line

A dual-lumen tunnelled central line exiting the chest wall beneath a transparent dressing, with two clamped coloured lumens.
General Ludd · CC BY-SA 3.0

What it is

A tunnelled central venous catheter exits the skin on the chest wall, runs a few centimetres under the skin (the tunnel) and then enters a central vein, with a cuff in the tunnel that tissue grows into to anchor it and act as an infection barrier. It is for long-term use - chemotherapy, long-term TPN, or frequent access. epic3 recommends Use a tunnelled or implanted central venous access device with a subcutaneous port for patients in whom long-term vascular access is required.

The ED-relevant problems are infection (exit-site, tunnel or bloodstream), occlusion/breakage, and dislodgement. Used in adults and children (paediatric oncology Hickman and Broviac lines are common); principles are the same, with the child's team directing care.

How to recognise it

What it gets confused with

A port-a-cath is fully implanted under the skin with nothing exiting the body - you see and feel a disc, not a protruding catheter. A Hickman has an external catheter you can see. Both are long-term chest devices.

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A tunnelled dialysis catheter is a large-bore tunnelled chest line too, but it is the patient's dialysis lifeline, locked with heparin or citrate, and must not be used for routine bloods or drugs. A Hickman is a smaller general-purpose line. Check what the line is for before using it.

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What goes wrong

Catheter-related bloodstream infection

Fever or rigors in a patient with a tunnelled line, with or without local signs. This is the default assumption until excluded.

Red flag
Take blood cultures before antibiotics - and from a tunnelled line, take a set from the line as well as peripherally, so the line can be implicated or cleared as the source. Treat sepsis; involve the owning team on whether the line stays.

Exit-site or tunnel infection

Exit-site: redness, discharge and tenderness at the skin. Tunnel: tenderness and erythema tracking along the subcutaneous course, which is more serious.

Red flag
A tunnel infection or an exit-site infection with systemic features is more likely to need line removal than a simple exit-site infection. Culture, start antibiotics per local policy, and refer.

Occlusion, breakage or dislodgement

Will not flush/aspirate; a split or leaking catheter; or a line that has partly pulled out.

Red flag
A split central line risks air embolism - clamp between the break and the patient and stop using it. A line that has pulled out needs an occlusive dressing and firm pressure over the entry site. If the patient becomes acutely breathless or shocked, suspect air embolism - head-down on the left side, high-flow oxygen. Do not force a blocked lumen.

The first ten minutes

  1. Assess and treat the clinical problem (sepsis, neutropenia, the presenting complaint) first.
  2. Suspected line sepsis: cultures before antibiotics where possible (peripheral, plus a set from the line if it is immediately available) - but never hold antibiotics in neutropenic sepsis or septic shock to get the line sample - then start sepsis/neutropenic-sepsis treatment per policy.
  3. Access the line only with strict asepsis - aseptic technique and hub decontamination for at least 15 seconds - and flush only with sterile saline.
  4. Clamp and stop using a split or dislodged line; refer.
  5. Call the owning team (oncology, nutrition, vascular access) about the device and whether it needs to come out.

Do not

Do not reflexively remove the line for fever alone.
Bloodstream infection is the default assumption, but removal is a considered decision with the owning team after cultures - some catheter infections are treated with the line in situ (systemic antibiotics, sometimes an antibiotic lock).
Do not let line sampling delay antibiotics in a septic or neutropenic patient.
A line-drawn culture paired with a peripheral one helps establish whether the line is the source, which guides whether it can be kept or must come out - so take cultures before antibiotics where you can. But in neutropenic sepsis or septic shock the antibiotic clock (within the hour) comes first: take peripheral cultures, add a line set only if it is immediately to hand, and do not wait to access the line.
Do not leave a split tunnelled line open or keep using it.
Air embolism and infection risk. Clamp between the break and the patient, stop using it, and refer for repair or exchange.

Who owns it

The team that uses the line - oncology/haematology, nutrition, or vascular access. Tell them the device, the local and systemic findings, the culture results, and whether the line still works.

Who to call

The team and the criteria are national. The phone number is local, and this tool does not know it. Find it once, now, and write it on the department's own card — that is the part no website can do for you.

Say the device name first
Open with laryngectomy, LVAD, shunt — the single word changes who comes and what they bring. Do not bury it in the history.
Say what you have already established
Whether the device is patent, whether it has been removed or disturbed, and what you have already tried. The specialist is deciding whether to walk or run.
Ask who owns it out of hours
Device ownership and the on-call route often differ from the implanting specialty, and it is frequently a regional centre rather than your own hospital.
The patient's own team is a resource, not an afterthought
Named nurse specialists, home-care companies and device helplines answer questions nobody else can, and the patient usually has the number.

When the device is not the problem

A patient with a device gets pneumonia, sepsis, pulmonary oedema and myocardial infarction at the same rate as everybody else. The device is the most visible thing about them and it attracts the whole assessment.

The NTSP says it out loud
The project's own manual warns that patients with tracheostomies can become unwell with all the problems that other patients get too. It is easy to become fixated with the tracheostomy. The same sentence applies to every device in this tool.
Clear the device, then leave it
Establish that the device is doing its job — the stoma is patent, the line draws back, the pump is running — and then assess the patient as you would anyone else.
The anchoring runs both ways
The opposite error is treating a device complication as a medical illness: a blocked gastrostomy read as vomiting, a baclofen pump failure read as sepsis.

What the patient will be carrying

Patients carry a line passport with the device, insertion date and the owning team's contact, and many know their line-flushing routine. Ask for it.

Scope of this page

This page covers recognising a tunnelled central line and the first ED steps for infection, occlusion and breakage: culture, treat, access aseptically, refer. It does not cover line insertion, exchange, thrombolytic unblocking, or the definitive decision to remove, which belong to the owning and vascular access teams. Used in adults and children; paediatric care is team-directed.

Sources