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Mats Stromberg
Multiple myeloma

Hi everyone,

just wanted to share with you and also ask for your view on access.

A couple of weeks ago I learned that I have multiple myeloma. I have already started chemo (cyclophosphamide) and high doses steroids. The plan is for me to eventually this autumn go through high dose melphalan (chemo) treatment with support from my own frozen stem cells collected just before. I'll get through this, make no mistake. I will be alright!

I wanted to ask you guys if you think that a double lumen 5 French PICC would be the appropriate venous access for me when it is time for high dose melphalan and stem cell support. I believe this should be safer for me than what they usually place, which is a non-tunneled jugular CVC (about 7 Fr, I think). I want to have as small infection risk as possible when my white cell count hits zero. I think that Sheryl McDiarmid's article in Journal of Infusion Nursing from 2006 supports this: Retrospective Evaluation of a Nurse-led Initiative in Vascular Access Options for Autologous Stem Cell Transplant Recipients Ranging From Hickman Catheters to Peripherally Inserted Central Catheters, J Infus Nurs 29(2)81-88. I have good peripheral veins, so the initial cyclophosphamide treatment and also stem cell harvest can be done with PIV's.

Mats in Stockholm

Hi Mats, so sorry to hear

Hi Mats, so sorry to hear about your diagnosis, but you sound so positive that I have no doubt your attitude will bring you through this. If it were me, I would think about 2 things - the length of time I would be needing my catheter and what physical activities I planned to do while it was in place. If this is a long time and you think you may feel well enough to be very active for some of the time, you might want to consider a tunneled catheter. Activity and PICCs don't always work so well together. Of course the dry skin of the extremities presents a lower risk of infection than the oil skin of the chest for a tunneled catheter. But you must also think about how the catheter hub is managed. Those risk for both catheters would be virtually the same for infection. If the hub of either catheter is not properly managed, you will have the risk of BSI.

The other consideration is how will they be harvesting your stem cells. If they plan to harvest through the same catheter as will later be used for infusion, they may need a larger lumen catheter. You are right to take such a proactive approach to your care and only you can decide what will be the best catheter for you. I wish you much success and please let us know how you are doing.  


Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257


Office Phone 770-358-7861

Mats Stromberg
Hi Lynn and thanks for

Hi Lynn and thanks for answering!

The first part of chemo with 3 doses of cyclophosfamide (2g + 2g + 4g) and harvest of stemcells will be well managed through PIV's. I have sort of normal male 46 year olds large veins in my arms that will fit big PIV's. No problem. I do not want them to use the same VAD for harvest and reinfusion, as that would be a large bore central dialysis catheter in my jugular, that will more often than cells harvested from PIV's, will show up with fungus in the bag when it is time for reinfusion. If then kept there for several weeks waiting to be used for the reinfusion, who knows what infectious, thrombotic etc complications will arise.This I do not want.

For high dose Melphalan with reinfusion of my saved and frozen stem cells the day after ("autologous stem cell transplant"), they usually place a short , untunneled CVC in the jugular. My thought is to at this point use a PICC instead. 4 Fr single of 5 Fr double lumen groshong placed by my workmate Karin who is a great PICC placer.

The length of time is uncertain. If no complications a few days, if complications (like infection with antibiotic need, TPN need from mouth/gastric damage, low Hgb with transfusion needs etc) length would be longer, but I think not above weeks/1 month. My thought is that I want to lower the risk of infection by choosing a PICC and maybe get a shorter duration need from that. IF they really want to put in a jugular CVC I will try to use contacts to make it tunneled or even place a venous access port, which they also use some times (that will always be single lumen - but complemented with the odd PIV)

Of course you are right that hub management and the expertise of the nurses caring for me and my access is of great importance. They are certainly more used to a jugular CVC than to a PICC. True is also that they almost count on having to administer antibiotics due to CRBSI, because they have a lot of them with the CVC's. My thought is to not having antibiotics through not having an infection, instead. I do not think that the catheter needs to be large bore, that need is at harvest time when large PIV's seem to be the best choice.

I feel that I have the expertise on VAD choice and PICC's that they do not have, that I have a good PICC placer at hand and a nurse PhD friend that is specialised in VAD's and infections that think also that my thoughts are in the right direction. I think I have a good physician caring for me that will listen to reason if put to her scientifically and well thought out.

Have you read the article I mention? Can I send it to you if you have not? I would love to know your thoughts.

Anyone else that have som input. This is the most important discussion I have ever started. I want to get this right. Sorry to be using so many words, but I am on high dose steroids these days……


Kevin Travis Flint
Mats, We often recommend


We often recommend mediports for our multiple myeloma pts.  NorthWestern Universtiy in Chicago has a great Multiple Myeloma treatment program and would be an excellent resource.  Many of our pts receive their tx/transplants there and have done incredible.


Mats Stromberg
Thanks Kevin, so would you

Thanks Kevin,

so would you go for the port rather than a PICC and why? How many lumen do you think is appropriate for any CVAD for high dose Melphalan +  stem cell reinfusion + any necessary supportive care? Can I access anything from your MM treatment program on line through the web? Great to hear that others in my situation do well, thanks for that.

Any PICC experience out there for pts in my situation?


Daphne Broadhurst
Mats, Having worked in the


Having worked in the PICC program cited in the article you mentioned, I'd be happy to share our recent experience with patient's receiving similar treatments. Please feel free to contact me at dbroadhurst[at]oms[dot]ca.

Wishing you all the best,


Daphne Broadhurst
Desjardins Pharmacy
Ottawa, Canada

Diana S.
Hi Mats, We use all types of

Hi Mats,

We use all types of CVCs including PICC lines for Autologous transplants with few line related complications.  Of course any central line in an immunosuppressed person is risky but we often have PICC lines in for 3-6 months with no CRBSI.  PICCs can be a little more tricky with reinfusion because we don't like to put frozen cells on a pump and the cells will not infuse via gravity into a PICC so they are pushed manually.  We never harvest out of the same catheter that will be used during transplant.

As far as antibiotics- almost every person undergoing transplant will experience a neutropenic fever and get placed on antibiotics but it doesn't mean that we always find a source of infection.  It is usually supportive until engraftment. 

A double lumen PICC is adequate for the prep and the supportive care post transplant.  I hope this helps you.  Good luck and best wishes for a speedy recovery!

Diana Shafer, RN, MSN, AOCN

Inpatient BMT, Oregon Health Science University



Terry Hall
So sorry to hear this news.
So sorry to hear this news. I believe that PICC lines are in many cases, the most appropriate central access device,  especially for short term therapies ie less than 6 months. However, in cases where central venous access may be required intermittently over the course of a year, perhaps more, I believe serious consideration should be given to the implanted Port. Some studies suggest that this VAD poses the lowest risk of CRBSI. Ports provide reliable central access when needed and have the advantage of requiring only monthly care when there is no need for ongoing IV therapy. A return to a completely normal lifestyle can occur when there is no need for continuous Port access. Food for thought. Good luck! 
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