In resuscitation situations, the securing of vascular catheters is an important but sometimes cumbersome process, particular when sutures are required for central lines or arterial lines.
Medical grade ‘superglue’ (cyanoacrylate) can be used and this has been described in the anaesthetic literature before(1). Now, further in vitro work shows the glue does not weaken the intravenous catheter and is not associated with bacterial colonisation(2).
I think this is perfect for resuscitation lines. Just last night I used this technique to secure a femoral arterial line during a cardiac arrest resuscitation. It was great not to have to faff around with sharp suture needles during CPR and the line felt very secure after just a few seconds.
1. Tissue adhesive as an alternative to sutures for securing central venous catheters
Anaesthesia. 2007 Sep;62(9):969-70
2. Cyanoacrylate tissue adhesives – effective securement technique for intravascular catheters: in vitro testing of safety and feasibility
Anaesth Intensive Care. 2012 May;40(3):460-6
[EXPAND Click for abstract]
Partial or complete dislodgement of intravascular catheters remains a significant problem in hospitals despite current securement methods. Cyanoacrylate tissue adhesives (TA) are used to close skin wounds as an alternative to sutures. These adhesives have high mechanical strength and can remain in situ for several days.
This study investigated in vitro use of TAs in securing intravascular catheters (IVC). We compared two adhesives for interaction with IVC material, comparing skin glues with current securement methods in terms of their ability to prevent IVC dislodgement and inhibit microbial growth. Two TAs (Dermabond, Ethicon Inc. and Histoacryl, B. Braun) and three removal agents (Remove™, paraffin and acetone) were tested for interaction with IVC material by use of tensile testing. TAs were also compared against two polyurethane (standard and bordered) dressings (Tegaderm™ 1624 and 1633, 3M Australia Pty Ltd) and an external stabilisation device (Statlock, Bard Medical, Covington) against control (unsecured IVCs) for ability to prevent pull-out of 16 G peripheral IVCs from newborn fresh porcine skin. Agar media containing pH-sensitive dye was used to assess antimicrobial properties of TAs and polyurethane dressings to inhibit growth of Staphylococcus aureus and Staphylococcus epidermidis.
Neither TA weakened the IVCs (P >0.05). Of removal agents, only acetone was associated with a significant decrease in IVC strength (P <0.05). Both TAs and Statlock significantly increased the pull-out force (P <0.01). TA was quick and easy to apply to IVCs, with no irritation or skin damage noted on removal and no bacterial colony growth under either TA.
An important consideration when siting your lines in your critical care patients who require renal replacement therapy…
Dual-lumen haemodiafiltration catheters enable continuous renal replacement therapy in the critically ill and are often co-located with central venous catheters used to infuse drugs. The extent to which infusions are immediately aspirated by an adjacent haemodiafiltration catheter remains unknown. A bench model was constructed to evaluate this effect. A central venous catheter and a haemodiafiltration catheter were inserted into a simulated central vein and flow generated using centrifugal pumps within the simulated vein and haemodiafiltration circuit. Ink was used as a visual tracer and creatinine solution as a quantifiable tracer. Tracers were completely aspirated by the haemodiafiltration catheter unless the infusion was at least 1 cm downstream to the arterial port. No tracer was aspirated from catheters infusing at least 2 cm downstream. Orientation of side ports did not affect tracer elimination. Co-location of central venous and haemodiafiltration catheters may lead to complete aspiration of infusions into the haemodiafilter with resultant drug under-dosing.
Adjacent central venous catheters can result in immediate aspiration of infused drugs during renal replacement therapy
Anaesthesia. 2012 Feb;67(2):115-121
A review showed that peripherally inserted central catheters were associated with higher rates of complications that standard central venous catheters
We undertook a review of studies comparing complications of centrally or peripherally inserted central venous catheters. Twelve studies were included. Catheter tip malpositioning (9.3% vs 3.4%, p = 0.0007), thrombophlebitis (78 vs 7.5 per 10 000 indwelling days, p = 0.0001) and catheter dysfunction (78 vs 14 per 10 000 indwelling days, p = 0.04) were more common with peripherally inserted catheters than with central catheter placement, respectively. There was no difference in infection rates. We found that the risks of tip malpositioning, thrombophlebitis and catheter dysfunction favour clinical use of centrally placed catheters instead of peripherally inserted central catheters, and that the two catheter types do not differ with respect to catheter- related infection rates.
Complications associated with peripheral or central routes for central venous cannulation
Anaesthesia. 2012 Jan;67(1):65-71
Central lines in the ED are more likely to get infected because they’re inserted under less scrupulously aseptic conditions than in ICU, done more urgently, and are more likely to be placed in the mucky old femoral site by clumsy emergency physicians who don’t wash their hands after scratching their arses. Anyway, the intensivists will usually replace them with a ‘more ideal’ line after ICU admission. Right? Well, that’s what’s often taught and assumed to be the case, but a new study from a single centre suggests otherwise. ED-placed central venous catheters (19% of which were femoral) were typically left in for 4 to 5 days. The infection rate was 1.9 per 1,000 catheter-days, similar to that reported for central lines in other ICU case series.
Infection and Natural History of Emergency Department–Placed Central Venous Catheters
Annals of Emergency Medicine 2010;56(5):492-7
Ultrasound-guided subclavian vein cannulation has reduced complications, but there is still a high incidence of failure to cannulate the vein and of accidental arterial cannulation. Vassallo & Bennett noticed that a fast running intravenous infusion in the ipsilateral arm of a patient produced variable echogenicity (lighter echos) in the subclavian vein. They describe deliberately using this appearance to both identify the subclavian vein and differentiate it from the subclavian artery.
With the intravenous infusion running with frequent drips in the drip chamber, the ultrasound beam is placed in long axis to the subclavian vessels in the subclavicular position. The angle of the ultrasound beam is adjusted to reveal both the subclavian vein and artery. The variable echogenicity, together with compression, can then be used to identify the vein. The presence of variable echogenicity in the vessel gives continuous feedback that the ultrasound beam has not drifted onto the artery. In cases where the ultrasound beam has included both artery and vein in the same image, this method has clearly identified the intended target vessel.
Subclavian cannulation with ultrasound: a novel method
An ultrasound study on infants and children under general anaesthesia evaluated the femoral vein with the patients’ legs at 30° and 60° of abduction and their hips externally rotated. Measurements were taken at the level of the inguinal crease and 1 cm below the crease.
Hip rotation with 60° leg abduction significantly decreased the overlap between femoral vein and femoral artery at the level of the inguinal crease in both infants and children.
The authors recommend the optimal place for femoral vein cannulation in paediatric patients seems to be at the level of the inguinal crease with 60° leg abduction and external hip rotation.
Ultrasonographic evaluation of the femoral vein in anaesthetised infants and young children
Bloods sampled from both femoral vein and SVC-sited catheters in critically ill patients showed good correlation in lactate levels but the oxygen saturation was not so reliable, with >5% variation in more than 50% and >15% variation in some patients. The authors suggest one reason is that the femoral catheter tip usually sits in the iliac vein and samples blood prior to the mixing of blood returning from intra-abdominal organs. They advise caution in using SfvO2 to guide resuscitation when narrow end points are used, as this may lead to inappropriate vasoactive drug or blood component therapy.
Femoral-Based Central Venous Oxygen Saturation Is Not a Reliable Substitute for Subclavian/Internal Jugular-Based Central Venous Oxygen Saturation in Patients Who Are Critically Ill
Chest. 2010 Jul;138(1):76-83
Previous work in severe sepsis/septic shock patients has shown that a decrease in lactate concentration by at least 10% during emergency department resuscitation predicts survival. Since this is a potential alternative resuscitation goal to a central venous oxygen saturation (ScvO2) of 70% (as per surviving sepsis campaign guidelines), lactate clearance was compared with ScvO2 in a randomised non-inferiority trial of 300 patients.
All patients were managed in the ED and received fluids, antibiotics, and vasopressors as needed. Then lactate clearance or ScvO2 were measured, and if the respective goals of 10% or 70% were not met, packed cells or dobutamine were given depending on haematocrit. Lactate clearance was the percentage decrease in lactate between two venous specimens taken two hours apart.
Interestingly only 29 patients received either packed cells or dobutamine. Each group was similar in terms of time to antibiotic therapy and amount of fluid given. Patients in the group resuscitated to a lactate clearance of 10% or higher had 6% lower in-hospital mortality than those resuscitated to an ScvO2 of at least 70% (95% CI for this difference, –3% to 15%) exceeding the –10% predefined noninferiority threshold.
The authors conclude ‘these data support the substitution of lactate measurements in peripheral venous blood as a safe and efficacious alternative to a computerized spectrophotometric catheter in the resuscitation of sepsis.’
Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial
JAMA. 2010 Feb 24;303(8):739-46
In a study of anaesthetised infants and children, the right internal jugular vein as assessed by ultrasonography was measured with the head in the neutral position, and then at 40 degrees and 80 degrees of rotation to the contralateral side. The 40 degree position resulted in an increase in IJV diameter but with less overlap with the carotid artery than the 80 degree position. The authors conclude that rotating the head 40 degrees to the left results in the best balance of increased IJV diameter versus overlap with the carotid.
Effects of head rotation on the right internal jugular vein in infants and young children
Anaesthesia Volume 65, Issue 3, Pages 272-276
A series of subclavian vein catheterisations is described in patients using the supraclavicular approach, with a high success rate and few complications. 290 of the 370 patients were mechanically ventilated at the time of the procedure
How they did it:
- The point of needle insertion was identified 1 cm cephalad and 1 cm lateral to the junction of the lateral margin of the clavicular head of the sternocleidomastoid muscle with the superior margin of the clavicle (claviculosternocleidomastoid angle)
- The direction of the needle was indicated by the line that bisects the claviculosternocleidomastoid angle with elevation 5–15 degrees above the coronal plane.
- The needle was advanced slowly with a constant negative pressure in the syringe.
- The vein was usually punctured between the clavicle and the attachment of the anterior scalene muscle to the first rib.
- The subclavian artery is situated posterior and slightly superior to the vein; if palpable, the pulse of the artery could be the important landmark
- The depth of catheter insertion was 14 cm for right side and 18 cm for left side catheterization.
Supraclavicular approach is an easy and safe method of subclavian vein catheterization even in mechanically ventilated patients: analysis of 370 attempts
Anesthesiology. 2009 Aug;111(2):334-9
EMRAP.TV has a video on supraclavicular central line insertion here