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Repair of long-term venous catheters
HOW I DO IT
Repair of Long-Term Venous Catheters Zena L. Leider, MD, FACS, Clearwater, Florida Donna Sweeney, RN, Clearwater, Florida Kathy Telesca, RPh, Clearwater, Florida Yvonne Bachman, RD, Clearwater, Florida
Long-term Silastic@ catheters are being inserted into the vena cava with increasing frequency for administration of antibiotics and hyperalimentation in the home setting. The complications of these catheters have been well documented in the surgical literature [1,2]. They develop leaks in the external segment, some separate between the Luer-Locke connecter and the Silastic tubing, some crack after repeated cross-clamping, and others are inadvertently cut by scissors during dressing changes. The repair kit currently on the market requires the use of glue and gloves, which make the repair procedure cumbersome. A new repair kit and the technique for its use are presented herein. The technique is simple to accomplish at the bedside or on an outpatient basis in the emergency room within a 5 minute period. Material The Leider long-term venous catheter repair kit (Cook, Inc, Bloomington, IN) is available for catheter sizes 4 F., 6.5 F., and 9.5 F. and includes sterile Ti-CronQ sutures, a sterile catheter portion with a preattached connecter, a reseal adapter, and a 5 cm3 syringe (Figure 1). Also needed for the procedure are sterile gloves and a sterile towel, masks, povidone-iodine wipes, scissors, 10 cm3 and 5 cm3 syringes with needles, alcohol wipes, a vial of sterile bacteriostatic saline solution, a vial of 1:lOO units of heparin solution, and a 22 gauge needle.
Technique After washing hands, with the catheter left clamped, each blade of the scissors is cleaned with a separate povidone-iodine wipe. Then, the end of the catheter is trimmed, coming from the patient straight across as close to the break as possible. The catheter end is then prepared with From the Nutrithal Support Service. Morton F. Plant ~ospiil, Clearwater, FMda. Requests fOr r0prifltS should be addressed to Zena L. Leider, MD, 2401 West Bay Drive, Largo, Florida 33540.
Volume 150, August lSS5
LUER LOCK CAP
HUBBED CATHETER
END
Ftgwe 1. A new ktt for repair of tong-term venouscatheters.
two povidone-iodine wipes, and placed on a sterile towel draped over the patient’s abdomen. A sterile field is then created and the sterile catheter portion with preattached connecter sterile Ti-Cron sutures, sterile reseal adapter, and 5 cm3 syringe with a 20 gauge needle is laid out. After putting on the sterile gloves and a mask (patient should also don a mask), the sterile reseal end is screwed into the adapter end of the new portion of sterile catheter. With a twisting motion, the connecter with the preattached catheter is inserted into the broken end of patient’s catheter. The connecter must be totally enclosed within the catheter. Care must be taken not to use the fingernails, as they will cut the catheter easily (Figure 2). Next, the TiCron suture is wrapped around the catheter at the indentation formed by the connecter, pulled very tightly and double knotted. This complete step is then repeated. It is of utmost importance to pull the suture very tightly or the connection will pull apart. Both sides of the connecter are then held while pulling to test the security of the repair without any tension being put on the entry site of the catheter. Next, the clamp is removed and the catheter aspirated to withdraw any air, and blood return is checked. The catheter should then be flushed with 10 ml of saline solution, then 5 ml of 1:lOO units of heparin solution and the catheter site redressed. Finally, the catheter is secured to the chest wall with tape. All catheters were repaired by the Morton F. Plant Hospital Nutritional Support Service within a 5 minute period after a minimal amount of practice of the technique of repair. The repaired catheters were used in the clinical setting to test the integrity of the repair with a 3 liter bag hyperalimentation system (amino acid, fat, and carbohydrate solution mixed together) and a volumetric pump
275
Leider et al
CATHETER CATHETER CONNECTOR
CATHETER ;~EPAIR END
running the solution at 50 ml/hour through the repaired catheter over a 24 hour period. The purpose of the test was to attempt to occlude the repaired segment if possible with a slow drip of hyperosmolar infusate. The repaired catheter was also flushed forcefully with 10 ml of the same solution in order to test for leakage of the repaired segments. All three sizes of the repaired catheters were tested and none leaked or occluded during clinical testing nor could they be pulled apart by manual force.
Summary
INDENTATION T
t
The insertion of long-term Silastic catheters into the vena cava for home parenteral nutrition, antibiotic administration, and chemotherapy is increasing; however, one of the often described complications of these catheters is breakage of the external segment of the catheter. A new device as well as a new method for repair of the catheter has been described. Clinical testing of the catheters repaired with this device by our nutritional support service has demonstrated no leakage or occlusion at the catheter repair site. We believe the catheter repair kit described is simpler to use than the repair kit currently on the market. References
SUTURE
F&m
276
2.
Method of repaIr.
1. Miller DG, lvey M, lvey T, Scribner BH. Experience with an indwelling rl@t atrial catheter for home parented rulrition. Sug Gynecol Obstet 1980;151:108-10. 2. Fleming CR, Witzke DJ, Beart RW Jr. Catheter-related complications in patients receiving home parenteral nutrition. Ann Surg 1980;192:593-9.
The Amarlcan Journal ol Surgery
Repair of Long-Term Venous Catheters Zena L. Leider, MD, FACS, Clearwater, Florida Donna Sweeney, RN, Clearwater, Florida Kathy Telesca, RPh, Clearwater, Florida Yvonne Bachman, RD, Clearwater, Florida
Long-term Silastic@ catheters are being inserted into the vena cava with increasing frequency for administration of antibiotics and hyperalimentation in the home setting. The complications of these catheters have been well documented in the surgical literature [1,2]. They develop leaks in the external segment, some separate between the Luer-Locke connecter and the Silastic tubing, some crack after repeated cross-clamping, and others are inadvertently cut by scissors during dressing changes. The repair kit currently on the market requires the use of glue and gloves, which make the repair procedure cumbersome. A new repair kit and the technique for its use are presented herein. The technique is simple to accomplish at the bedside or on an outpatient basis in the emergency room within a 5 minute period. Material The Leider long-term venous catheter repair kit (Cook, Inc, Bloomington, IN) is available for catheter sizes 4 F., 6.5 F., and 9.5 F. and includes sterile Ti-CronQ sutures, a sterile catheter portion with a preattached connecter, a reseal adapter, and a 5 cm3 syringe (Figure 1). Also needed for the procedure are sterile gloves and a sterile towel, masks, povidone-iodine wipes, scissors, 10 cm3 and 5 cm3 syringes with needles, alcohol wipes, a vial of sterile bacteriostatic saline solution, a vial of 1:lOO units of heparin solution, and a 22 gauge needle.
Technique After washing hands, with the catheter left clamped, each blade of the scissors is cleaned with a separate povidone-iodine wipe. Then, the end of the catheter is trimmed, coming from the patient straight across as close to the break as possible. The catheter end is then prepared with From the Nutrithal Support Service. Morton F. Plant ~ospiil, Clearwater, FMda. Requests fOr r0prifltS should be addressed to Zena L. Leider, MD, 2401 West Bay Drive, Largo, Florida 33540.
Volume 150, August lSS5
LUER LOCK CAP
HUBBED CATHETER
END
Ftgwe 1. A new ktt for repair of tong-term venouscatheters.
two povidone-iodine wipes, and placed on a sterile towel draped over the patient’s abdomen. A sterile field is then created and the sterile catheter portion with preattached connecter sterile Ti-Cron sutures, sterile reseal adapter, and 5 cm3 syringe with a 20 gauge needle is laid out. After putting on the sterile gloves and a mask (patient should also don a mask), the sterile reseal end is screwed into the adapter end of the new portion of sterile catheter. With a twisting motion, the connecter with the preattached catheter is inserted into the broken end of patient’s catheter. The connecter must be totally enclosed within the catheter. Care must be taken not to use the fingernails, as they will cut the catheter easily (Figure 2). Next, the TiCron suture is wrapped around the catheter at the indentation formed by the connecter, pulled very tightly and double knotted. This complete step is then repeated. It is of utmost importance to pull the suture very tightly or the connection will pull apart. Both sides of the connecter are then held while pulling to test the security of the repair without any tension being put on the entry site of the catheter. Next, the clamp is removed and the catheter aspirated to withdraw any air, and blood return is checked. The catheter should then be flushed with 10 ml of saline solution, then 5 ml of 1:lOO units of heparin solution and the catheter site redressed. Finally, the catheter is secured to the chest wall with tape. All catheters were repaired by the Morton F. Plant Hospital Nutritional Support Service within a 5 minute period after a minimal amount of practice of the technique of repair. The repaired catheters were used in the clinical setting to test the integrity of the repair with a 3 liter bag hyperalimentation system (amino acid, fat, and carbohydrate solution mixed together) and a volumetric pump
275
Leider et al
CATHETER CATHETER CONNECTOR
CATHETER ;~EPAIR END
running the solution at 50 ml/hour through the repaired catheter over a 24 hour period. The purpose of the test was to attempt to occlude the repaired segment if possible with a slow drip of hyperosmolar infusate. The repaired catheter was also flushed forcefully with 10 ml of the same solution in order to test for leakage of the repaired segments. All three sizes of the repaired catheters were tested and none leaked or occluded during clinical testing nor could they be pulled apart by manual force.
Summary
INDENTATION T
t
The insertion of long-term Silastic catheters into the vena cava for home parenteral nutrition, antibiotic administration, and chemotherapy is increasing; however, one of the often described complications of these catheters is breakage of the external segment of the catheter. A new device as well as a new method for repair of the catheter has been described. Clinical testing of the catheters repaired with this device by our nutritional support service has demonstrated no leakage or occlusion at the catheter repair site. We believe the catheter repair kit described is simpler to use than the repair kit currently on the market. References
SUTURE
F&m
276
2.
Method of repaIr.
1. Miller DG, lvey M, lvey T, Scribner BH. Experience with an indwelling rl@t atrial catheter for home parented rulrition. Sug Gynecol Obstet 1980;151:108-10. 2. Fleming CR, Witzke DJ, Beart RW Jr. Catheter-related complications in patients receiving home parenteral nutrition. Ann Surg 1980;192:593-9.
The Amarlcan Journal ol Surgery