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Modified catheter for prolonged central venous use
Modified Catheter for Prolonged Central Venous Use By S. Frank Redo New York, New York • A modification of an existing Broviac type of central venous catheter is described. The catheter has t w o suture fixation rings distal to the Dacron cuff, which anchor the catheter to the patient and minimize the risk of displacement or migration until tissue-cuff adherence has taken place. Th e technique for using the catheter is described. Copyright © 1995by W.B. Saunders Company INDEX WORDS: Venous access, central venous catheters.
ENTRAL VENOUS catheters with a Dacron cuff for prolonged use are commonly used for the administration of parenteral nutrition, chemotherapy, other therapeutic drugs, antibiotics, and blood. The Dacron cuff is affixed to the catheter to allow tissue ingrowth that will anchor the catheter in place. Such tissue ingrowth may take several weeks to occur, especially in patient s who receive steroids or chemotherapeutic agents. Becaus.e of this, the catheter may be accidentally dislodged from the central vein before tissue-cuff adhesion has occurred. Experience with the use of such catheters and the not uncommon displacement of the catheter before the tissue-cuff adherence, despite various suturing techniques aimed at preventing extrusion 1-5 have led to the modification of the catheter to minimize the risk of early displacement and migration. In our experience the incidence of catheter displacement was about 10% to 15% in patients under 2 years of age and about 5% for older children and adults.
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DESCRIPTION OF MODIFIED CATHETER
The modification (for use in infants, children, and adults) consists of placement of two suture fixation rings (S!LASTIC ® (Dow Coming, Midland, MI), 2.5 cm distal to the Dacron cuff for infants and children, and 2.5 or 5 cm distal to the cuff for adults. The sizes of commercially available catheters are 3, 4, 6.5, and 9.5F for single lumen, and 5, 6, 7, 9, 10, and 12F for double lumen. The catheters are available from Cook Critical Care (Bloomington, IN).
From the Div&ion of Pedia~c Surgery, The New York HospitalCornell University Medical Center, New York, NY. Address reprint requests to S. Frank Redo, MD, Division of Pediatric Surgery, The New York Hospital-Cornell University Medical Center, 525 E 68th St, New York, NY10021. Copyright © 1995 by W.B. Saunders Company 0022-3468/95/3011-0002503.00/0
1544
Fig 1. Modified central venous catheter. Note the circumferential suture fixation rings distal to the cuff (arrows).
TECHNIQUE
The catheter is inserted in the usual fashion, either percutaneously or by cutdown. The Dacron cuff, which is 2.5 cm proximal to the fixation rings, is positioned so that the suture fixation rings are just outside the skin exit site. A 4-0 or 3-0 Prolene suture is placed in the skin and subcutaneous tissue beneath the catheter, just distal to the proximal fixation ring (Fig 1). A second suture is inserted distal to the
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Fig 2. Sutures are placed around the circumferential suture fixation rings to anchor the catheter to the chest wall. The fixation rings should be positioned just distal to the skin exit site.
Journal of Pediatric Surgery, Vo130, No 11 (November), 1995: pp 1544-1545
MODIFIED CATHETER FOR CENTRAL VENOUS USE
1545
s e c o n d fixation ring ( F i g 2). T h e two s u t u r e s a r e left in p l a c e until tissue-cuff a d h e r e n c e is secure, w h i c h m a y t a k e as long as 3 to 4 weeks. DISCUSSION
T h e c a t h e t e r with s u t u r e fixation rings has b e e n u s e d successfully in 89 p a t i e n t s , 51 u n d e r a n d 38 o~)er
2 y e a r s of age. I n two infants, t h e s u t u r e s a r o u n d t h e fixation cuffs b e c a m e loose a f t e r 1 w e e k , b u t in no instance were the catheters displaced or extruded. S u t u r e fixation o f t h e c a t h e t e r by m e a n s o f t h e rings m i n i m i z e s t h e risk o f t h e c a t h e t e r b e i n g d i s p l a c e d o r d i s l o d g e d f r o m t h e c e n t r a l vein, until tissue-cuff a d h e r e n c e has o c c u r r e d .
REFERENCES
1. Wheeler RA, Griffiths DM, Burge DM: Retrograde tunnel: A method for the fixation of long-term pediatric central venous catheters. JPEN 15:114-115, 1991 2. Alfieris GM, Wing CW, Hoy GR: Securing Broviac catheters in children. J Pediatr Surg 22:825-826, 1987 3. Goolishian W, Konefal S: An alternative method of securing Broviac catheters in children and infants. JPEN 13:218-219, 1989
4. Powers MN, Myers RB, Bryant R, et al: A clinical report on the comparison of a drain/tube attachment device with conventional suture methods in securing percutaneous tubes and drains. J Enterostomal Ther 15:206-209, 1988 5. Sheldon J, Bond MD, Bonna S, et al: Exit site purse-string suture to secure long-term venous catheters. JPEN 17:583-584, 1993
ENTRAL VENOUS catheters with a Dacron cuff for prolonged use are commonly used for the administration of parenteral nutrition, chemotherapy, other therapeutic drugs, antibiotics, and blood. The Dacron cuff is affixed to the catheter to allow tissue ingrowth that will anchor the catheter in place. Such tissue ingrowth may take several weeks to occur, especially in patient s who receive steroids or chemotherapeutic agents. Becaus.e of this, the catheter may be accidentally dislodged from the central vein before tissue-cuff adhesion has occurred. Experience with the use of such catheters and the not uncommon displacement of the catheter before the tissue-cuff adherence, despite various suturing techniques aimed at preventing extrusion 1-5 have led to the modification of the catheter to minimize the risk of early displacement and migration. In our experience the incidence of catheter displacement was about 10% to 15% in patients under 2 years of age and about 5% for older children and adults.
C
DESCRIPTION OF MODIFIED CATHETER
The modification (for use in infants, children, and adults) consists of placement of two suture fixation rings (S!LASTIC ® (Dow Coming, Midland, MI), 2.5 cm distal to the Dacron cuff for infants and children, and 2.5 or 5 cm distal to the cuff for adults. The sizes of commercially available catheters are 3, 4, 6.5, and 9.5F for single lumen, and 5, 6, 7, 9, 10, and 12F for double lumen. The catheters are available from Cook Critical Care (Bloomington, IN).
From the Div&ion of Pedia~c Surgery, The New York HospitalCornell University Medical Center, New York, NY. Address reprint requests to S. Frank Redo, MD, Division of Pediatric Surgery, The New York Hospital-Cornell University Medical Center, 525 E 68th St, New York, NY10021. Copyright © 1995 by W.B. Saunders Company 0022-3468/95/3011-0002503.00/0
1544
Fig 1. Modified central venous catheter. Note the circumferential suture fixation rings distal to the cuff (arrows).
TECHNIQUE
The catheter is inserted in the usual fashion, either percutaneously or by cutdown. The Dacron cuff, which is 2.5 cm proximal to the fixation rings, is positioned so that the suture fixation rings are just outside the skin exit site. A 4-0 or 3-0 Prolene suture is placed in the skin and subcutaneous tissue beneath the catheter, just distal to the proximal fixation ring (Fig 1). A second suture is inserted distal to the
_J
J @
Fig 2. Sutures are placed around the circumferential suture fixation rings to anchor the catheter to the chest wall. The fixation rings should be positioned just distal to the skin exit site.
Journal of Pediatric Surgery, Vo130, No 11 (November), 1995: pp 1544-1545
MODIFIED CATHETER FOR CENTRAL VENOUS USE
1545
s e c o n d fixation ring ( F i g 2). T h e two s u t u r e s a r e left in p l a c e until tissue-cuff a d h e r e n c e is secure, w h i c h m a y t a k e as long as 3 to 4 weeks. DISCUSSION
T h e c a t h e t e r with s u t u r e fixation rings has b e e n u s e d successfully in 89 p a t i e n t s , 51 u n d e r a n d 38 o~)er
2 y e a r s of age. I n two infants, t h e s u t u r e s a r o u n d t h e fixation cuffs b e c a m e loose a f t e r 1 w e e k , b u t in no instance were the catheters displaced or extruded. S u t u r e fixation o f t h e c a t h e t e r by m e a n s o f t h e rings m i n i m i z e s t h e risk o f t h e c a t h e t e r b e i n g d i s p l a c e d o r d i s l o d g e d f r o m t h e c e n t r a l vein, until tissue-cuff a d h e r e n c e has o c c u r r e d .
REFERENCES
1. Wheeler RA, Griffiths DM, Burge DM: Retrograde tunnel: A method for the fixation of long-term pediatric central venous catheters. JPEN 15:114-115, 1991 2. Alfieris GM, Wing CW, Hoy GR: Securing Broviac catheters in children. J Pediatr Surg 22:825-826, 1987 3. Goolishian W, Konefal S: An alternative method of securing Broviac catheters in children and infants. JPEN 13:218-219, 1989
4. Powers MN, Myers RB, Bryant R, et al: A clinical report on the comparison of a drain/tube attachment device with conventional suture methods in securing percutaneous tubes and drains. J Enterostomal Ther 15:206-209, 1988 5. Sheldon J, Bond MD, Bonna S, et al: Exit site purse-string suture to secure long-term venous catheters. JPEN 17:583-584, 1993