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Peripherally inserted central catheters are used for a variety of parenteral therapies. This article discusses the advantages of securing these catheters and different methods of securement.
The most common invasive procedure performed in hospitals is the insertion of a vascular access device. This procedure has the rare complication of catheter emboli. Accidental cutting of a peripheral catheter, the use of duplex ultrasound to locate the cut and the extraction of the catheter through a venesection is described. If peripheral extraction fails, percutaneous extraction or thoracotomy should be tried, in that order. The immediate precautions have an impact on the final results.
Research into the importance of skin cleansing before venepuncture is inconclusive. This article suggests that erring on the side of caution is the best way forward until more firm evidence is found.
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Over a 9-year period (July 1981-December 1985--pre-ATLS period; January 1986-June 1990--post-ATLS period), the hospital charts of 813 trauma patients with ISS > or = 16 were reviewed (n = 413, pre-ATLS and n = 400, post-ATLS) in order to assess the impact of the ATLS program. The frequency of endotracheal intubation (ET), nasogastric tube insertion (NG), intravenous access (i.v.), Foley catheterization of the bladder (Foley) and chest tube insertion (CT) were compared by Pearson Chi-square analysis. Overall, pre-ATLS vs. post-ATLS frequencies (%) were 83.5 vs. 65.3 for ET, 97.3 vs. 98.0 for i.v., 74.6 vs. 96.3 for Foley, 68.3 vs. 91.3 for NG, and 18.4 vs. 47.0 for CT. In the emergency room these frequencies (%) were 26.1 vs. 36.4 for ET, 98.8 vs. 98.7 for i.v., 11.0 vs. 97.1 for Foley, 3.2 vs. 95.9 for NG, and 3.9 vs. 95.2 for CT. The differences in the application of these life saving procedures between the pre-ATLS and post-ATLS periods were statistically significant (p < 0.05) except i.v. access, which showed no difference between the pre-ATLS and post-ATLS groups. Of the patients with severe chest injuries (AIS > or = 3) 87.7% had chest tubes post ATLS (94.4% in ER) compared with 48.1% pre ATLS (3.2% in ER). These differences were associated with significant improvement in trauma patient outcome post ATLS. We conclude that the frequency of lifesaving interventions, particularly in the ER, was increased post ATLS.(ABSTRACT TRUNCATED AT 250 WORDS)
PURPOSE: To evaluate and compare the analgesic efficacy and anti-inflammatory effects of topical piroxicam gel vs eutectic mixture of local anesthetic (EMLA) cream applied to the peripheral venous cannulation site in adult volunteers. METHODS: Piroxicam gel and EMLA cream were randomly applied on the dorsum of the right and left hand of ten volunteers who acted as their own control. A venous cannula was inserted (no iv infusion) and removed after one hour. Pain scores and signs of inflammation were noted at the cannulation site up to 48 hr. RESULTS: Pain scores with piroxicam gel were higher on cannulation and on advancement of the cannula (P < 0.05). Thereafter, pain scores were significantly higher with EMLA (P < 0.05). Blanching was present at all the peripheral venous sites treated with EMLA cream. Signs of inflammation (erythema, edema) were not more frequent with EMLA than with piroxicam (P > 0.05). Induration was more frequent with EMLA at six hours. CONCLUSION: In volunteers EMLA cream is associated with less pain on cannulation and cannula advancement compared to piroxicam gel. Topical application of piroxicam gel before peripheral venous cannulation alleviates pain and, possibly, inflammation in the period subsequent to cannulation itself.
To obtain a clear view with angioscopy, blood must be displaced. Carbon dioxide (CO2) gas has proved to be a safe intraarterial contrast agent, and it may have advantages over saline solution as an infusion medium for angioscopy. This study compared the use of CO2 gas and saline solution in the femoral artery, in the presence and absence of a proximal occlusion, in nine pigs and six dogs. The applicability of CO2 gas in the coronary arteries was also evaluated. In total 185 angioscopy procedures were evaluated. With proximal occlusion, angioscopy with CO2 gas was successful in all 28 peripheral procedures, whereas with saline solution only 65% of the procedures resulted in a clear view (p less than 0.005). Without proximal occlusion, angioscopy was successful with CO2 gas and saline solution in 61% and 3% of procedures, respectively (p less than 0.0001). Cardiovascular parameters and blood gases showed minor changes after administration of CO2 gas. During coronary angioscopy with CO2 gas, mechanical heart failure occurred in all instances, which was lethal in 12 animals. None of the animals died as a result of saline angioscopy. In conclusion, CO2 gas is a safe medium for angioscopy in the peripheral arteries and in general offers a better view than saline solution. In contrast to saline solution, without proximal balloon occlusion CO2 gas provided a clear view in 61% of the peripheral procedures. In the coronary arteries, however, CO2 angioscopy was generally fatal in both animal models.
We investigated the role of peripheral sympathetic neurons and the adrenal medulla in the cardiovascular responses to cocaine in conscious, unrestrained Sprague-Dawley rats. Surgical adrenal demedullation (ADM) and/or chemical peripheral sympathectomy was used to eliminate one or both components of the sympathoadrenal axis. Phentolamine (5 mg/kg i.v.) was used to evaluate whether cocaine elicited epinephrine (EPI) release from the adrenal medulla. Significant EPI release by cocaine would result in "epinephrine reversal" after phentolamine pretreatment. Cocaine (2.5 mg/kg i.v.) was used in all experiments except the dose-response relationship study. In normal rats, cocaine caused a transient increase in mean blood pressure (MBP). Pretreatment with phentolamine reversed this BP response and this depressor effect was blocked by propranolol (2 mg/kg i.v.) suggesting that the pressor effect of cocaine was mediated by EPI. Chemical sympathectomy alone partially inhibited the pressor effect of cocaine, but pretreatment with phentolamine still reversed the residual action of cocaine on MBP at this time. Two weeks after ADM, the effect of cocaine on MBP was not significantly different from that of the sham-operated rats. However, pretreatment with phentolamine inhibited but did not reverse the effect of cocaine on MBP at that time. In rats with both ADM and chemical sympathectomy, cocaine caused only a decrease in MBP that was not blocked by propranolol or atropine methylnitrate, presumably because of its direct depressive actions. Results of this study suggest that both peripheral sympathetic neurons and the adrenal medulla play important roles in the cardiovascular actions of cocaine.
Covenant Healthcare System is a 500-bed facility in Saginaw, Michigan. A peripherally inserted central catheter (PICC) program was instituted there in 1990 when it was St. Lukes Hospital. Over the course of 17 years, 30 nurses had been trained to place PICCs in their spare time. A "PICC, stick, and run team" was established in 1998 but was unsuccessful. After a merger with Saginaw General Hospital, Covenant Healthcare created two full-time vascular access specialty positions. This nursing-based PICC program with full-time staffing has revitalized vascular access at Covenant Healthcare System. Currently, PICCs are placed proactively at the beginning of hospital stays. Peripheral catheter restarts have been replaced with reliable PICC access sites. Delayed discharge for PICC insertion is no longer an issue.
A double-blind, randomised, placebo-controlled study was undertaken to determine whether topical application of a nonsteroidal anti-inflammatory gel to skin overlying peripheral vein cannula sites has a role in reducing the incidence or delaying the onset of peripheral vein thrombophlebitis. Fifty normal subjects had intravenous cannulae placed in right and left arms. Subjects were randomised to receive twice daily application of either active nonsteroidal anti-inflammatory gel or placebo gel to each cannula site. Cannula sites were observed and signs and symptoms of inflammation recorded up to 108 h. If any site had signs extending beyond 2 cm then the cannula was removed. Cannula sites that had 'active' gel applied had half the incidence of marked signs at 108 h (44% vs 22%, p less than 0.05). These results suggest that local application of topical nonsteroidal anti-inflammatory gel to cannula sites may have a significant role to play in the prevention of peripheral vein thrombophlebitis.
OBJECTIVE: To determine the efficacy of continuous, low-dose heparin infusion in prolonging peripheral venous catheter patency in neonates. DESIGN: Randomized, prospective study. SETTING: Level III neonatal intensive-care unit. PARTICIPANTS: 113 neonates requiring i.v. therapy. INTERVENTIONS: The neonates were randomly assigned to heparin (n = 63). The heparin group received 1/2 unit of heparin per milliliter of continuous intravenous infusate or intermittent heparin flush. MAIN OUTCOME MEASURES: Low-dose heparin infusion does not make a difference in the duration of peripheral venous catheter patency. The incidence of catheter-related complications in the heparin group is the same as for those receiving no heparin. RESULTS: The mean duration of catheter patency was 62.75 hours in the heparin group and 27.3 hours in the no-heparin group (p = .0001). The occurrence of infection, bleeding, and extravasation injury was zero in the sample studied. The incidence of phlebitis was 18 cases in 132 (13%) in the heparin group and 13 cases in 122 (10%) in the no-heparin group. According to chi-square analysis, the difference between groups was not statistically significant (p greater than .05). CONCLUSION: Low-dose heparin infusion in peripheral venous catheters in neonates increased the duration of intravenous catheter patency (p = .0001) without increased risks of bleeding, infection, phlebitis, or extravasation injury.
OBJECTIVE: To determine the degree to which a dual-lumen peripheral catheter prevented precipitation of solutions known to be incompatible due to pH during simultaneous infusion in an in vitro model. METHODS: An in vitro model was devised to simulate peripheral venous blood flow from an antecubital source to systemic circulation. Ondansetron was simultaneously infused with fluorouracil, aminophylline, sodium bicarbonate, and ampicillin sodium in concentrations reflective of clinical conditions into the Twin Cath 20/22 (the dual-lumen catheter used in this experiment). Study solutions were primed with the prepared drug solution and administered for 15 minutes. Phase I used Normosol-R as the diluent to gather preliminary data; phase II used human plasma. All samples were obtained immediately before the start of the infusion and at 5, 10, and 15 minutes during the infusion, and 5 minutes after the infusion. Samples were visually inspected at each time point for precipitation and analyzed in duplicate by the appropriate stability-indicating HPLC method (except for sodium bicarbonate). Compatibility was defined as no visual evidence of precipitation and no more than 15% mean change in final versus initial concentration. RESULTS: Phase I experiments showed immediate precipitation in Normosol-R within the venous flow. However, in phase II, because of the buffering capacity that plasma proteins add to plasma, no precipitation occurred. All the drug combinations used in this study have been reported to be incompatible at the concentrations tested; however, we detected no incompatibilities. CONCLUSIONS: The results of this study indicate that using a dual-lumen peripheral catheter, such as the Twin Cath, may allow solutions incompatible due to pH to be administered simultaneously.
To assess the accuracy of venous blood sampling obtained from peripheral intravenous infusion lines, peripheral saline locks, and by peripheral venipuncture, dual blood samples from 55 hospitalized patients were compared for test reliability. Tests included complete blood cell counts, electrolyte studies, and general survey panels. Results showed that within certain limitations, blood sampling from a wide range of peripheral indwelling devices is reliable for many routine blood tests.
Percutaneous atherectomy was performed using the Simpson Atherocath on 131 patients (87 male, 66%) with a mean age of 65 years. Clinical characteristics included evidence of significant coronary disease in 50%, hypertension in 46%, diabetes in 41%, and prior neurologic deficit in 32% of patients. The indication for atherectomy was claudication in 114 (87%) and rest pain, gangrene, or ulcer in 17 patients (13%). Atherectomy was successfully performed in 136/139 stenoses (98%) and in 56/56 occluded vessels with or without prior balloon angioplasty. No serious complications resulting in limb loss or emergency vascular surgery were encountered. Histopathology of retrieved specimens showed that 66% had atheromatous plaque, 45% had tunica media, and 30% had a form of thrombus. Material obtained from an occluded vessel was more likely to have thrombus and tunica media present than that from a stenosis (P less than 0.02 and P less than 0.05, respectively). Early angiographic follow-up (mean time, 17 weeks) showed a relatively low (17%) lesion recurrence rate. Percutaneous atherectomy can be successfully utilized in stenotic and occluded peripheral arteries with good success and no serious complications; stenoses appear to have a low recurrence rate.
PURPOSE: Using peripheral venous pressure (PVP) instead of central venous pressure (CVP) as a volume monitor decreases patient risks and costs, and is convenient. This study was undertaken to determine if PVP predicts CVP in pediatric patients. METHODS: With ethical approval and informed consent, 30 pediatric patients aged neonate to 12 yr requiring a central venous line were studied prospectively in a tertiary care teaching hospital. In the supine position, PVP and CVP were simultaneously transduced. Ninety-six paired recordings of CVP and PVP were made. Correlation and Bland-Altman analysis of agreement of end-expiratory measurements were performed. RESULTS: The mean (SD; range) CVP was 10.0 mmHg (6.0; -1.0 to 27.0); the mean PVP was 13.7 mmHg (6.3; 0.0 to 33.0); offset (bias) of PVP > CVP was 3.7 mmHg with SD 2.6. The 95% confidence intervals (CI) for the bias were 3.2 to 4.1 mmHg. In the Bland-Altman analysis, lower and upper limits of agreement (LOA; CI in parentheses) were -1.5 (-2.3 to -0.7) and 8.8 (8.1 to 9.6) mmHg. Eight of 96 points were outside the limits of agreement. The correlation of PVP on CVP was r = 0.92, P < 0.0001. For a subset of ten patients (20 simultaneous recordings) with iv catheters proximal to the hand, limits of agreement were better - offset: 3.8 mmHg (+/- 1.4); lower LOA: 1.2 mmHg (0.25 to 2.1); upper LOA: 6.6 mmHg (5.7 to 7.5). CONCLUSION: Peripheral venous pressure measured from an iv catheter in the hand predicts CVP poorly in pediatric patients.
Evaluation of the Amplatz rotational catheter for the recanalisation of acute thrombotic occlusions in various vascular regions. The Amplatz air-driven rotational catheter was used in 5 patients with acute vessel occlusion in various vascular regions: superficial and profundal femoral artery respectively and popliteal artery with tibiofibular trunk (case 1 and 2), a Collier-Shunt (case 3), the left main pulmonary artery (case 4) and the portal vein after TIPS procedure (case 5). A complete or partial recanalisation was achieved in all cases. Time accounted for recanalisation was between 40 and 90 seconds. No adjunctive intervention was necessary. No complications occurred. The Amplatz thrombectomy device allows a fast, safe and effective mechanical thrombectomy of peripheral arteries and haemodialysis shunts. Partial recanalisation of large caliber vessels is also possible.
OBJECTIVE: The purpose of this study was to evaluate the complications of peripherally inserted central catheter use in an obstetrics population at a single institution over a 5-year period. STUDY DESIGN: We conducted a descriptive retrospective review of all obstetrics patients with peripherally inserted central catheter insertion during the antepartum period at Good Samaritan Regional Medical Center, from January 1, 1997, through September 30, 2001. RESULTS: During the 5 years of the study, complete data regarding the primary admission diagnoses for peripherally inserted central catheter placement and associated complications were available for 52 cases. An associated complication rate of 50% (n = 26 cases) was noted. The complications included culture-proved line infection (n = 9/52 complications, 17%), presumed line infection (n = 6/52 complications, 12%), cellulitis (n = 4/52 complications, 8%), mechanical line failure (n = 4/52 complications, 8%), pain that required line discontinuation (n = 2/52 complications, 4%), and superficial thrombophlebitis (n = 1/52 complications, 2%). A chi(2) analysis was performed, and preterm labor may be associated with an increased risk for peripherally inserted central catheter complication (P =.012). CONCLUSION: Patients who receive a peripherally inserted central catheter during pregnancy are at significant risk for infectious complications. Alternative treatment approaches are suggested, where appropriate.
BACKGROUND: Previous studies in adults have demonstrated a clinically useful correlation between central venous pressure (CVP) measured from a peripheral intravenous catheter and that measured from a central venous catheter. The current study prospectively compares CVP measurements from a central catheter and a peripheral catheter in infants and children. METHODS: The study cohort included patients younger than 12 years presenting for a surgical procedure for which central venous access was necessary. CVP was measured simultaneously every 15 minutes for a total of 10 measurements from the central venous catheter and the peripheral IV catheter using standard pressure transducers, which were zeroed at the phlebostatic axis. RESULTS: The cohort for the study included 30 infants and children ranging in age from 1 to 12 years. The peripheral IV catheter from which the CVP was measured ranged from a 24 to an 18 gauge. In 5 of the patients, there was no increase in the CVP value from the peripheral IV catheter in response to a sustained inspiratory breath or occlusion of the extremity above the catheter. In these 5 cases, the difference between the CVP measured from the central and peripheral catheter was 16 +/- 5 mm Hg versus 5 +/- 3 mm Hg in the other 25 patients (P < 0.0001). In the remaining 25 patients, the difference between the CVP measured from the peripheral and the central site was 5 +/- 3 mm Hg. There was no difference in the central versus peripheral CVP measurement depending on the size of the IV cannula, its location (upper versus lower extremity), or the patient's position. CONCLUSION: CVP can be measured from a peripheral IV catheter in infants and children provided that there is continuity with the central venous compartment demonstrated by showing an increase in the CVP from the peripheral IV catheter in response to a sustained inspiratory effort and by occlusion of the extremity above the site of the catheter.