Invasive Monitoring and Life Support Procedures in Bone Marrow Failure ALAND. TURNSULL,M.D. PATIENTS WITH CHEMOTHERAPY-INDUCED MARROW FAILURE who require invasive hemodynamic monitoring, ventilator support, plasmapheresis or hemodialysis represent 15% to 20% of the Critical Care Unit annual census of the Memorial Sloan Kettering Cancer Center. Thrombocytopenia (5,00010,000/cu mm) and leukopenia (1,000/cu mm or less) are common, increasing the risk of percutaneous central venous cannulation, endotracheal intubation for tracheostomy, indwelling arterial pressure catheters or arteriovenous shunts for hemodialysis. These important procedures need not be deferred when they can be performed safely with strict asepsis and skilled technique. CENTRAL VENOUS ACCESS
The Cordis sheath introducer system (Cordis Corp., Miami, Fla.; model no. 501608) is a significant advance in catheter technology and has become our preferred method of central venous access under these circumstances' (Fig 3-1). This polyethylene sheath system was originally designed for angiography purposes, but its unique hemostatic valve assembly and side port extension is of great value because of its versatility in the critically ill cancer patient. The unit is placed in an internal jugular or subclavian vein after percutaneous insertion of a standard subclavian catheter of sufficient internal diameter (Desirer Co., Sandy, Utah; model no. 755) to accept a guidewire over which the catheter is removed and Fig 3-1.-Top: The Cordis sheath, introducer and guidewire; bottom: The
DesiretDialysis Catheter.
26
l
Fig 3-2.-The Cordis sheath and pulmonary artery catheter.
the dilator carrying the sheath then introduced. Pulmonary artery pressure monitoring catheters (Fig 3-2}, pacing electrodes or parenteral nutrition lines may be inserted through the hemostatic valve while the side port can be used for other purposes. Alternatively, insertion of a 30.5-cm, 13-gauge Desiret catheter through the valve provides two portals of access from a single venipuncture and prevents possible aspiration of air through the valve during sudden increases in intrathoracic negative pressure. The Cordis sheath has been inserted safely despite severe thrombocytopenia in over 30 patients by first cannulating the subclavian or internal jugular vein with the smaller-diameter Arrow internal jugular angiocath (Arrow Corp., Reading, Pa.; model no. AK04000) and then passing the Cordis guidewire through it. Although this requires two separate kits, the principle of an initially small venipuncture followed by sequential dilation assures passage of the much larger-bore Cordis sheath without bleeding. A safe alternative in the presence of severe coagulopathy is cannulation of the external jugular vein with a Blitt "J wire" and catheter (Argon Corp., Garland, Tex.; model no. 497601) through which the Cordis guidewire can be passed, followed by the vessel dilator and sheathY
INDWELLING ARTERIAL CATHETERS Intra-arterial monitoring with an 18-20-gauge, 6.25-cm Longdwell indwelling catheter (Beckton-Dickinson Co., Ruther27
ford, N.J.; model no. 6743), placed percutaneously3 or by cutdown in the radial artery at the wrist, is indicated for most patients with shock, acute respiratory failure or complicated diabetes. After confirming the presence of ulnar artery flow by palpation or Doppler ultrasound, a 1-cm incision exposing the artery for direct puncture is preferred in the thrombocytopenic patient. Multiple samples for blood gas analysis can be provided with the continuous Po 2 and Pco 2 indwelling arterial probe and analyzer (Ohio Sentorr Blood Gas Analyzer, Madison, Wis.; model no. 747-8000900) in patients requiring prolonged ventilatory support. This unit allows frequent simultaneous changes to be made in levels of inspired oxygen, positive end-expiratory pressure and minute ventilation with direct digital readout of the effect of these changes. Alternate sites for cannulation include the dorsalis pedis or superficial temporal artery. We have no experience with percutaneous brachial artery4 catheterization, which is potentially dangerous in the presence ofthrombocytopenia.
ACUTE HEMODIALYSIS Most acute hemodialyses are carried out in this unit with the Uni-flow system, utilizing a single 17.5-cm Desiret dialysis catheter inserted through the hemostatic valve of a Cordis catheter and removed at the end of the procedure. 1 Adequate blood flows of 200- 250 ml/min and satisfactory urea clearances have been demonstrated in over 40 patients for as long as 6 weeks of repeated use. Modifications in the Cordis sheath have been designed, allowing it to be used when regional heparinization is required and with any type of dialysis machine. This method has also been used for plasmapheresis alone or in combination with hemodialysis. Over 200 patients have had Cordis sheaths inserted during the past 2 years in this unit, and only 4 episodes of catheter-related sepsis have been recorded.
TRACHEOSTOMY Because of the feared hemorrhagic complications of tracheostomy, prolonged endotracheal intubation is usually preferred when ventilator support is needed in thrombocytopenic patients with diffuse interstitial pneumonia and respiratory failure. Disadvantages of this method include gum, tongue and pharyngeal bleeding; accumulation of mucus; and inadequate oral and pharyngeal toilet despite diligent nursing care2 Putrid collections of clots and mucus in the posterior pharynx can contaminate the distal trachea despite an inflated tube cuff; all are potentially dangerous, especially in leukopenic patients. We adopted recently the policy of early tracheostomy when prolonged intubation is necessary despite pIatelet counts as low as 10,000]cu mm 28
and have had no complications in 35 patients. While transfusing pIatelets, a vertical 3-cm midline incision is made in the neck, beginning at the cricoid cartilage. A surgical electrocautery unit, elective transection and suture ligation of the thyroid isthmus and coagulation of the incised edges of tracheal mucosa are imp o r tan t to assure hemostasis. The procedure is performed in the intensive care unit after first ve nt i l a t i ng the intubated patient for 5 min u tes with 100% oxygen to p r e v e n t hypoxia during extubation and insertion of the tracheostomy tube. Usually a considerable a m o u n t of clot and mucus is removed by tracheal aspiration through the newly placed tracheostomy tube despite careful aspiration of the oropharynx before deflating t he endotracheal balloon. These techniques have made a very real contribution to the care of the acutely ill patient with bone m a r r o w failure. T hey evolved from an obvious need, evidenced by inadequately monitored patients referred in shock or congestive failure, others with large neck h e m a t o m a s or hemopneumothoraces after unsuccessful attemp ts at central venous cannulation and wrists swollen to the point of vascular compromise from multiple radial a r t e r y punctures for blood gas analyses. The problem of vascular access is due to the fact t h a t m a n y cancer patients have t hei r peripheral veins thrombosed from prior c h e m o t h e r a p y and other infusions at a time of crisis, which sets the stage for potential complications. The simplicity of the methods described justify t hei r use in these circumstances, but their safety is dependent on skilled technique. Th ey ar e not "teaching" procedures for j uni or house officers. REFERENCES 1. Turnbull, A., Carlon, G., Bains, M., and Makowsky, M.: Multiple purpose central venous access using the Cordis catheter sheath system, Crit. Care Med. 7:30, 1979. 2. Blitt, C. D., Wright, W. A., Petty, W. C., and Webster, T. A.: Central venous catheterization via the external jugular vein: A technique employing the "J wire," J.A.M.A. 229:817, 1975. 3. DeAngelis, J.: Percutaneous Vascular Catheterization, in Well, M. It., and Henning, R. J. (eds.):Handbook of Critical Care Medicine (Miami: Symposia Specialists Inc., 1978),p. 47. 4. DeAngelis,J.: Axillary arterial monitoring,Crit. Care Med. 4:205, 1976. 5. Turnbull, A., and Carlon, G.: Airway management in the thrombocytopenic patient, Crit. Care Med. 7(2):76, 1979.
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The Cordis sheath introducer system (Cordis Corp., Miami, Fla.; model no. 501608) is a significant advance in catheter technology and has become our preferred method of central venous access under these circumstances' (Fig 3-1). This polyethylene sheath system was originally designed for angiography purposes, but its unique hemostatic valve assembly and side port extension is of great value because of its versatility in the critically ill cancer patient. The unit is placed in an internal jugular or subclavian vein after percutaneous insertion of a standard subclavian catheter of sufficient internal diameter (Desirer Co., Sandy, Utah; model no. 755) to accept a guidewire over which the catheter is removed and Fig 3-1.-Top: The Cordis sheath, introducer and guidewire; bottom: The
DesiretDialysis Catheter.
26
l
Fig 3-2.-The Cordis sheath and pulmonary artery catheter.
the dilator carrying the sheath then introduced. Pulmonary artery pressure monitoring catheters (Fig 3-2}, pacing electrodes or parenteral nutrition lines may be inserted through the hemostatic valve while the side port can be used for other purposes. Alternatively, insertion of a 30.5-cm, 13-gauge Desiret catheter through the valve provides two portals of access from a single venipuncture and prevents possible aspiration of air through the valve during sudden increases in intrathoracic negative pressure. The Cordis sheath has been inserted safely despite severe thrombocytopenia in over 30 patients by first cannulating the subclavian or internal jugular vein with the smaller-diameter Arrow internal jugular angiocath (Arrow Corp., Reading, Pa.; model no. AK04000) and then passing the Cordis guidewire through it. Although this requires two separate kits, the principle of an initially small venipuncture followed by sequential dilation assures passage of the much larger-bore Cordis sheath without bleeding. A safe alternative in the presence of severe coagulopathy is cannulation of the external jugular vein with a Blitt "J wire" and catheter (Argon Corp., Garland, Tex.; model no. 497601) through which the Cordis guidewire can be passed, followed by the vessel dilator and sheathY
INDWELLING ARTERIAL CATHETERS Intra-arterial monitoring with an 18-20-gauge, 6.25-cm Longdwell indwelling catheter (Beckton-Dickinson Co., Ruther27
ford, N.J.; model no. 6743), placed percutaneously3 or by cutdown in the radial artery at the wrist, is indicated for most patients with shock, acute respiratory failure or complicated diabetes. After confirming the presence of ulnar artery flow by palpation or Doppler ultrasound, a 1-cm incision exposing the artery for direct puncture is preferred in the thrombocytopenic patient. Multiple samples for blood gas analysis can be provided with the continuous Po 2 and Pco 2 indwelling arterial probe and analyzer (Ohio Sentorr Blood Gas Analyzer, Madison, Wis.; model no. 747-8000900) in patients requiring prolonged ventilatory support. This unit allows frequent simultaneous changes to be made in levels of inspired oxygen, positive end-expiratory pressure and minute ventilation with direct digital readout of the effect of these changes. Alternate sites for cannulation include the dorsalis pedis or superficial temporal artery. We have no experience with percutaneous brachial artery4 catheterization, which is potentially dangerous in the presence ofthrombocytopenia.
ACUTE HEMODIALYSIS Most acute hemodialyses are carried out in this unit with the Uni-flow system, utilizing a single 17.5-cm Desiret dialysis catheter inserted through the hemostatic valve of a Cordis catheter and removed at the end of the procedure. 1 Adequate blood flows of 200- 250 ml/min and satisfactory urea clearances have been demonstrated in over 40 patients for as long as 6 weeks of repeated use. Modifications in the Cordis sheath have been designed, allowing it to be used when regional heparinization is required and with any type of dialysis machine. This method has also been used for plasmapheresis alone or in combination with hemodialysis. Over 200 patients have had Cordis sheaths inserted during the past 2 years in this unit, and only 4 episodes of catheter-related sepsis have been recorded.
TRACHEOSTOMY Because of the feared hemorrhagic complications of tracheostomy, prolonged endotracheal intubation is usually preferred when ventilator support is needed in thrombocytopenic patients with diffuse interstitial pneumonia and respiratory failure. Disadvantages of this method include gum, tongue and pharyngeal bleeding; accumulation of mucus; and inadequate oral and pharyngeal toilet despite diligent nursing care2 Putrid collections of clots and mucus in the posterior pharynx can contaminate the distal trachea despite an inflated tube cuff; all are potentially dangerous, especially in leukopenic patients. We adopted recently the policy of early tracheostomy when prolonged intubation is necessary despite pIatelet counts as low as 10,000]cu mm 28
and have had no complications in 35 patients. While transfusing pIatelets, a vertical 3-cm midline incision is made in the neck, beginning at the cricoid cartilage. A surgical electrocautery unit, elective transection and suture ligation of the thyroid isthmus and coagulation of the incised edges of tracheal mucosa are imp o r tan t to assure hemostasis. The procedure is performed in the intensive care unit after first ve nt i l a t i ng the intubated patient for 5 min u tes with 100% oxygen to p r e v e n t hypoxia during extubation and insertion of the tracheostomy tube. Usually a considerable a m o u n t of clot and mucus is removed by tracheal aspiration through the newly placed tracheostomy tube despite careful aspiration of the oropharynx before deflating t he endotracheal balloon. These techniques have made a very real contribution to the care of the acutely ill patient with bone m a r r o w failure. T hey evolved from an obvious need, evidenced by inadequately monitored patients referred in shock or congestive failure, others with large neck h e m a t o m a s or hemopneumothoraces after unsuccessful attemp ts at central venous cannulation and wrists swollen to the point of vascular compromise from multiple radial a r t e r y punctures for blood gas analyses. The problem of vascular access is due to the fact t h a t m a n y cancer patients have t hei r peripheral veins thrombosed from prior c h e m o t h e r a p y and other infusions at a time of crisis, which sets the stage for potential complications. The simplicity of the methods described justify t hei r use in these circumstances, but their safety is dependent on skilled technique. Th ey ar e not "teaching" procedures for j uni or house officers. REFERENCES 1. Turnbull, A., Carlon, G., Bains, M., and Makowsky, M.: Multiple purpose central venous access using the Cordis catheter sheath system, Crit. Care Med. 7:30, 1979. 2. Blitt, C. D., Wright, W. A., Petty, W. C., and Webster, T. A.: Central venous catheterization via the external jugular vein: A technique employing the "J wire," J.A.M.A. 229:817, 1975. 3. DeAngelis, J.: Percutaneous Vascular Catheterization, in Well, M. It., and Henning, R. J. (eds.):Handbook of Critical Care Medicine (Miami: Symposia Specialists Inc., 1978),p. 47. 4. DeAngelis,J.: Axillary arterial monitoring,Crit. Care Med. 4:205, 1976. 5. Turnbull, A., and Carlon, G.: Airway management in the thrombocytopenic patient, Crit. Care Med. 7(2):76, 1979.
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