Techniques, Materials,
and Devices
Retrograde Tunnel: A Method for the Fixation of Long-Term Pediatric Central Venous Catheters R. A. WHEELER,
FRCS, D. M. GRIFFITHS, M.CH., FRCS,
From the Wessex Regional Centre for Pediatric
AND
D. M.
BURGE, MRCP, FRCS
Surgery, Southhampton General Hospital, Southampton, England
ABSTRACT. The fashioning of a subcutaneous tunnel has become an integral part of the placement of central venous catheters (CVC). Several methods have been described, but the long-term CVCs in pediatric practice pose special problems, particularly that of the patients continually testing the CVC’s
fixation. A
polyurethane CVC is used that has not been previously described in pediatric usage and a retrograde tunneling technique has been developed which affords immediate and secure fixation. (Journal of Parenteral and Enteral Nutrition :114-115, 1991) 15
One of the earliest
descriptions of the subcutaneous distal end of the Cuff Cath 16G catheter is introduced. for pediatric nutrition. General At this stage, the cuff is lying at the infraclavicular anesthesia is often mandatory and this has enabled a wound. The flow switch is then cut off the proximal end variety of approaches both to the central veins and to of the CVC, and the cut end sleeved over the steel tunneling to be used. tunneling rod. This is then pushed subcutaneously to a Until now, the various tunneling techniques for cuffed point in the mid-axillary line at the level of the nipple, catheters have all been limited to an antegrade approach and delivered through a 2-mm incision. The exteriorized because the luer lock of the Hickman-type CVC has been section is cut to a convenient length and a second flow undetachable. Thus, the catheter tip has had to be led switch, supplied in the pack, is firmly attached. At the infraclavicular incision, a small subcutaneous through the tunnel from the exit site before being delivered into the separate venotomy wound, ready for intro- pocket is fashioned. By gentle traction on the CVC duction into the vein. beyond the exit site, the cuff is pulled into the pocket This means that the cuff, on which the fixity of the and the wound closed (Fig. 1). CVC depends, has had to traverse that section of the No further dressing or fixation is required. Nothing tunneling of CVC
was
subcutaneous tunnel which separates it from the exit wound. The distal section of the tunnel is thus too wide to restrain the cuff. An unrestrained cuff means an unfixed CVC, hence in the first postoperative fortnight, various stitches, elastoplast, and disabling maneuvers are required to hold the CVC in place while tissue ingrowth into the cuff occurs. The recent reports 1,3 of various methods of securing cuffed CVCs in children while awaiting fixation are a testimony to this continuing problem. This is the first description of the use of the retrograde tunnel in pediatric practice, which has been made possible by the use of a polyurethanè CVC with a detachable hub (Cuff Cath, Viggo Spectramed). A method is described which ensures immediate secure CVC fixation.
with a greater external diameter than the CVC itself has traversed the subcutaneous tunnel, so it is not possible to pull the cuff out. When the CVC is no longer needed, the old wound can be reopened under local or general anesthesia and the
TECHNIQUE The central vein is cannulated by whatever technique is favored. Our standard approach is a percutaneous puncture of the right subclavian vein, via a 1.5-cm infraclavicular incision. The vein dilator is introduced followed by a splittable sheath, through which the precut
Reprint requests: Mr. R. A. Wheeler, Wessex Regional Center for Surgery, Southampton General Hospital, Tremona Road, Southampton, England S09 4xY.
h.
Pediatric
FiG. 1. The retrograde tunneling technique. 114
Downloaded from pen.sagepub.com at Bobst Library, New York University on June 30, 2015
115
exteriorized; the distal CVC is divided and pulled the exit site, the cuff and proximal CVC are delivered through the infraclavicular site and the wound
cuff
out at
closed. RESULTS
Sixteen CVCs have been inserted in 14 patients using this technique, mean age 3 years (3 months to 10 years), mean weight 20 kg (6.3-36). The CVCs have been in situ for a mean of 83 days (range 18-180). No cuffs have moved from the pocket, no CVC have been inadvertently removed, and there have been no problems with the flow
switch.
the external diameter of the 16G (1.8 mm) is sufficiently small to allow insertion through a splittable sheath. This allows the option of a percutaneous approach, rather than the formal internal jugular vein cut down currently used by many pediatric surgical centers: the latter ap-
proach may have been dictated by the external diameter of a Hickman-type CVC required to deliver the same flow
rate
(3.2 mm). CONCLUSION
We conclude that the technique of retrograde tunnela safe and effective way of obtaining immediate and secure central venous catheter fixation in children.
ing represents
DISCUSSION
The tunnel was originally devised as a technique for in patients receiving long-term parreducing CVC sepsis enteral therapy, 1° but can also be used to secure the CVC. While tissue ingrowth into a Dacron cuff is an effective method for long-term fixation, catheters still get accidentally removed during the immediate postoperative period.2,3 To have immediate secure fixation at the time of CVC insertion seems a clear advantage. A further benefit of the polyurethane Cuff Cath is that
REFERENCES 1. Wilmore
DW, Dudrick SJ: Growth and development of an infant receiving all nutrients exclusively by vein. JAMA 203:140-144,
1968 2. Alfieris
GM, Wing CW, Hoy GR: Securing Broviac catheters in children. J Pediatr Surg 22:825-826, 1987 3. Goolishan W, Konefal S: An alternative method of securing Broviac catheters in children and infants. JPEN 13:218-210, 1989 4. Keohane PP, Jones BJM, Attrill H: Effect of catheter tunneling and a nutrition nurse on catheter sepsis during parenteral nutrition. A controlled trial. Lancet 2:1388-1390, 1983
Downloaded from pen.sagepub.com at Bobst Library, New York University on June 30, 2015
and Devices
Retrograde Tunnel: A Method for the Fixation of Long-Term Pediatric Central Venous Catheters R. A. WHEELER,
FRCS, D. M. GRIFFITHS, M.CH., FRCS,
From the Wessex Regional Centre for Pediatric
AND
D. M.
BURGE, MRCP, FRCS
Surgery, Southhampton General Hospital, Southampton, England
ABSTRACT. The fashioning of a subcutaneous tunnel has become an integral part of the placement of central venous catheters (CVC). Several methods have been described, but the long-term CVCs in pediatric practice pose special problems, particularly that of the patients continually testing the CVC’s
fixation. A
polyurethane CVC is used that has not been previously described in pediatric usage and a retrograde tunneling technique has been developed which affords immediate and secure fixation. (Journal of Parenteral and Enteral Nutrition :114-115, 1991) 15
One of the earliest
descriptions of the subcutaneous distal end of the Cuff Cath 16G catheter is introduced. for pediatric nutrition. General At this stage, the cuff is lying at the infraclavicular anesthesia is often mandatory and this has enabled a wound. The flow switch is then cut off the proximal end variety of approaches both to the central veins and to of the CVC, and the cut end sleeved over the steel tunneling to be used. tunneling rod. This is then pushed subcutaneously to a Until now, the various tunneling techniques for cuffed point in the mid-axillary line at the level of the nipple, catheters have all been limited to an antegrade approach and delivered through a 2-mm incision. The exteriorized because the luer lock of the Hickman-type CVC has been section is cut to a convenient length and a second flow undetachable. Thus, the catheter tip has had to be led switch, supplied in the pack, is firmly attached. At the infraclavicular incision, a small subcutaneous through the tunnel from the exit site before being delivered into the separate venotomy wound, ready for intro- pocket is fashioned. By gentle traction on the CVC duction into the vein. beyond the exit site, the cuff is pulled into the pocket This means that the cuff, on which the fixity of the and the wound closed (Fig. 1). CVC depends, has had to traverse that section of the No further dressing or fixation is required. Nothing tunneling of CVC
was
subcutaneous tunnel which separates it from the exit wound. The distal section of the tunnel is thus too wide to restrain the cuff. An unrestrained cuff means an unfixed CVC, hence in the first postoperative fortnight, various stitches, elastoplast, and disabling maneuvers are required to hold the CVC in place while tissue ingrowth into the cuff occurs. The recent reports 1,3 of various methods of securing cuffed CVCs in children while awaiting fixation are a testimony to this continuing problem. This is the first description of the use of the retrograde tunnel in pediatric practice, which has been made possible by the use of a polyurethanè CVC with a detachable hub (Cuff Cath, Viggo Spectramed). A method is described which ensures immediate secure CVC fixation.
with a greater external diameter than the CVC itself has traversed the subcutaneous tunnel, so it is not possible to pull the cuff out. When the CVC is no longer needed, the old wound can be reopened under local or general anesthesia and the
TECHNIQUE The central vein is cannulated by whatever technique is favored. Our standard approach is a percutaneous puncture of the right subclavian vein, via a 1.5-cm infraclavicular incision. The vein dilator is introduced followed by a splittable sheath, through which the precut
Reprint requests: Mr. R. A. Wheeler, Wessex Regional Center for Surgery, Southampton General Hospital, Tremona Road, Southampton, England S09 4xY.
h.
Pediatric
FiG. 1. The retrograde tunneling technique. 114
Downloaded from pen.sagepub.com at Bobst Library, New York University on June 30, 2015
115
exteriorized; the distal CVC is divided and pulled the exit site, the cuff and proximal CVC are delivered through the infraclavicular site and the wound
cuff
out at
closed. RESULTS
Sixteen CVCs have been inserted in 14 patients using this technique, mean age 3 years (3 months to 10 years), mean weight 20 kg (6.3-36). The CVCs have been in situ for a mean of 83 days (range 18-180). No cuffs have moved from the pocket, no CVC have been inadvertently removed, and there have been no problems with the flow
switch.
the external diameter of the 16G (1.8 mm) is sufficiently small to allow insertion through a splittable sheath. This allows the option of a percutaneous approach, rather than the formal internal jugular vein cut down currently used by many pediatric surgical centers: the latter ap-
proach may have been dictated by the external diameter of a Hickman-type CVC required to deliver the same flow
rate
(3.2 mm). CONCLUSION
We conclude that the technique of retrograde tunnela safe and effective way of obtaining immediate and secure central venous catheter fixation in children.
ing represents
DISCUSSION
The tunnel was originally devised as a technique for in patients receiving long-term parreducing CVC sepsis enteral therapy, 1° but can also be used to secure the CVC. While tissue ingrowth into a Dacron cuff is an effective method for long-term fixation, catheters still get accidentally removed during the immediate postoperative period.2,3 To have immediate secure fixation at the time of CVC insertion seems a clear advantage. A further benefit of the polyurethane Cuff Cath is that
REFERENCES 1. Wilmore
DW, Dudrick SJ: Growth and development of an infant receiving all nutrients exclusively by vein. JAMA 203:140-144,
1968 2. Alfieris
GM, Wing CW, Hoy GR: Securing Broviac catheters in children. J Pediatr Surg 22:825-826, 1987 3. Goolishan W, Konefal S: An alternative method of securing Broviac catheters in children and infants. JPEN 13:218-210, 1989 4. Keohane PP, Jones BJM, Attrill H: Effect of catheter tunneling and a nutrition nurse on catheter sepsis during parenteral nutrition. A controlled trial. Lancet 2:1388-1390, 1983
Downloaded from pen.sagepub.com at Bobst Library, New York University on June 30, 2015
