Name: Insertion and Securing the Catheter
Uploaded: 2023-03-31T14:00:00
Description: Watch this Scientific Journal Video about Insertion and Securing the Catheter at JoVE.com

The video demonstrates the surgical procedure for implanting a Hickman catheter in swine, detailing catheter length adjustment, vessel preparation, securing sutures, and confirming catheter patency. It reports a successful patent rate of 78.13% in a study of 32 swine, noting minor repair needs and effective outcomes for catheter management.

insertion and securing the catheter

Hickman-katheter voor langdurige vasculaire toegang bij varkens

The indispensable role of central venous catheters (CVCs) in patient care is owed to their convenience, favorable safety profile, and versatility1. Functions of a CVC include reliable access for total parenteral nutrition, hematopoietic stem cell transplantation, plasmapheresis/apheresis, and efficient fluid, blood, or co-drug administration2. In veterinary medicine, CVCs also minimize animal discomfort via the rapid dilution of irritant drugs and blood sampling without repeated venipuncture3. Despite their broad applications, the use of CVCs in large animal research still presents several considerable challenges4.
Percutaneous CVC placement via a guidewire or introducer catheter can be difficult for non-veterinary researchers, particularly in animals with deep venous structures5. An improper CVC installation technique may result in inadvertent placement into nearby structures, necessitating ultrasound-guided placement or a postprocedure radiography of the positioning6. However, compared to human operating rooms, ultrasounds are not readily available in many large animal research laboratories. Further, long-term use of indwelling catheters can result in line kinking, puncture, infection, or extrication by animals, with the possible disruption of timely treatment, clinical monitoring, and research outcomes4,7. Replacement of the CVC requires additional resources, including material procurement, surgical scheduling, fasting time, and radiographic access. CVC-related complications can therefore create significant technical and financial barriers or a disruption to productive translational research, particularly in swine. Contamination by food or feces, scratching against cage walls, and kicking sites of irritation may compromise a CVC, and the risk of CVC-related complications is amplified by long-term use. Thus, safe and uncomplicated maintenance of a CVC in swine requires careful consideration of CVC choice, placement, securement, protection, sanitation, and surveillance.
The Hickman catheter (HC) used in this protocol is a tunneled CVC with a polyester cuff and one to three lumens, that is commonly used for long-term intravenous access in humans and animals1,4,8,9. The tunneled catheter approach has been associated with lower complication rates and maintenance costs relative to non-tunneled variations10,11,12. The cuff reduces HC extrication by incorporating into the subcutaneous tissues surrounding the skin exit site. The multi-lumen design also enables the separation of medication administration and blood draws, thereby minimizing blood sample contamination and inaccuracy. Despite this, HC use is not without challenges, the most common of which include fracture, migration, occlusion, and infection13,14,15,16. Proper installation and maintenance of a HC are therefore indispensable skills when used in translational research. However, the current literature offers little guidance for best-practices for HC use in swine during long-term trials5,6,17.
The purpose of this study is to outline an optimized approach for HC insertion into the internal jugular vein (IJV), skin securement, and durable protection that minimizes long-term catheter-related complications and discomfort in swine. A discussion of the important considerations for HC use, potential challenges that may be encountered, and modifications that may improve the quality of this approach is included.

Auteur in de schijnwerpers: Hickman-kathetergebruik voor langdurige vasculaire toegang in een preklinisch varkensmodel  

Hickman-kathetergebruik voor langdurige vasculaire toegang in een preklinisch varkensmodel

This protocol describes a reliable and reproducible technique for the insertion and maintenance of a tunnel Hickman catheter for long-term vascular access in a large animal model. The approach allows for convenient daily sampling of whole blood from awake animals and intravenous administration of medication and fluids. Some of the main challenges to the long-term central venous lines in large animals are infection and damages.As large animals are occasionally able to gain access to the lines and cause mechanical trauma. To mitigate these challenges, our group has invented our special pouches that protects the line while still allowing easy access to the same catheter. Central venous catheters are invaluable devices in large animal research as they facilitate a wide range of medical applications, but there is no consensus on the best practices for their insertion and maintenance.In response, we have proposed a protocol that comprehensively describes an approach for proper placement of a tunneled Hickman catheter in pigs that minimizes catheter-related complications and morbidity. The use of our approach in over 100 pigs has resulted in long-term patency and minimal complication rates. This protocol offers a method to optimize the lifespan of the Hickman catheter, and guidance for approaching issues during its use.

Watch this Scientific Journal Video about Insertion and Securing the Catheter at JoVE.com

Insertion and Securing the Catheter  

Inbrengen en vastzetten van de katheter

Snijd het uiteinde van de katheter af tot ongeveer de lengte waarop deze tot een derde van de lengte van het borstbeen van het varken zou reiken. Pak met een Adson-Brown-pincet het midden van het geïsoleerde IJV-segment vast en maak halverwege het vat een snede met een gebogen Metzenbaum-schaar. Terwijl u het IJV-segment vasthoudt, steekt u de aderprikker in het caudale segment van het vat.Terwijl de spanning op de schedelnaadband behouden blijft. Breng het uiteinde van de katheter caudaal in het vat en rijg het in. Zodra de katheter volledig is ingebracht, knoopt u de caudale hechtdraad één keer vast om de Hickman-katheter tijdelijk vast te zetten.Zodra de doorgankelijkheid is bevestigd, knoopt u de caudale hechtdraad twee keer vast om het distale IJV-segment rond de intraveneuze katheter vast te zetten. Knoop vervolgens de schedelhechting één keer vast om de bloedstroom in het IJV-segment af te sluiten. Eenmaal gedaan om de ventrale operatieplaats te sluiten, hecht eerst platysma eenvoudig onderbroken hechtingen met een 3-0 gevlochten resorbeerbare hechting.Sluit vervolgens subcuticulaire lopende hechtingen met een 3-0 monofilament resorbeerbare hechting. Om de Hickman-katheter aan de huid van het dier te bevestigen, oriënteert u de Hickman-katheter zo dat deze een U-vorm vormt. Identificeer vervolgens drie punten.Het eerste punt bevindt zich binnen twee centimeter van de uitgangslocatie. Het tweede punt is over het gevorkte gedeelte van de katheter waar de rode en witte lijnen uiteenlopen. En het derde punt bevindt zich aan de bovenkant van de U tussen de eerste twee punten.Plaats op elk punt een stuk medische tape van drie centimeter van een inch over de katheter om aan elke kant een vleugel te creëren. Met een O synthetisch monofilament, niet-resorbeerbaar polypropyleen hechtdraad, bevestig je elke vleugel aan de huid via een enkele eenvoudige onderbroken hechting. Voeg op het tweede punt over het gevorkte gedeelte een enkele onderbroken hechting toe door de opening tussen de twee lijnen en zorg ervoor dat de knoop bovenop de tape ligt om irritatie te voorkomen.Test de doorgankelijkheid van de witte en rode lijnen buiten het steriele veld via bloedafnames en spoelingen met 10 milliliter 0,9% normale zoutoplossing en 10 milliliter gehepariniseerde zoutoplossing. Zodra het katheterzakje met het gewenste aantal flappen is gemaakt, lijnt u het gat en de flap uit met het punt waar de lijnen de kraag verlaten, en oriënteert u het zo dat de opening caudaal is. Zorg ervoor dat het zakje zich op de middellijn of iets lateraal van de dorsale nek bevindt.Trek vervolgens de rode en witte lijnen door het gat en flap één, zorg ervoor dat de lijnen plat liggen tussen flap één en twee met flap drie naar boven gericht. Gebruik een 0 synthetisch monofilament, niet-resorbeerbaar polypropyleen hechtdraad, bevestig het zakje aan de kraag met een eenvoudige onderbroken hechting in elke hoek en halverwege elk uiteinde. Hecht niet door de huid.In een representatief cohort van 32 varkens met een eindpunt variërend van acht tot 132 dagen, bleven 78,13 van de Hickman-katheters patent tot het experimentele eindpunt. In 9,38% van de gevallen waren kleine reparaties nodig, terwijl het percentage verwijderingen of vervangingen voor en na 30 dagen respectievelijk 9,38% en 12,5% bedroeg. Redenen voor compromissen in de lijn waren onder meer verplaatsing, lekke banden en interne blokkades.Tijdige reparatie en vervanging toonden echter een 100% functioneel slagingspercentage aan zonder noemenswaardige interferentie met het verzamelen van gegevens.

Research

JoVE Journal

Medicine

Insertion and Securing the Catheter

Hickman Catheter Use for Long-Term Vascular Access in a Preclinical Swine Model

Central venous catheters (CVCs) are invaluable devices in large animal research as they facilitate a wide range of medical applications, including blood monitoring and reliable intravenous fluid and drug administration. Specifically, the tunneled multi-lumen Hickman catheter (HC) is commonly used in swine models due to its lower extrication and complication rates. Despite fewer complications relative to other CVCs, HC-related morbidity presents a significant challenge, as it can significantly delay or otherwise negatively impact ongoing studies. The proper insertion and maintenance of HCs is paramount in preventing these complications, but there is no consensus on best practices. The purpose of this protocol is to comprehensively describe an approach for the insertion and maintenance of a tunneled HC in swine that mitigates HC-related complications and morbidity. The use of these techniques in &gt;100 swine has resulted in complication-free patent lines up to 8 months and no catheter-related mortality or infection of the ventral surgical site. This protocol offers a method to optimize the lifespan of the HC and guidance for approaching issues during use.

A reliable and reproducible approach for the insertion and maintenance of a tunneled Hickman catheter for long-term vascular access in swine is described. Placement of a central venous catheter allows for convenient daily sampling of whole blood from awake animals and intravenous administration of medication and fluids.

Central venous catheters (CVCs) are invaluable devices in large animal research as they facilitate a wide range of medical applications, including blood ...

Internal Jugular Vein Identification and Catheter Exit Site Preparation

To begin, place the anesthetized swine on the operating table. In the ventral field, make a four-centimeter incision between the trachea and the medial border of the sternocleidomastoid muscle. Divide the platysma and dissect the connective tissue to expose the internal jugular vein, or IJV, on the lateral border of the sternocleidomastoid muscle.Then isolate three to four centimeters of the IJV by dividing its branches with 4.0 coated and braided non-absorbable suture ties. Circumferentially dissect away from the surrounding connective tissue. At the cranial end of the IJV, pass a coated and braided non-absorbable suture tie twice underneath the vessel to create a loop around it.At the coddle end, pass a suture tie once underneath the vessel to create a sling. For catheter exit site preparation. Reposition the swine via lateral tilt toward the non-surgical side to expose the ipsilateral dorsal surgical field.Once the limbs are resecured, with a number 10 blade scalpel, make a 0.5 centimeter puncture in the skin at the desired catheter exit site, three centimeters lateral to the vertebral column, and five centimeter coddle to the head.

Identificatie van de inwendige halsader en voorbereiding van de katheteruitgang

Introduction and Tunneling of Catheter

For tunneling of the catheter, remove the wet gauze and reidentify the isolated IJV segment, then choose a target entry site for catheter introduction subcutaneously at the same depth as the IJV, deeper than the sternocleidomastoid, and between the two coated and braided non-absorbable suture ties. Hold the Hickman catheter introducer in the dominant hand in the dorsal surgical field and suspend the remaining length of the catheter in the air above the sterile field. The non-dominant hand should be in the ventral surgical field.Insert the introducer into the exit puncture site with the dominant hand, pointing the tip of the device toward the non-dominant hand in the ventral field. Push the tip of the introducer superficially and medially to tunnel the catheter through the adipose tissue, feeling for the emergence of the tip with a non-dominant hand. Once the tip emerges at the target entry site, pull the introducer and catheter through the subcutaneous tunnel until the cuff of the main line is just underneath the surface of the skin of the dorsal field.

Introductie en tunneling van katheter

Cut the end of the catheter to approximately the length at which it would reach down to one third of the length of the swine's sternum. Using Adson-Brown forceps, grasp the middle of the isolated IJV segment and make a cut halfway through the vessel with curved Metzenbaum scissors. While holding the IJV segment, insert the vein pick into the caudal segment of the vessel.While maintaining tension on the cranial suture tie. Insert and thread the end of the catheter into the vessel caudally. Once the catheter is fully inserted, knot the caudal suture tie once to temporarily secure the Hickman catheter.Once patency is confirmed, knot the caudal suture tie twice to secure the distal IJV segment around the intravenous catheter. Then knot the cranial suture tie once to occlude blood flow in the IJV segment. Once done to close the ventral surgical site, first suture platysma simple interrupted sutures with a 3-0 braided absorbable suture.Then close subcuticular running sutures with a 3-0 monofilament absorbable suture. To secure the Hickman catheter to the animal's skin, orient the Hickman catheter so that it forms a U shape. Then identify three points.The first point is within two centimeters of the exit site. The second point is over the forked portion of the catheter where the red and white lines diverge. And the third point is at the top of the U between the first two points.At each point, place a three centimeter piece of one inch medical tape over the catheter to create a wing on each side. With a O synthetic monofilament, non-absorbable polypropylene suture, secure each wing to the skin via a single simple interrupted suture. At the second point over the forked portion, add a single interrupted suture through the gap between the two lines and ensure that the knot lies on top of the tape to prevent irritation.Test the patency of the white and red lines outside the sterile field via blood draws and flushes using 10 milliliters of 0.9%normal saline and 10 milliliters of heparinized saline. Once the catheter pouch with the desired number of flaps is created, align the hole and flap one with the point where the lines exit the collar, orienting it so that it's opening is caudal. Ensure the pouch is on the midline or slightly lateral to the dorsal neck.Then pull the red and white lines through the hole and flap one, ensuring the lines lay flat between flaps one and two with flap three facing up. Using a 0 synthetic monofilament, non-absorbable polypropylene suture, secure the pouch to the collar with a simple interrupted suture at each corner and midway along each end. Do not suture through the skin.In a representative cohort of 32 swine with endpoint ranging from eight to 132 days, 78.13 of Hickman catheters remained patent until the experimental endpoint. Small repairs were required in 9.38%of cases, while rates of removal or replacement before and after 30 days were 9.38%and 12.5%respectively. Reasons for line compromises included displacement, puncture, and internal blockage.However, timely repair and replacement demonstrated a 100%functional success rate without significant interference with data collection.