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

Catetere di Hickman per l'accesso vascolare a lungo termine nei suini

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.

Autore in primo piano: Uso del catetere di Hickman per l'accesso vascolare a lungo termine in un modello suino preclinico  

Uso del catetere di Hickman per l'accesso vascolare a lungo termine in un modello preclinico di suino

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  

Inserimento e fissaggio del catetere

Tagliare l'estremità del catetere all'incirca alla lunghezza in cui arriverebbe fino a un terzo della lunghezza dello sterno del suino. Usando la pinza Adson-Brown, afferrare il centro del segmento IJV isolato e praticare un taglio a metà del vaso con le forbici Metzenbaum curve. Tenendo premuto il segmento IJV, inserire il plettro della vena nel segmento caudale del vaso.Mantenendo la tensione sulla fascetta di sutura cranica. Inserire e infilare l'estremità del catetere nel vaso caudalmente. Una volta che il catetere è completamente inserito, annodare una volta la fascetta di sutura caudale per fissare temporaneamente il catetere di Hickman.Una volta confermata la pervietà, annodare due volte la fascetta di sutura caudale per fissare il segmento distale dell'IJV attorno al catetere endovenoso. Quindi annodare una volta la fascetta di sutura cranica per occludere il flusso sanguigno nel segmento IJV. Una volta fatto per chiudere il sito chirurgico ventrale, prima sutura platisma semplice suture interrotte con una sutura riassorbibile intrecciata 3-0.Quindi chiudere le suture sottocuticolari con una sutura riassorbibile monofilamento 3-0. Per fissare il catetere di Hickman alla pelle dell'animale, orientare il catetere di Hickman in modo che formi una forma a U. Quindi identifica tre punti.Il primo punto si trova a meno di due centimetri dal sito di uscita. Il secondo punto si trova sopra la porzione biforcuta del catetere dove le linee rosse e bianche divergono. E il terzo punto è in cima alla U tra i primi due punti.In ogni punto, posiziona un pezzo di tre centimetri di nastro medico da un pollice sopra il catetere per creare un'ala su ciascun lato. Con una sutura in polipropilene sintetico monofilamento O non assorbibile, fissare ogni ala alla pelle tramite un'unica sutura semplice interrotta. Nel secondo punto sopra la parte biforcuta, aggiungi una singola sutura interrotta attraverso lo spazio tra le due linee e assicurati che il nodo si trovi sopra il nastro per evitare irritazioni.Testare la pervietà delle linee bianche e rosse al di fuori del campo sterile tramite prelievi di sangue e lavaggi utilizzando 10 millilitri di soluzione fisiologica normale allo 0,9% e 10 millilitri di soluzione fisiologica eparinizzata. Una volta creata la sacca del catetere con il numero desiderato di lembi, allineare il foro e il lembo con il punto in cui le linee escono dal collare, orientandolo in modo che l'apertura sia caudale. Assicurati che la sacca si trovi sulla linea mediana o leggermente lateralmente al collo dorsale.Quindi tira le linee rosse e bianche attraverso il foro e fai il lembo uno, assicurandoti che le linee siano piatte tra i lembi uno e due con il lembo tre rivolto verso l'alto. Utilizzando una sutura in polipropilene monofilamento sintetico 0 non assorbibile, fissare la sacca al collare con una semplice sutura interrotta ad ogni angolo e a metà di ciascuna estremità. Non suturare attraverso la pelle.In una coorte rappresentativa di 32 suini con endpoint compreso tra 8 e 132 giorni, il 78,13 dei cateteri di Hickman è rimasto brevettato fino all'endpoint sperimentale. Nel 9,38% dei casi sono state necessarie piccole riparazioni, mentre i tassi di rimozione o sostituzione prima e dopo 30 giorni sono stati rispettivamente del 9,38% e del 12,5%. I motivi per cui la linea è stata compromessa includevano lo spostamento, la foratura e il blocco interno.Tuttavia, la riparazione e la sostituzione tempestive hanno dimostrato un tasso di successo funzionale del 100% senza interferenze significative con la raccolta dei dati.

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 ...

Ricerca

Medicina

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.

Identificazione della vena giugulare interna e preparazione del sito di uscita del catetere

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.

Introduzione e tunneling del catetere

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.