Bedside Insertion of Hickman Catheter
ABSTRACT & COMMENTARY
Synopsis: These authors report on 54 double lumen Hickman catheters percutaneously inserted and followed in patients undergoing bone marrow transplantation. The catheters were placed in an average of 35 minutes at the patients’ bedsides, without fluoroscopic control, and with only minor immediate complications in a few patients. Catheters remained in place a median of 70 days.
Source: Muhn M, et al. Anesth Analg 1997;84:80-84.
The need for long-term vascular access has resulted in development of a variety of catheters with low propensity for thrombosis and fracture. Infection is reduced by tunneling the catheter, creating a subcutaneous barrier to skin flora colonization. These devices are usually placed in the operating room and/or with radiographic control to guarantee asepsis and correct placement. The cost and inconvenience of using an operating room makes a non-operating room placement technique very attractive. This group reports on results of 54 catheters prospectively placed in 53 patients in a special care unit awaiting bone marrow transplantation.
Patients were minimally sedated with a benzodiazepine and monitored with ECG, automated blood pressure device, and pulse oximetry. Under local anesthesia and aseptic precautions, a guide wire was percutaneously placed in the internal jugular or subclavian vein. The wire insertion site was enlarged to about 1 cm, a separate exit incision was made, and the Hickman catheter tunneled to the guide wire. A dilator and peel-away sheath were placed over the guide wire, and the catheter was trimmed to the correct length and placed through the sheath. The incisions were closed and dressed and a chest radiograph was used to confirm correct catheter tip location. No prophylactic antibiotics were used.
All placements were successful. Despite the high risk for complications in these patients, due to coagulapathy, previous radiation, and having other central catheters in place, there were no serious immediate complications. Minor problems were difficulty in placing the wire or sheath (13 patients) and misplacement requiring manipulation under fluoroscopy (3 patients). Catheters were left in place an average of 70 days (3-214 days), experienced a low incidence of mechanical failure (5 catheters), caused no cases of thrombosis, were infrequently associated with infection (28 catheters), and rarely required removal due to infection (14 catheters, in place 12-191 days). Positive blood culture incidence was 0.45 per 100 catheter days, which was comparable to that in other reports in neutropenic patients.
COMMENT BY CHARLES G. DURBIN, JR, MD
Bedside placement of tunneled catheters is less expensive, more convenient, and involves less risk than placing these catheters in an operating room or a radiology suite. This report confirms that the technique is technically feasible. The important ingredient in adopting this approach is having experienced operators and a competent team performing the catheterizations. The logical choice would be a group of intensivists who frequently perform short-term central line placement. The added tunneling procedure is easy to master and useful for other indwelling catheters as well (e.g., epidural and intraventricular drains) to reduce infectious complications.
The importance of this report is to stimulate clinicians to consider use of this type of catheters for intermediate duration in critically ill patients. The success of percutaneous placement increases the use of this approach. Instead of repeated line changes for fevers, percutaneous placement of a Hickman catheter for use for the duration of the critical illness may reduce patient risk and cost of care. This procedure needs further evaluation, especially with respect to the infection risk of leaving the catheter in place in the face of documented bacteremia.
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