Silicone Rubber Catheters Research Articles

The Removal of Central Venous Silicone Rubber Catheters

To the Editor.— Dr Fisher 1 reports the spontaneous erosion of the Dacron cuff several months after an extraction of the Hickman catheter. I was pleased to see in his article the description of his technique of removal, as I have yet to see a Hickman catheter slip out of its Dacron cuff. The hazards of the catheter breaking between the exit side and the cuff during a traction effort could well facilitate an air embolus at the time of the breakage unless the catheter was guaranteed to be full of clotted blood. For this reason and particularly because of the totally innocuous procedure of cutting down on the Dacron cuff I find it hard to justify even trying to remove Hickmans by traction with the intent of leaving the Dacron cuff in the soft tissues. I would heartily endorse Dr Fisher's conclusion that in the future the catheter be

The Removal of Central Venous Silicone Rubber Catheters

To the Editor.— After reading Dr Fisher's1 article, I am amazed that the author was able to remove any Hickman catheter by traction. With the Dacron cuff bonded to the catheter, it is our experience that it is firmly adherent and would take much more than gentle traction to remove this. In fact, it would take tearing away this cuff from the surrounding tissue to which it was bonded by fibrous ingrowth. In our experience, we remove these in the office, placing a small amount of local anesthesia over the cuff, making a small incision, dissecting around the cuff, and easily removing the cuff and entire catheter. One stitch is needed to close the small skin opening. We have had no infectious complications from this procedure, and this virtually eliminates the complication of a retained foreign body.

The Removal of Central Venous Silicone Rubber Catheters

To the Editor.— Complications associated with the use of indwelling right atrial catheters include infection, thrombosis, dislodgement, migration of the catheter tip, subcutaneous catheter leak, and erosion of the Dacron cuff. 1-6 We report retention of a catheter fragment followed by recurrent bacteremia. Report of a Case.— A 56-year-old woman with a history of recurrent urinary tract infections was treated with a six-week course of ampicillin through a Hickman catheter for an Escherichia coli vertebral osteomyelitis. After an additional sevenday regimen of cefamandole for a urinary tract infection caused by Klebsiella pneumoniae , the catheter was removed. One month later, the patient experienced K pneumoniae sepsis (urine culture showed growth of only Candida tropicalis ) for which she was treated with two weeks of cefotaxime via a second Hickman catheter. She was then transferred to a rehabilitation facility. Five weeks later, the patient again experienced K pneumoniae sepsis, which responded to cefotaxime.

Internal jugular vein cannulation using 2 silastic catheters. A new, simple and safe long-term vascular access for extracorporeal treatment.

Subclavian vein cannulation, although a major progress in temporary vascular access, was associated with a significant morbidity and mortality. A safer alternative technique would therefore be welcome. For the last 2 years, we developed a new approach consisting in internal jugular vein cannulation (IJVC) with 2 silicone rubber catheters with a long-term proved biocompatibility. 138 pairs of cannulae were inserted in 129 uremics patients. Mean duration of use was 54 days (1 day to 17 months). More than 3,000 high-performance HD sessions were performed. IJVC handling and care was easily managed by nurses. Low incidence of complications was observed: 2 thrombosis episodes, 3 skin infection with 2 septicemiae, 1 air embolism, 1 anaphylactoid reaction. No death was related to the technique itself. IJVC offers a new method of percutaneous central vein cannulation, providing a safe and reliable temporary vascular access immediately usable for all kinds of extracorporeal treatment.

Complication of a Hickman Catheter

INDWELLING central venous silicone rubber catheters (Broviac and Hickman) have gained widespread acceptance in patients requiring parenteral nutritional support or repeated venous access for cancer chemotherapy. Complications following catheter placement have been rare and include bacteremia, fungemia, local infection, hematoma formation, and catheter malfunction including migration, breakage, and occlusion.^1,2Virtually no reports of significant complications following catheter removal have been published. The following case report describes the spontaneous cutaneous erosion of a retained Dacron cuff nine months after Hickman catheter removal. <h3>Report of a Case</h3> A 24-year-old man was found to have an osteogenic sarcoma of the right humerus in February 1979. He was referred to a physician at Memorial Hospital in New York and received preoperative chemotherapy, limb-sparing surgical resection, and postoperative chemotherapy (T-10 protocol).³In April 1983 he developed a recurrence in the apex of his right lung, with thoracic outlet involvement. He returned to Memorial

A uni-directional urethral force gauge.

Until now urethral transducers have had poor circumferential resolution and have been inadequate for assessing whether the forces closing the female urethra are equally distributed around its circumference or whether they are greater in some directions than others. This paper describes a urethral force gauge which is capable of measuring urethral occlusive forces in a uni-directional manner because it is sensitive to forces around only 20 degrees of the urethral circumference. The gauge comprises a sensor, utilising two semi-conductor strain gauges, mounted at the tip of a 14 F silicone rubber catheter. It has been used in the investigation of 232 female patients and has proved to be reliable and robust.

Embolisation of silicone rubber catheters used for intravenous feeding; a preventable complication

The advantages of silicone rubber central venous catheters are widely recognised, but embolisation of the whole catheter can occur due to malfunction of the hub which is used to clamp the catheter to the female luer connector. Two cases are described in which silicone rubber catheters were successfully removed from the heart using percutaneous techniques. A modification is suggestion to prevent this complication.

Allergic Eosinophilic Dermatitis Due to Silicone Rubber: A Rare but Troublesome Complication of the Tenckhoff Catheter

A 42-year-old Japanese woman developed an eczematous skin rash around the catheter exit during continuous ambulatory peritoneal dialysis (CAPD). The same kind of lesion developed around a Scribner shunt exit. Skin biopsy indicated chronic eosinophilic dermatitis. In the patch test she developed an allergic reaction to the silicone rubber catheter but not to the antiseptic solutions. Based on these findings, we concluded that her “eczematous” rash represented an allergic response to silicone rubber in the peritoneal catheter. To this date the literature contains no reports of such a catheter complication in CAPD. Catheter complications in patients on CAPD are mainly infection and mechanical dysfunction such as poor drainage or leaks (I, 2). Eosinophilic dermatitis around the catheter exit caused by the silicone rubber is extremely uncommon (3). As yet no reports have been published concerning this rare catheter complication.

Totally implanted device for venous access. Experience in tumour patients.

A device for central venous access consisting of a subcutaneous injection portal (Port-A-Cath) connected to a silicone rubber catheter was implanted in 30 tumour patients. The system was used mainly for the administration of antineoplastic drugs. During the investigation period (18 months) the systems remained in function for a median time of 155 days (range 7-372 days). Drug injections were given to 22/30 patients on a median of 11 occasions (range 2-65). Continuous infusions were administered to 17/30 patients for a median time of 15 days (range 1-43). Routine flushing with heparinized saline was performed monthly. Ten patients died with the system still functioning. In another 18 cases the devices were working at the completion of the study. One catheter extravasated. Skin erosion at the site of the portal occurred in 2 cases, in one of which the system had to be extracted. Partial caval thrombosis developed around a catheter tip in one case. No system became occluded or infected. Overall patient acceptance was excellent.

Long-term alimentation by a new indwelling tube gastrostomy technique.

Use of a Gore-Tex peritoneal catheter as a feeding gastrostomy tube can virtually eliminate the complications associated with long-term feeding gastrostomy. The tube consists of a radiopaque 18 F silicone rubber catheter having a toadstool-shaped, expanded polytetrafluorethylene flange and cuff around its midportion. Epithelial tissue grows into the interstices of the Gore-Tex flange, and fibroplasia incorporates the cuff into the tissue, fixing the tube firmly in place and preventing its inadvertent removal. In addition, the tissue ingrowth creates a physiologic barrier that prevents efflux of intragastric contents and discourages influx of microorganisms or other contaminants along the gastrostomy tract. Thus far, Gore-Tex feeding gastrostomies have been placed for two to 11 months in six critically ill malnourished patients who required long-term or permanent gastrostomy feeding. No complications have occurred, patient safety and satisfaction have been greatly increased, efficacy of nutritional rehabilitation has been enhanced, and the patients' quality of life has been vastly improved.

A model of catheter colonisation in vitro and its relationship to clinical catheter infections

A laboratory model for colonisation of silicone-rubber catheters by staphylococci is described. The criteria for true colonisation that involves adhesion of the organisms to the luminal surface are discussed. Light and scanning electron micrographs of the microcolonies produced in the laboratory model suggest that the same mechanisms of adhesion, involving extracellular slime, apply as in clinically colonised catheters. Potential uses of the model, for studying further the mechanisms of colonisation and particularly its prevention and treatment, are discussed.

Care of the central venous catheterization site: the use of a transparent polyurethane film.

Studies of care of patients with central venous catheters report a 3-7% incidence of catheter-induced sepsis when sterile gauze and tape are used as an occlusive dressing. The technique requires that the dressing be changed three times each week for catheterization site inspection. From June 1979 to September 1980, a noncomparative evaluation of a transparent, self-adhesive, polyurethane dressing which is permeable to water vapor but not bacteria was performed. This dressing was used for the care of 100 consecutive patients with central venous catheters. Dressing life averaged 5.3 days with silicone rubber catheters and 4.3 days for polyvinyl chloride catheters. One patient developed catheter induced sepsis (incidence 1%). This dressing material: (1) is acceptable for use as a dressing of central venous catheters; (2) continuously permits inspection of the insertion sites; (3) decreases nursing hours; (4) provides a comfortable dressing which secures the catheter to the patient; and (5) is durable even when exposed to high humidity therapy devices, or when possible permits the patient to take showers.

Bacterial adherence and glycocalyx formation in osteomyelitis experimentally induced with Staphylococcus aureus.

A surgical procedure allowed the placement of a silicone rubber catheter in the marrow cavity of the tibia of a rabbit and also allowed the introduction of a sclerosing agent (sodium morrhuate) and cells of Staphylococcus aureus. Osteomyelitis developed in 60% of the animals so treated, and the infecting microorganism was recovered from the infected tibias of the animals that developed this disease. All blood cultures taken 24 h after the infection were negative for S. aureus. Radiological findings consisted of osteolytic changes, the occurrence of sequestration and periosteal reactions, and sclerosis in the infected bones. Sections of bone prepared for histological examination confirmed the diagnosis of osteomyelitis. Transmission and scanning electron microscopy of samples of bone marrow, bone chips, and the catheters taken from the infected tibiae revealed gram-positive cocci embedded in a very extensive matrix of ruthenium red-staining glycocalyx adhering to the bone and the implanted catheter. It is proposed that this extensive glycocalyx served a protective function for the bacteria and was important in bacterial adherence and thus played an important role in bacterial persistence and the development of osteomyelitis in these rabbits.

A radiological study after parenteral nutrition through silicone rubber catheters: Fibrin sleeves without thrombosis

Injection of contrast material through 38 central silicone rubber catheters at the time of withdrawal after a mean catheter life of 55 days (range 5–369) has shown no evidence of occult venous thrombosis despite the presence of a fibrin sleeve around the whole length of the intravascular portion in 37 cases. The presence of this fibrin sleeve appears to have been harmless. The absence of thrombosis suggests that silicone rubber is the material of choice for central venous feeding catheters and that the addition of heparin to the infusion fluid is unnecessary.

CaxP and Ca/P in the parenteral feeding of preterm infants.

Preterm infants requiring prolonged intravenous feeding frequently develop pathologic fractures and rickets. Infants who receive large amounts of calcium have fewer fractures. This observation led us to determine the maximal amounts of calcium and phosphate that can be added to parenteral nutrition solutions without the precipitation of calcium phosphate and to determine the optimal ratio of calcium to phosphate in these solutions. Clinical observations and in vitro experiments indicate that the product of calcium x phosphate (CaxP) in the dextrose-amino acid solution should not exceed 75 square millimolar (square millimole per square liter) to prevent calcium phosphate precipitation in barium-impregnated silicone rubber catheters and should not exceed 100 square millimolar in solutions administered through peripheral veins. Seven intake and output studies were performed in preterm infants to determine the ratio of calcium to phosphate (Ca/P) in the total parenteral nutrition solutions that minimized urinary losses. A Ca/P ratio of 5.0 minimized the sum of the calcium plus phosphate losses in the urine. However, experience with long-term total parenteral nutrition in preterm infants, awareness of the acute and life-threatening effects of body phosphate depletion, and an unmeasured endogenous enteric calcium secretion all suggest that a Ca/P ratio of approximately 3.0 provides a safer compromise between the acute and serious complications of phosphate deficiency and the chronic problems of fractures and rickets due to calcium deficiency.

Direct central vein puncture for silicone rubber catheter insertion (An alternative technique for Broviac catheter placement): T. A. Stellato, M. W. Gauderer, A. M. Cohen. Surgery 90:896–899, (November), 1981

Direct central vein puncture for silicone rubber catheter insertion (An alternative technique for Broviac catheter placement): T. A. Stellato, M. W. Gauderer, A. M. Cohen. Surgery 90:896–899, (November), 1981

Long term parenteral therapy by percutaneous tunneled silicone central venous catheter—A follow-up of 300 catheters

We have developed a technique for the management of central venous catheters which incorporates percutaneous insertion and daily care for routine use in different wards. A follow-up of the first 300 catheters is presented. When intravenous therapy was planned for more than two weeks, a silicone rubber catheter was introduced percutaneously with a skin tunnel and the position of the tip in the lower superior vena cava checked by venous pressure measurement. The metal hub of the catheter was disinfected daily by heating with a modified soldering iron which has been proved to be effective by in vitro testing with different microorganisms. The external jugular vein was used in 164 cases (55 per cent) the internal jugular vein in 115 (38 per cent) and the remaining catheters were inserted by the subcalvian or antecubital route. Correct positioning was obtained in 96 per cent and serious early or late complications were rare there being only one case of septicaemia in a total treatment period of 270 months. One patient developed a lung infarct, but no case of pneumothorax has been seen. The mean duration of the catheters was 27 days (range 1–239) and the common reasons for termination were cessation of need in 84 per cent, mechanical obstruction in 6 per cent and inadvertent removal in 6 per cent. The described method has proved to be safe and to function well on ordinary wards.

Long-term parenteral nutrition. II. Catheter-related complications.

Catheter-related complications were investigated in 70 patients receiving long-term parenteral nutrition (LTPN) for 1 to 63 months (median, 4.5 months) with a total observation period of 816 patient-months. Two hundred and three central venous catheters were used: 52 Broviac silicone rubber catheters and 151 Intracaths or Argyle baby feeding tubes made from polyvinyl chloride with plasticizers. The median duration was longer for Broviac catheters (5.0 months) than for the other catheters (1.1 months). Pneumothorax and/or subcutaneous emphysema occurred in 14 of 113 subclavian vein punctures (12%). Forty-eight episodes of catheter sepsis occurred in 27 patients. The incidence of sepsis was lower for Broviac catheters (0.3 per catheter-year) than for the other catheter types (0.9 per catheter-year). Catheter-induced thrombosis of a central vein was shown by phlebography 35 times among 25 (52%) of te 48 patients investigated, corresponding to an overall incidence of 1 in 22 patient-months. Total occlusion of a central vein occurred in 14 cases. The incidence of thrombosis was lower for Broviac catheters (0.5 per catheter-year) than for the other catheters (1.6 per catheter-year). Partial venous occlusions usually resolved after heparin therapy and/or catheter exchange, whereas total occlusions usually persisted for years. No correlation was found between incidence of complications and catheter lifetime. Seventeen patients died while receiving LTPN. In three patients death was related to LTPN: catheter sepsis, subdural haematoma possibly due to anticoagulant therapy, and respiratory failure caused by pulmonary infection after iatrogenic pneumothorax. For LTPN we recommend Broviac catheters, which showed longer duration, lower complication rate, and higher patient compliance. Catheter sepsis should be treated with both catheter exchange and antibiotics. Because of the high incidence of thrombosis we recommend that all patients on LTPN receive anticoagulant therapy. However, the value of anticoagulant therapy is not proved in a prospective, controlled study.

1171 CONTINUOUS INTRAVENOUS INSULIN DELIVERY IN AMBULATORY ADOLESCENT DIABETICS

Devices and methods for long term intravenous insulin infusion in ambulatory patients have recently been developed. With informed consent we studied 7 non-obese uncomplicated Type I diabetics (aged 15-17y) who received insulin for 14-23 days by central venous infusion (CVII). All subjects were studied in hospital with otherwise unrestricted activity and received 3 daily meals and an evening snack of constant caloric content. Under local anesthesia, a thin silicone rubber catheter was inserted into a branch of the external jugular vein, advanced to the SVC and tunnelled subcutaneously to exit in the supramammary region, where it was connected to the portable system consisting of a small peristaltic pump, a flow rate controller and a reservoir of soluble insulin. Insulin was infused at a constant basal rate of 17±3 mU/min. The rate was increased 15 minutes from the start of a meal 4-5 fold for 60-120 min then returned to the basal rate in a 2 step fashion over 40-120 min. Fasting plasma glucose (mean±SEM) was 262±40 prior to infusion and fell to 92±9 mg/dl on CVII with increases during mealtimes from 80±3 to 115±3 mg/dl at 41±3 min pc. Mean urinary glucose excretion of 55 g/day fell to 1.9 during CVII and fasting serum cholesterol of 220±28 and triglycerides of 281±94 fell to 138±13 and 115±24 mg/dl respectively. Mean HgbAl (N:6.5 - 8.5%) fell from 14.8 to 10.7% by the end of the study period. All indices of control showed improvement with p <0.05. There were no catheter related complications and the system was well accepted by all subjects. We conclude that in ambulatory adolescent diabetics continuous central venous insulin infusion without continuous glucose sensing is feasible for the prolonged normalization of glycemia and other indices of metabolic control.

A home program of long-term total parenteral nutrition in children

Three children--ages 4 months, 5 months, and 14 years--have been on a program of total parenteral nutrition at home for ten, 23 and 44 months respectively, as of January, 1978. Using a specially designed silicone rubber catheter, placed in the right atrium, total nutritional needs of these children were delivered nightly by family members; the children carried out normal activity during the day with the catheter line maintained by a heparin lock. Normal skeletal development and weight gain have been achieved while allowing these children normal social and psychlogic development outside the hospital. During the course of the therapy the patients had multiple metabolic abnormalities which were successfully treated by replacement therapy. The duration of catheter patency ranged from three to 22 months. Catheter sepsis or mechanical failure occasionally required catheter removal and replacement.