Negative-Pressure Wound Therapy in a Patient with Osteomyelitis Caused by Multidrug-Resistant Bacterial Infection: A Case Report

Uncontrolled infection, especially with multidrug-resistant bacteria, may significantly inhibit wound healing. Although negative-pressure wound therapy can help prevent infection, it is contraindicated in patients with untreated infections, including osteomyelitis. Here, we report successful wound healing by negative-pressure wound therapy in a patient with refractory osteomyelitis due to multiple multidrug-resistant bacterial infections. Soft tissue infection and osteomyelitis progressed deeply through subcutaneous tunneling; hence, bacteria were not excreted from the affected area. Negative-pressure wound therapy reduced the bacterial load and resolved the patient’s condition. Healing by secondary intention progressed with subsequent formation of granulation tissue. Despite recommendations against negative-pressure wound therapy in patients with osteomyelitis, this study highlights the application of the technique for infection control in patients with multidrug-resistant bacterial infections and osteomyelitis.

Rapid Assessment of Vascular Exit Site and Tunneling Options (RAVESTO): A new decision tool in the management of the complex vascular access patients

In the last decade, different standardized protocols have been developed for a systematic ultrasound venous assessment before central venous catheterization: RaCeVA (Rapid Central Vein Assessment), RaPeVA (Rapid Peripheral Vein Assessment), and RaFeVA (Rapid Femoral Vein Assessment). Such protocols were designed to locate the ideal puncture site to minimize insertion-related complications. Recently, subcutaneous tunneling of non-cuffed central venous access devices at bedside has also grown in acceptance. The main rationale for tunneling is to relocate the exit site based on patient factors and concerns for dislodgement. The tool we describe (RAVESTO—Rapid Assessment of Vascular Exit Site and Tunneling Options) defines the different options of subcutaneous tunneling and their indications in different clinical situations in patients with complex vascular access.

Subcutaneous tunneling technique to improve outcomes for patients undergoing chemotherapy with peripherally inserted central catheters: a randomized controlled trial

Objective To compare the value of the subcutaneous tunneling technique versus the normal technique in improving the outcomes of patients undergoing chemotherapy with peripherally inserted central catheters (PICCs). Methods One hundred thirty patients were randomly divided into an experimental group (subcutaneous tunneling technique) and control group (normal technique) according to the PICC placement technique, and clinical data were compared between the groups. Results In total, 129 PICCs were successfully inserted. Compared with the control group, the experimental group had a lower occurrence of complications after placement (especially catheter dislodgement: 3.1% vs. 15.4%, venous thrombosis: 3.1% vs. 15.4%, and wound oozing: 14.1% vs. 27.7%), lower occurrence of unscheduled PICC removal (3.1% vs. 13.8%), greater comfort during placement (14.16 ± 2.21 vs. 15.09 ± 2.49 on a scale ranging from 6 to 30 points, with higher scores indicating lower degrees of comfort), and lower costs of PICC maintenance (median (interquartile range) per-day maintenance cost: 13.90 (10.99–32.83) vs. 15.69 (10.51–57.46) Yuan). The occurrence of complications and amount of bleeding during placement were not significantly different between the two groups. Conclusions The subcutaneous tunneling technique can improve PICC placement by reducing complications and costs of maintenance with better patient comfort during placement.

Placement of Totally Implantable Venous Access Ports Using the Single-Incision Technique: Outcomes and Complications

Background: A totally implantable venous access port (TIVAP) is an essential component of care for oncology patients. Conventional placement of the TIVAP is performed through the internal jugular vein or the subclavian vein using a tunneled catheter, which involves creating two incisions. However, the conventional technique has several potential limitations. To address these limitations, a single-incision technique without a second incision or subcutaneous tunneling has been extensively tested since first being introduced by Glenn in 2007. Objectives: The purpose of this study was to evaluate the technical success, clinical outcomes, and complications of the single-incision technique for the placement of TIVAPs. Patients and Methods: Between January 2013 and June 2017, 182 TIVAPs were placed by a single-incision technique in 175 patients, including 79 men and 96 women (mean age, 62.4 years; range: 20 - 88 years). Electronic medical records were retrospectively reviewed to obtain patient data, outcomes, and complication rates. Results: A total of 40,594 catheter maintenance days (median, 221.9 days; range, 1 - 889 days) were recorded for 182 TIVAPs in 176 patients. Technical and clinical success rates were both 100%. A total of 25 complications (complication rate, 13.74%) occurred, including catheter occlusion (5.49%), catheter-related infection (5.49%), wound dehiscence (1.10%), catheter kinking (0.55%), venous thrombosis (0.55%), and extravasation during infusion (0.55%). Conclusion: The single-incision technique for TIVAP via the axillary vein was safe and efficient with high technical and clinical success rates. This new technique may be a good alternative to conventional techniques.

Alternative exit sites for central venous access: Back tunneling to the scapular region and distal tunneling to the patellar region

Uncooperative elderly patients with cognitive disorder are often confused and/or agitated. Risk of involuntary venous access device dislodgment is high in these patients. This is equally likely with peripherally inserted central catheters and centrally inserted central catheters but less common with femorally inserted central catheters. Solutions to this problem include strict continuous patient observation, using sutures or subcutaneous anchored securement, wrapping the arm to “hide” the line, or using soft mittens to occupy the hands. However, some patients are able to disrupt the dressing, dislodge the catheter, and often pull the catheter out completely. In some cases, the patient may also overcome the resistance offered by the stitches or by the subcutaneous anchored securement device. In a recent paper on the impact of subcutaneously anchored securement in preventing dislodgment, the only demonstrated failures occurred in non-compliant elderly patients. Creation of an alternative exit site is an emerging trend in patients with cognitive impairment at high risk for catheter dislodgement. Subcutaneous tunneling from traditional insertion sites such as the jugular, axillary, or femoral veins allows placement of the exit site in a region inaccessible to the patient. The following two case reports demonstrate the technique for tunneling a femorally inserted central catheter downward to the patellar region and for tunneling a centrally inserted central catheter to the scapular region. Internal review board approval was not deemed necessary as subcutaneous tunneling is not a new technique. In our experience, such maneuvers can be successfully performed at the bedside.

P2851Transvenous lead placement in the setting of venous obstruction: outcomes of tunneling technique versus venoplasty

Background Venous stenosis is a well-recognized complication of transvenous leads when patients require lead revisions or device upgrade. In these cases, balloon venoplasty or alternative venous access with subcutaneous tunneling can be performed. Purpose Compare the outcomes of venoplasty vs. tunneling in patients requiring additional transvenous lead implantation. Methods A single center retrospective cohort study of all patients undergoing lead implantation/revision requiring venoplasty or tunneling from 2005–2017. Chi-squared and Wilcoxon Rank-Sum tests were used to compare categorical and continuous variables. Results Ninety five patients met our inclusion criteria (60 venoplasty & 35 tunneling). There was no difference in procedure success rates (p-value=0.98). Tunneling was associated with less fluoroscopy time but higher incidence of acute complications (0% vs. 23%, p-value=0.002) most requiring invasive intervention and/or blood product transfusion. Long term outcomes were comparable and related to lead failure or infection. Outcomes for tunneling vs. venoplasty Variable Tunneling (n=35) Venoplasty (n=60) p-value Age Y 67 (23–84) 70 (29–91) 0.25 Male (%) 24 (69%) 41 (68%) 0.98 Number of existing leads 2.1 (1–4) 2.4 (0–4) 0.1 Age of oldest lead 7.0 (0–21) 7.2 (0–33) 0.73 Number of new leads 1.2 (1–3) 1.4 (1–3) 0.26 Fluoroscopy time (SD) min 29.2 (21.3) 39.7 (21.5) 0.012 Procedure success (%) 35 (100%) 55 (92%) 0.9 Acute complications (%) 8 (23%)1 0 (0%) 0.0002 Pocket hematoma/bleed 4 (11%)2 Hemothorax 2 (6%)3 Pericarditis 1 (3%) Lead compromise 1 (3%) Follow up M 18 (0–76) 28 (0–98) N/A Long term lead issues (%) 6 (17%) 10 (17%) 0.95 Long term complication requiring intervention 4 (11%) 8 (13%) N/A Procedure success: functional lead placed as a result of venoplasty or tunneling. 1Two patients required blood products. 2Two patients required invasive intervention. 3One patient required chest tube and the other ICU admission. Conclusions Balloon venoplasty is associated with similar rates of success and a less incidence of acute complications when compared subcutaneous tunneling. Acknowledgement/Funding NIH T32 Training Grant HL07111-40

Long-term clinical outcomes of the single-incision technique for implantation of implantable venous access ports via the axillary vein

Purpose To evaluate long-term clinical outcomes and complications of the single-incision technique for implantation of totally implantable venous access ports (TIVAPs) via the axillary vein. Materials and Methods A total of 932 TIVAPs were placed in 927 patients between May 2012 and October 2014 using a single-incision technique. Patients included 620 men and 307 women with a mean age of 60.0 years. TIVAPs were placed via the left (n = 475) and right (n = 457) axillary veins after making a single oblique vertical incision and medial side pocket without subcutaneous tunneling. We retrospectively reviewed medical records to evaluate status of the patients and TIVAPs, complications, and reasons for explantation. In patients who still had a TIVAP in place, we calculated the duration of TIVAP use from the cut-off day of November 1, 2015. Results Clinical follow-up was obtained for a total device service period of 311,069 days with a median indwelling time of 467 days (range: 3-1097 days). A total of 37 (4.0%) complications developed. Early complications (n = 4) were one case each of stenosis of the brachiocephalic vein by tumor growth, thrombosis of axillary vein, intravascular migration, and malfunction depending on patient's position. Late complications (n = 33) were suspected catheter-related blood stream infection (n = 23), local infection of the pocket (n = 4), symptomatic stenosis and thrombosis of central vein (n = 4), malfunction by fibrin sleeve (n = 1), and intravascular migration (n = 1). Conclusions A single-incision technique for TIVAP implantation via the axillary vein seems to be safe with a low risk of complication.

A Prospective, Randomized Study comparing the Efficacy and Safety of Adhesive Strip (Steri-Strips™) Fixation vs Subcutaneous Tunneling for securing Epidural Catheters in Pediatric Patients

ABSTRACT Introduction Effective epidural catheter fixation is a key aspect of postoperative pain management in pediatric patients. We conducted a prospective, randomized study comparing the efficacy and safety of adhesive strip (Steri-Strips™) vs subcutaneous tunneling for successful epidural catheter fixation. Materials and methods American Society of Anesthesiologists (ASA) grades I and II patients between the age group of 1 day and 12 years were included in the study. The parameters studied were inward and outward migration, and dislodgment of catheter. Erythema, induration, catheter snapping, catheter obstruction, total duration of epidural infusion, and catheter tip culture were also recorded. Feedback from the operator for ease of fixation technique was noted and reviewed. Results This study was performed in 64 patients posted for various abdominal, thoracic, and genital surgeries, requiring postoperative epidural analgesia. The epidural catheter was successfully placed in the first attempt in 61 patients. Outward migration was seen in six patients with Steri-Strips-taped catheters and in one patient with a tunneled catheter. Accidental removal was done in five patients with tunneled catheters and one patient with strip-taped catheter. Rescue analgesics were required in these patients. No inward migration of catheter was seen in both the groups. Bleeding from tunneling site was seen in five patients. Conclusion In comparison with a tunneling technique for epidural catheter fixation, a simple method of applying Steri-Strips™ to epidural catheters significantly reduces the incidence of accidental removal. How to cite this article Kulkarni KS, Dave NM, Kulkarni SS, Nataraj G, Shinde S, Chincholi I, Garasia M. A Prospective, Randomized Study comparing the Efficacy and Safety of Adhesive Strip (Steri-Strips™) Fixation vs Subcutaneous Tunneling for securing Epidural Catheters in Pediatric Patients. Res Inno in Anesth 2017;2(2):40-44.