Placement of an Arterial Line
http://www.100md.com
《新英格兰医药杂志》
To the Editor: The Video in Clinical Medicine "Placement of an Arterial Line" (April 13 issue)1 nicely illustrates the technique of inserting a radial arterial line. However, many clinicians will not agree about the necessity of going through both walls of the artery in the "over-the-wire" technique. With the use of current wire-equipped arterial catheters, it is not necessary to puncture both walls of the artery. Once the tip of the needle is in the lumen and there is adequate back blood flow, the wire can be advanced into the artery, followed by the actual catheter. In addition, in keeping with the high quality of the Journal, the Videos in Clinical Medicine series should depict techniques correctly. The correct method of holding a needle driver is to insert the first and fourth fingers through the rings of the needle driver, not the first and third, as shown in the video.
Luis D. Berrizbeitia, M.D.
University Medical Center at Princeton
Princeton, NJ 08540
ldberriz@ctsx.net
References
Tegtmeyer K, Brady G, Lai S, Hodo R, Braner D. Placement of an arterial line. N Engl J Med 2006;354:e13-e13.
To the Editor: Substantial evidence implicates the securement of sutures in two important types of infections: catheter-related bloodstream infections and human immunodeficiency virus infection and hepatitis from accidental needle-stick injuries.1,2,3 This evidence controverts the assertion by Tegtmeyer et al. that "suturing is the preferred method."
Crnich and Maki report that sutured lines were associated with a 10 percent rate of catheter-related bloodstream infections, whereas lines secured with a sutureless method had an infection rate of less than 1 percent (P<0.01).3 Accordingly, the guidelines of the Centers for Disease Control and Prevention state, "sutureless securement devices can be advantageous . . . in preventing catheter-related bloodstream infections."4 Furthermore, sutureless securement devices eliminate the risk of accidental needle sticks, prompting the Occupational Safety and Health Administration (OSHA) to issue a blood-borne fact sheet delineating the "direct risk" of suture and mandating annual review of alternative securement techniques.5 Finally, the 2006 Infusion Nursing Standards of Practice exclude suture and transparent dressings from acceptable methods of catheter stabilization, stating: "Whenever feasible, using a manufactured catheter stabilization device is preferred."6 The Videos in Clinical Medicine series should include a demonstration of sutureless securement for line stabilization.
Steven F. Bierman, M.D.
University of California, San Diego
San Diego, CA 92103
sbierman@venetec.com
Dr. Bierman reports having served as a consultant for Bard Medical Division, a manufacturer and distributor of suture-free securement devices for a variety of medical catheters.
References
Schears GJ, Liebig C, Frey AM, et al. StatLock catheter securement device significantly reduces central venous catheter complications. In: Compendium of successful practices. Vol. 1. North Adams, Mass.: National Patient Safety Foundation, 2000:28-37.
Yamamoto AJ, Solomon JA, Soulen MC, et al. Sutureless securement device reduces complications of peripherally inserted central venous catheters. J Vasc Interv Radiol 2002;13:77-81.
Crnich CJ, Maki DG. The promise of novel technology for the prevention of intravascular device-related bloodstream infection. I. Pathogenesis and short-term devices. Clin Infect Dis 2002;34:1232-1242.
Guidelines for the prevention of intravascular catheter-related infections. MMWR Recomm Rep 2002;51:7-7.
Occupational Safety & Health Administration. Bloodborne fact sheet #7. (Available at http://www.OSHA.gov.)
Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurse 2006;29:Suppl 1:S1.
The authors reply: We produced the arterial-line video with the goal of visually illustrating and complementing the bedside teaching of arterial-line placement. As we note at the beginning of the video, there are many techniques for placing an arterial line. Dr. Berrizbeitia comments correctly and succinctly that newer devices exist that facilitate the use of the over-the-wire technique without puncturing the posterior wall of the artery. Given the time constraints inherent in the use of video and the international reach of the Journal, we chose to demonstrate the technique using more commonly available catheters. We appreciate Dr. Berrizbeitia's comments regarding the correct finger placement for use with the needle driver.
Dr. Bierman makes excellent points regarding the use of sutureless catheter-securement devices. We completely agree with the issue of patient and provider safety and understand the critical importance of adhering to the guidelines of OSHA and the Joint Commission on Accreditation of Healthcare Organizations. We are also aware of literature suggesting that these devices may reduce the risk of bloodstream infections and, certainly, the risk of accidental needle-stick injury. It is important to note that the current literature either relates to securing central venous catheters or compares securement devices with tape. Arterial catheters, because they are placed distally on extremities, have an increased potential for high levels of tension owing to patient movement.1 The risk of infection associated with arterial catheters is also unclear, with reported risks ranging from 0.5 percent2 to 7.7 percent,3 so the extent of the reduction in infection realized by not using sutures is unclear. Our video clearly mentions the use of sutureless securement devices when such devices are available. We look forward to the time when these devices are universally available to and affordable by every facility that uses arterial-line placement. However, given the dire and sometimes life-threatening complications associated with the dislodgment of arterial catheters and the limited length of our video, we elected to emphasize the more universally available method of catheter securement.
Ken Tegtmeyer, M.D.
Dana A.V. Braner, M.D.
Susanna Lai, M.P.H.
Oregon Health & Science University
Portland, OR 97239
branerd@ohsu.edu
References
Patel N, Smith CE, Pinchak AC, Hancock DE. Evaluation of different methods of securing intravenous catheters: measurement of forces during simulated accidental pullout. Can J Anaesth 1995;42:504-510.
El-Hamamsy I, Durrleman N, Stevens LM, et al. Incidence and outcome of radial artery infections following cardiac surgery. Ann Thorac Surg 2003;76:801-804.
Traore O, Liotier J, Souweine B. Prospective study of arterial and central venous catheter colonization and of arterial- and central venous catheter-related bacteremia in intensive care units. Crit Care Med 2005;33:1276-1280.
Luis D. Berrizbeitia, M.D.
University Medical Center at Princeton
Princeton, NJ 08540
ldberriz@ctsx.net
References
Tegtmeyer K, Brady G, Lai S, Hodo R, Braner D. Placement of an arterial line. N Engl J Med 2006;354:e13-e13.
To the Editor: Substantial evidence implicates the securement of sutures in two important types of infections: catheter-related bloodstream infections and human immunodeficiency virus infection and hepatitis from accidental needle-stick injuries.1,2,3 This evidence controverts the assertion by Tegtmeyer et al. that "suturing is the preferred method."
Crnich and Maki report that sutured lines were associated with a 10 percent rate of catheter-related bloodstream infections, whereas lines secured with a sutureless method had an infection rate of less than 1 percent (P<0.01).3 Accordingly, the guidelines of the Centers for Disease Control and Prevention state, "sutureless securement devices can be advantageous . . . in preventing catheter-related bloodstream infections."4 Furthermore, sutureless securement devices eliminate the risk of accidental needle sticks, prompting the Occupational Safety and Health Administration (OSHA) to issue a blood-borne fact sheet delineating the "direct risk" of suture and mandating annual review of alternative securement techniques.5 Finally, the 2006 Infusion Nursing Standards of Practice exclude suture and transparent dressings from acceptable methods of catheter stabilization, stating: "Whenever feasible, using a manufactured catheter stabilization device is preferred."6 The Videos in Clinical Medicine series should include a demonstration of sutureless securement for line stabilization.
Steven F. Bierman, M.D.
University of California, San Diego
San Diego, CA 92103
sbierman@venetec.com
Dr. Bierman reports having served as a consultant for Bard Medical Division, a manufacturer and distributor of suture-free securement devices for a variety of medical catheters.
References
Schears GJ, Liebig C, Frey AM, et al. StatLock catheter securement device significantly reduces central venous catheter complications. In: Compendium of successful practices. Vol. 1. North Adams, Mass.: National Patient Safety Foundation, 2000:28-37.
Yamamoto AJ, Solomon JA, Soulen MC, et al. Sutureless securement device reduces complications of peripherally inserted central venous catheters. J Vasc Interv Radiol 2002;13:77-81.
Crnich CJ, Maki DG. The promise of novel technology for the prevention of intravascular device-related bloodstream infection. I. Pathogenesis and short-term devices. Clin Infect Dis 2002;34:1232-1242.
Guidelines for the prevention of intravascular catheter-related infections. MMWR Recomm Rep 2002;51:7-7.
Occupational Safety & Health Administration. Bloodborne fact sheet #7. (Available at http://www.OSHA.gov.)
Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurse 2006;29:Suppl 1:S1.
The authors reply: We produced the arterial-line video with the goal of visually illustrating and complementing the bedside teaching of arterial-line placement. As we note at the beginning of the video, there are many techniques for placing an arterial line. Dr. Berrizbeitia comments correctly and succinctly that newer devices exist that facilitate the use of the over-the-wire technique without puncturing the posterior wall of the artery. Given the time constraints inherent in the use of video and the international reach of the Journal, we chose to demonstrate the technique using more commonly available catheters. We appreciate Dr. Berrizbeitia's comments regarding the correct finger placement for use with the needle driver.
Dr. Bierman makes excellent points regarding the use of sutureless catheter-securement devices. We completely agree with the issue of patient and provider safety and understand the critical importance of adhering to the guidelines of OSHA and the Joint Commission on Accreditation of Healthcare Organizations. We are also aware of literature suggesting that these devices may reduce the risk of bloodstream infections and, certainly, the risk of accidental needle-stick injury. It is important to note that the current literature either relates to securing central venous catheters or compares securement devices with tape. Arterial catheters, because they are placed distally on extremities, have an increased potential for high levels of tension owing to patient movement.1 The risk of infection associated with arterial catheters is also unclear, with reported risks ranging from 0.5 percent2 to 7.7 percent,3 so the extent of the reduction in infection realized by not using sutures is unclear. Our video clearly mentions the use of sutureless securement devices when such devices are available. We look forward to the time when these devices are universally available to and affordable by every facility that uses arterial-line placement. However, given the dire and sometimes life-threatening complications associated with the dislodgment of arterial catheters and the limited length of our video, we elected to emphasize the more universally available method of catheter securement.
Ken Tegtmeyer, M.D.
Dana A.V. Braner, M.D.
Susanna Lai, M.P.H.
Oregon Health & Science University
Portland, OR 97239
branerd@ohsu.edu
References
Patel N, Smith CE, Pinchak AC, Hancock DE. Evaluation of different methods of securing intravenous catheters: measurement of forces during simulated accidental pullout. Can J Anaesth 1995;42:504-510.
El-Hamamsy I, Durrleman N, Stevens LM, et al. Incidence and outcome of radial artery infections following cardiac surgery. Ann Thorac Surg 2003;76:801-804.
Traore O, Liotier J, Souweine B. Prospective study of arterial and central venous catheter colonization and of arterial- and central venous catheter-related bacteremia in intensive care units. Crit Care Med 2005;33:1276-1280.