BOTH ENDS OF THE LINE: A CLINICAL AND PATIENT PERSPECTIVE ON CATHETER SECUREMENT

In 2012 I met a couple of gentlemen at an AVA conference expo (aka IV Geek Theme Park) who showed me a device that had a chance to survive the demands of long-term acute care patients with central venous access devices (CVAD). Until the opportunity to stroll the aisles of the expo, my team was securing CVADs with an adhesive engineered securement device (AESD), a transparent semi-permeable membrane (TSM), and then covered with an elastic net. Although far superior to sutures, this type of adhesive-based securement could not hold up to patients on long-term ventilation, total parenteral nutrition, and frequent physical repositioning.

With the disruption of the adhesive securement, a CVAD would retract out of the superior vena cava and require replacement. Unfortunately, replacing a CVAD in this patient population is often more difficult secondary to the numerous invasive lines they have received in their extensive recovery phase. Therefore, finding even the possibility of genuinely securing the CVAD for these patients was worth investigating.

The subcutaneous anchor made sense to me immediately. Growing up helping my father build things, I have understood various methods to secure one thing to another; tape, glue, nails, staples, anchors, et al. The SASS seemed like an ingenious answer to what, in a simplistic view, is an anchoring issue. Why expect a tiny tube to stay in place with adhesives designed not to stick too hard to the skin surface? Instead, anchor the line under the skin and keep that anchor holding the catheter for the duration of therapy.

The subcutaneous anchor securement system (SASS) took my team a short time to master placement and removal.1 We followed the first 20 patients from implant to explant. My team was impressed with this small orange device’s ability to do what all securement manufacturers claim, keep the CVAD in place until no longer needed. In addition, none of the patients with the SASS experienced catheter dislodgement, and none had a bloodstream infection related to the CVAD. The outcome seems evident that a securement device would perform the role it was engineered to do, but this remains a problem for many patients in many settings.2

Change is difficult for everyone, but when it comes to securing any vascular access catheter, many hospitals still rely on sutures which were an improvised method that followed the birth of CVADs in the 1950s.3 Using sutures to secure external devices

M.L. Hawes, RN, DNP, CRNI, VA-BCTM

“I HAVE NOW EXPERIENCED LIFE FROM BOTH ENDS OF THE LINE. CLINICALLY I HAVE STABILIZED A MULTITUDE OF PICCS IN PATIENTS OF ALL AGES AND BODY TYPES WITH SASS SINCE 2012. NOW, AS A PATIENT WHO HAS LIVED WITH A LINE ANCHORED IN PLACE, I FOUND THE EXPERIENCE UNREMARKABLE. WHICH IS EXACTLY WHAT PATIENTS WOULD PREFER. “

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14 BOTH ENDS OF THE LINE, CONTINUED FROM PREVIOUS PAGE

was a sufficient stop-gap measure before the development of tools engineered for securing central and peripheral vascular catheters. Despite the decades of research, CDC guidelines, manufacturer’s specifications that sutures are for wound closure, occupational safety regulations, et al. clinicians still rely on this improvised off-label method of temporary securement.3,4

Subcutaneous anchoring provides under the skin stabilization without all the adverse outcomes of inconsistent suturing techniques.5,6 How is the change to a device engineered for stabilization so problematic for some clinicians? I believe it may be that we are loyal to whatever we learned and mastered at the beginning of our careers. We are also accustomed to using whatever is supplied in the kit. However, my issue was that my patients were losing their lines with the current stabilization method. I needed the problem to stop for my patients more than I needed comfort with what I already knew and the convenience of what I already had.

Karma . . . After decades of placing vascular access devices in patients of all ages, teaching others to do the same, I had the pleasure of receiving a peripherally inserted central catheter (PICC) secured with a SASS for six weeks of intravenous antibiotics following sepsis. I had the chance to experience life with a tube hanging out of my arm. During this time, I had raised garden beds to build, dirt to haul, and paving stones to place in preparation for planting season. Through the unsanctioned strain of garden preparations and activities of daily living, my PICC stayed anchored in its original position.

After six weeks, my infection was defeated, and my PICC was ready to be removed. Multiple phone calls with home health, infectious disease, and my surgeon failed to obtain an official order to remove my line. As a seasoned vascular access specialist and nurse, I felt qualified to remove my line. I had always wondered what it felt like to live with a PICC and a SASS, and for me, the worst part was the itching under the dressing and covering it for a shower. However, the PICC and SASS did not cause any discomfort, not even with onehanded self-directed removal.

I have now experienced life from both ends of the line. Clinically I have stabilized a multitude of PICCs in patients of all ages and body types with SASS since 2012. Now, as a patient who has lived with a line anchored in place, I found the experience unremarkable, which is exactly what patients would prefer.

REFERENCES

1. SecurAcath, Interrad Medical Inc. SecurAcath, subcutaneous catheter securement system, instructions for use. SecurAcath.com Retrieved July 8, 2021. https://securacath.com/wp-content/ uploads/2020/05/1386-002-rF-IFUSecurAcath-US.pdf

2. McParlan D, Edgar L, Gault M, Gillespie S, Menelly R, Reid M. Intravascular catheter migation: A cross-sectional and health-economic comparison of adhesive and subcutaneous engineered stabilisation devices for intravascular device securement. The Journal of Vascular Access. 2019; 1-6. doi: 101177/1129729819851059

3. Noel-Lamy M. The Seldinger technique: A short history, and its applications 60 years later. University of Toronto Medical Journal. 2015; 93(1): 30-31.

4. Johnson & Johnson, Inc. Nonabsorbable suture catalog. Johnson & Johnson.com 2019; Retrieved July 8, 2021. https://www.jnjmedicaldevices.com/ sites/ default/files/user_uploaded_assets/ pdf_assets/2019-10/ 115681-190531_WC_ Suture_ Catalog_2019_Update_297_7_ CA.pdf

5. Struck MF, Friedrich L, Schleifenbaum S, Kirsten H, Schummer W, Winkler BE. Effectiveness of different central venous catheter fixation suture techniques: An in vitro crossover study. PLoS ONE. 2019;14(9): https://doi.org/10.1371 / journal.pone.0222463

6. Brescia F, Pittiruti M, Roveredo L, et al. Subcutaneously anchoed securement for peripheally inserted central catheters: Immediate, early, and late complications. The Journal of Vascular Access. 2021; 1-5. doi: 10.1177/11297298211025430