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.