St. Joseph's University Medical Center, Paterson, NJ, USA.
Catholic University Hospital, Rome, Italy.
J Vasc Access. 2021 Nov;22(6):992-996. doi: 10.1177/1129729820940178. Epub 2020 Jul 9.
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.
不合作且认知障碍的老年患者常感到困惑和/或激动。这些患者中心静脉置管和经外周中心静脉置管的非自愿导管移位风险很高，但股静脉置管的风险较低。解决这个问题的方法包括严格持续的患者观察、使用缝线或皮下锚定固定、将手臂包裹起来“隐藏”导管，或使用软手套占据双手。然而，有些患者能够破坏敷料、拨出导管，并经常将导管完全拔出。在某些情况下，患者可能还会克服缝线或皮下锚定固定装置的阻力。在最近一篇关于皮下锚定固定预防导管移位影响的论文中，唯一被证明的失败发生在不遵守规定的老年患者中。在认知障碍且导管移位风险高的患者中，创建替代出口部位是一种新兴趋势。从传统的插入部位（如颈静脉、腋窝或股静脉）进行皮下隧道，可以将出口部位放置在患者无法触及的区域。以下两个病例报告展示了将股静脉置管向下隧道至髌骨区域和将中心静脉置管隧道至肩胛骨区域的技术。由于皮下隧道不是新技术，因此不需要内部审查委员会的批准。根据我们的经验，这种操作可以在床边成功进行。
