central lines - skin necrosis?

[doctorFred]

put in two IJs yesterday, one with an attending who insisted i make air ties to suture the catheter just off the skin in order to prevent skin necrosis. second time, chief resident just ran the straight needle through the skin, through the anchoring holes on the cath, and tied it tight, saying he had never seen any real cases of skin necrosis from a central line secured too tight and close to the skin.

any input? does it matter? is it only older attendings that use air ties on their central lines?

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[tkim]

I've never heard of an air tie. What is it?

 

[doctorFred]

I've never heard of an air tie. What is it?

you put the needle through the skin, make your first throw, push the knot down until it's about 1 cm off the skin, then make your second throw and tie it tight on top of the first, so that there's small separation between the knot and the skin ("air" knot.) then you thread the needle through the anchor on the cath, so that it's secured, but not directly against the skin.

 

[docB]

I do the air ties. It just makes sense that a cinched down knot securing the hub will reduce blood flow and could eventually lead to necrosis and failure of the anchor. Moreover there's no reason not to do it.

 

[tkim]

you put the needle through the skin, make your first throw, push the knot down until it's about 1 cm off the skin, then make your second throw and tie it tight on top of the first, so that there's small separation between the knot and the skin ("air" knot.) then you thread the needle through the anchor on the cath, so that it's secured, but not directly against the skin.

Ah, okay. I've done these, but never heard of it called that.

 

[Apollyon]

Ah, okay. I've done these, but never heard of it called that.

Me neither. You're not alone.

 

[tkim]

http://www.onthecuspstophai.org/StopFAQs-7620.html

"12. What is the best method or device for securing the central line to the skin? Does suture type or technique matter?

Performing an "air tie" reduces skin necrosis but there is no preferred method for suturing or securing the line to the skin. Silk or other sterile surgical suture will work fine. Sterile stapling devices also are fine."

So this document is on a couple of websites, word for word, the same document. No citations, no source.

I've always tied down to skin, 'air ties' once or twice - don't recall why - probably an attending directing me to do so, but I've yet to see skin necrosis on one of the ties to skin, either.

 

[Hamhock]

I too have never heard of "air tie" either...but I will go one step further and admit that I just tie the line to the skin.

[Or maybe I don't understand what is being described as an "air tie".]

I just put the blue thingy on the white thingy on the central line thingy about 0.5 cm from the skin insertion and tie that puppy down with the gap filled by the "biopatch".

I may be making a big mistake, but I have never heard of skin necrosis from a central line...definitely never seen it...and I have put in many central lines at multiple hospitals in four states.

Any evidence for the "air tie"? Anyone here ever actually seen this central line skin necrosis? (of course, maybe not if everyone is doing "air tie")

HH

HH

 

[southerndoc]

I do the air ties. It just makes sense that a cinched down knot securing the hub will reduce blood flow and could eventually lead to necrosis and failure of the anchor. Moreover there's no reason not to do it.

I'm assuming you do air ties with your laceration repairs as well? I'm being sarcastic of course. If you tie it with a lot of pressure, yea, you'll get skin necrosis. However, I don't tie it with that much tension, so it's like doing a laceration repair -- enough to hold it in place, not enough tension to create problems. I never do air ties though.

 

[Flopotomist]

how is doing an air tie, and then smashing the tube down with a tegaderm any different than just tying the darn thing down in the first place? Either way you have a tube pressing against skin.

 

[deleted109597]

Tegaderm doesn't smash it on the skin. It doesn't have enough thickness to do so.
If you tie a knot tight enough it will necrose the skin though. If you put them prone and they laid on it, it might also cause necrosis via pressure ulcer.

 

[quinsy]

when I am teaching medical students 'ideal central line technique' I will show them how you can tie the first knot after laying the dilator on top of where you're about to tie, so that your first knot has a little dilator-sized opening and never gets too tight. I think it's a nice little trick to keep new folks mindful of their knot tightness.

When I was a med student I had to go cut the central line sutures out of patients, and it could be more challenging and also painful for them to try to cut the knots when there was all this inflammation/granulation tissue that had grown over the knot that was tied down tight to the skin. I didn't see skin necrosis, but I thought it seemed kinder to be aware of the fact that tight knots don't end up easy to remove, even though we never have to deal with this ourselves.

 

[doctorFred]

when I am teaching medical students 'ideal central line technique' I will show them how you can tie the first knot after laying the dilator on top of where you're about to tie, so that your first knot has a little dilator-sized opening and never gets too tight. I think it's a nice little trick to keep new folks mindful of their knot tightness.

When I was a med student I had to go cut the central line sutures out of patients, and it could be more challenging and also painful for them to try to cut the knots when there was all this inflammation/granulation tissue that had grown over the knot that was tied down tight to the skin. I didn't see skin necrosis, but I thought it seemed kinder to be aware of the fact that tight knots don't end up easy to remove, even though we never have to deal with this ourselves.

that's interesting. i actually haven't been using the dilator during line insertion itself.. maybe i'll give that a shot.

 

[southerndoc]

I've stopped suturing central lines (my subclavians anyhow). We use a stat lock device that works well. Just can't use it very well on the neck.

 

[napster]

I've stopped suturing central lines (my subclavians anyhow). We use a stat lock device that works well. Just can't use it very well on the neck.

How do you secure the stat lock to the skin?

 

[MSmentor018]

that's what I was taught too

 

[Smurfette]

As a surgeon, I've seen a significant wound develop at a central line site only once, and it was determined to be pyoderma gangrenosum. The tightness of the suture didn't have anything to do with it from what I could tell, although I met the patient after the wound happened.

I don't air knot lines intentionally. But when patients lose their access due to inadequately secured lines, it's such a PITA that most people default to tie them fairly snug. Snug, not super-tight. The air knots give a few cm of "give" to a line that is often just enough to allow the line to dislodge after an accidental snag. Especially since this always happens to large, poorly cooperative or confused patients....

 

[Hernandez]

I've stopped suturing central lines (my subclavians anyhow). We use a stat lock device that works well. Just can't use it very well on the neck.

I ****IN hate stat locks. They've based the loss of more centra lines than the ER residents who don't suture the hub and only the retainer. I have never seen skin necrosis from tight sutures, and I place them snug as I hate replacing lines at 2am

 

[Hernandez]

How do you secure the stat lock to the skin?

It's an adhesive backed plastic lock that sticks to the skin

 

[Groove]

You guys are too high tech for me. I had never even heard of an "air tie" before reading this thread. I just...tie it man. Not too loose, not too tight, just the old fashioned common sense approach.

 

[jdh71]

I've heard the term "air-tie" but don't do them. Never seen skin necrosis from lines sutured to the skin. Agree with Hern and Smurfette if you leave too much give it's enough to snag the line and pull it out.

 

[southerndoc]

Our intensivists prefer them. We haven't had a line pulled out accidentally yet. Incidentally I did have a patient pull out a subclavian that was sutured in (tightly) during my SICU rotation during residency.

 

[Hernandez]

Our intensivists prefer them. We haven't had a line pulled out accidentally yet. Incidentally I did have a patient pull out a subclavian that was sutured in (tightly) during my SICU rotation during residency.

Sutures aren't perfect, but in my experience better than statoocks. Part of the reason they may prefer them is due to them being part of the "bundle" to lower clabsi. By frankly, they have not been proven to do that by themselves, they do lower accidental needle sticks. Unless they've improved in the last 2 years, i won't be using them. My last hospital went on a kick where they demanded we use stat locks, within a 2-3 week period I had somewhere between 5-10 lines pull out due to them. Thankfully my attendings backed me up when I told the clip board nurses that until they have to put in the replacement line back in at 2 am, they don't get to make the determination on how i secured my lines

 

[southerndoc]

Sutures aren't perfect, but in my experience better than statoocks. Part of the reason they may prefer them is due to them being part of the "bundle" to lower clabsi. By frankly, they have not been proven to do that by themselves, they do lower accidental needle sticks. Unless they've improved in the last 2 years, i won't be using them. My last hospital went on a kick where they demanded we use stat locks, within a 2-3 week period I had somewhere between 5-10 lines pull out due to them. Thankfully my attendings backed me up when I told the clip board nurses that until they have to put in the replacement line back in at 2 am, they don't get to make the determination on how i secured my lines

5-10? Wow. That's an impressive number. Our ICU nurses are more protective of central lines. We've been using them for two years and not a single line pulled out that our ICU nurse manager is aware of. We almost always do subclavians.

 

[Hernandez]

5-10? Wow. That's an impressive number. Our ICU nurses are more protective of central lines. We've been using them for two years and not a single line pulled out that our ICU nurse manager is aware of. We almost always do subclavians.

Part of the problem is at that hospital was two fold, they almost mandated we do US guided IJs, which are much more prone to being pulled out, and they had an odd dressing care routine that used an agressive cleaning mixture that degraded the stat lock's adhesive. Granted that rough few weeks for me put a bad taste in my mouth (and to top it off, it was the weeks leading up to my sons birth, so I was q2 for over 2 weeks so I wouldn't have to make up call afterwards) and I haven't used a one since then, now I've not had any PICC lines being pulled out with the stat locks here, so perhaps they've improved.

 

[core0]

I air knot all my central lines but not because of skin necrosis. You get a tremendous amount of edema post resuscitation which then resolves somewhat. If you suture the line directly to the skin when the edema lessens it makes the suture loose and the line can slip through the knot. If you do an air knot and then tie the suture around the line, the line has a harder time slipping out.

 

[ucsfstudents]

Youtube video showing a air knot or "air tie"

https://www.youtube.com/watch?v=0Pe4bgyAZPk
Her first knot is the air knot.