Leaking CPNB -- solutions?

[Oggg]

We just started doing adductor canal catheter infusions for TKA and the nurses are really upset about leakage from the insertion site. We'be told them its normal and they should just wipe it away and reinforce with tape as nexessary. but When pts get up to walk, the fluid runs down their leg into their wound dressing.

We occasionally use dermaflex, a generic Dermabond, to seal the site, but its expensive. Also, when used on surgical wounds, it takes like 7 minutes to dry. Wiki says its 2-octyl cyanoacrylate.

I think the BlockJocks ppl were using histoacryl, which is butyl-cyanoacrylate. Apparently you only have to wait 30 seconds. On their videos they have a small bottle (15ml?) and they use it on multiple patients, by using a sterile straw to withdraw a few drops. I think it's expensive too, but if you can use it multidose it would be cheaper. I only found single patient use 0.5ml ampules on Google.

Does anyone have experience with these glues? Cost is important at my hospital.

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[Oggg]

http://pubmedcentralcanada.ca/pmcc/articles/PMC1285596/pdf/archemed00022-0081b.pdf

LetterstotheEditor 161 The useofHistoacryltissueadhesivefortheprimaryclosureofscalpwounds
Sir
I read with great interest the article by Morton et al. (Archives of Emergency Medicine, June1988).Iwouldbeinterestedtoknowwhethertheyusedonevialofglueperpatient or whether the same vial was used for many patients. With the former case the expense could be quite high ifused on a regular basis whereas with the latter case multiple patientcontactwithasinglevialisclearlyinadvisable.
In the Paediatric Accident and Emergency Department of Guy's Hospital, we have foundawayofovercomingtheseproblems.Theapplicatoronthevialiscutatitswidest marking. This allows a fine, sterilized capillary tube to be inserted into the vial.
Sufficientglueentersthetubingbycapillaryattraction.On applyingthetubingtothe woundasmallamountofglueisdeposited.We havefounditeasiertocontrolthe positioning of the glue and also the amount delivered when capillary tubing is used.
In an unpublished series of 20 cases of facial lacerations treated in this manner and with up to a 3 month follow-up period, we have found no complications and excellent cosmeticresults.
Capillarytubingisinexpensiveandthusenablestheuseofhistoacrylgluetobeavery cost-effectiveoption.
D.WATSON
Accident and Emergency Department, Guy'sHospital,
StThomas' Street,
London, England
The useofHistoacryltissueadhesivefortheprimary closureofscalpwounds
Sir
Mr Watson'snoteaboutthere-useofasinglevialofHistoacrylisveryrelevant.We also re-usethevial.Our method ofdoingthisistocuttheapplicatoratitswidestmarking. We thenplaceasterileneedleontheend.Thisneedleisusedtoapplythegluetothe wound. The needle isthen removed and the glue stored with a second sterileneedle in place.
This works quite efficiently and in a similar manner to the capillary tube which Mr Watson describes.
DrMcCabeetal.pointoutaveryimportantcomplicationofHistoacryl.We always pointoutthechanceofthiscomplicationtothenursesandIam pleasedtosaysofarI have not encountered any problems. This may be because I tend not to use the glue for forehead lacerations, concentrating mainly on scalps.
Ihavealsotriedknottinghairoverscalplacerations.Inmy experienceIhavefound thatmostofmy patientstendtobebald,skinheads,orotherwiseunsuitableforthis procedure.

 

[Mr Wizard]

We just started doing adductor canal catheter infusions for TKA and the nurses are really upset about leakage from the insertion site. We'be told them its normal and they should just wipe it away and reinforce with tape as nexessary. but When pts get up to walk, the fluid runs down their leg into their wound dressing.

We occasionally use dermaflex, a generic Dermabond, to seal the site, but its expensive. Also, when used on surgical wounds, it takes like 7 minutes to dry. Wiki says its 2-octyl cyanoacrylate.

I think the BlockJocks ppl were using histoacryl, which is butyl-cyanoacrylate. Apparently you only have to wait 30 seconds. On their videos they have a small bottle (15ml?) and they use it on multiple patients, by using a sterile straw to withdraw a few drops. I think it's expensive too, but if you can use it multidose it would be cheaper. I only found single patient use 0.5ml ampules on Google.

Does anyone have experience with these glues? Cost is important at my hospital.

I typically will use the dermabond to help secure the catheter in place and to prevent leakage. Another option that we are currently looking at is the catheter over needle kits that have been shown to have decreased incidence of dislodgement and leakage. The question would be if these kits would be cheaper than addition of a glue to the cost of your standard block kits.

[

Can J Anaesth. 2012 Jul;59(7):655-61. doi: 10.1007/s12630-012-9713-9. Epub 2012 May 8.
Less leakage and dislodgement with a catheter-over-needle versus a catheter-through-needle approach for peripheral nerve block: an ex vivo study.
Tsui BC, Tsui J.

Abstract
PURPOSE: The objective of this study was to compare the catheter-through-needle (CTN) and catheter-over-needle (CON) catheterization techniques ex vivo by measuring leak pressure around the catheter and the catheter's resistance to pulling force.

METHODS: Using an ex vivo porcine limb model, we compared the conventional CTN design with the CON design with respect to the ability to resist leakage at the catheter insertion site under high injection pressure and the force required to withdraw the catheter from tissue. One CON assembly (MultiSet, Pajunk) and three CTN assemblies (Contiplex, B.Braun; StimuCath, Arrow; Stimulong Sono, Pajunk) were studied. Ten porcine hind limbs were used to test leakage and another ten were used to measure withdrawal force. Catheters were placed at angles of 15° and 30° at depths of 3 cm and 5 cm. Leakage was assessed visually at the insertion site, and pressure was measured at the moment leakage occurred. Withdrawal force was measured by pulling the catheter from the tissue.

RESULTS: No evidence of leakage was detected at the CON catheter insertion site at the highest pressure applied (1,000 mmHg) (n = 40). The CON assembly withstood significantly higher injection pressure than the CTN catheters without causing leaks at the catheter insertion site [CON, mean (standard deviation) > 1,000 (0) mmHg; B.Braun, 596 (92) mmHg; Pajunk Stimulong, 615 (107) mmHg; and Arrow, 422 (104) mmHg; P < 0.001 CON vs CTN]. The force required to withdraw the catheter from the porcine limb was greater with CON catheters [3.8 (0.8) N] than with any of the CTN catheters [range, 0.4 (0.2) - 0.8 (0.2) N], depending on depth, angle, and manufacturer (P < 0.001 CON vs CTN).

CONCLUSION: In the porcine leg model, CON catheterization provides greater resistance to leakage under high injection pressure and greater holding force in tissue than traditional CTN catheters.

 

[deleted126335]

We just started doing adductor canal catheter infusions for TKA and the nurses are really upset about leakage from the insertion site. We'be told them its normal and they should just wipe it away and reinforce with tape as nexessary. but When pts get up to walk, the fluid runs down their leg into their wound dressing.

We occasionally use dermaflex, a generic Dermabond, to seal the site, but its expensive. Also, when used on surgical wounds, it takes like 7 minutes to dry. Wiki says its 2-octyl cyanoacrylate.

I think the BlockJocks ppl were using histoacryl, which is butyl-cyanoacrylate. Apparently you only have to wait 30 seconds. On their videos they have a small bottle (15ml?) and they use it on multiple patients, by using a sterile straw to withdraw a few drops. I think it's expensive too, but if you can use it multidose it would be cheaper. I only found single patient use 0.5ml ampules on Google.

Does anyone have experience with these glues? Cost is important at my hospital.

We use dermabond. Takes less than a minute to dry up enough so they don't leak. Went with a cheaper alternative...Got lots of leaks....Back to Dermabond.

 

[BobBarker]

Bolus it with bupivicaine and pf dexamethasone and pull it!

 

[urge]

krazy glue?

 

[Oggg]

We are going to try out some catheter over needle systems. There is the Pajunk E catheter and the Contiplex C.
Anyone have any experience with these?

 

[Oggg]

There is a South American/ Brazilian? Study that showed you could use the cheaper Krazy glue as a decent replacement for Dermabond.

 

[deleted126335]

There is a South American/ Brazilian? Study that showed you could use the cheaper Krazy glue as a decent replacement for Dermabond.

Expectations and standards are just a bit lower there.

 

[urge]

There is a South American/ Brazilian? Study that showed you could use the cheaper Krazy glue as a decent replacement for Dermabond.

Isn't it the same thing?

A friend of mine from residency crazy glued all her wounds and swore by it.

Cyanoacrylate is the generic name for substances such as methyl-2-cyanoacrylate, which is usually sold under the trademarks Superglue and Krazy Glue, and 2-octyl cyanoacrylate, which is used in medical glues such as Dermabond and Traumaseal. Cyanoacrylate adhesives are sometimes known as "instant adhesives". The acronym "CA" is quite commonly used for industrial grades.

Not technically the same thing but I cannot tell the difference. And most likely you cannot either.

 

[urge]

Marketed to fix cracked ceramics or torn leather and plastic, the high-powered adhesive is now being recommended by dermatologists to seal tears in human skin.

http://abcnews.go.com/Health/Story?id=118174&page=1

 

[pgg]

Isn't it the same thing?

There are lots of different cyanoacrylate adhesives. Supposedly the medical ones are hypoallergenic and less brittle. I'm sure that's what Dermabond(tm) wants us to believe anyway.

A friend of mine from residency crazy glued all her wounds and swore by it.

Not technically the same thing but I cannot tell the difference. And most likely you cannot either.

I bet it's fine and I wouldn't hesitate to use Krazy Glue on myself if I got a cut, but you know if the surgeon cuts the nerve in six places and the patient sues, they'll blame the block and the lawyer will say "that jackass used Krazy Glue from Ace Hardware to dress my client's wound" and then you're boned.

 

[Oggg]

I tried the E-catheter for an in plane posterolateral CISB. 18g x 75mm. I got my needle just in the sheath, deep to C6, and got good spread. It really looks like a PIV. Looked pretty secure, but I wasn't confident that it would stay put the interscalene space, so I still put dermaflex at the insertion. I didn't try to advance the outer catheter within the sheath, although I will try it next time. Maybe it will curl in the space.

 

[fakin' the funk]

We just started doing adductor canal catheter infusions for TKA and the nurses are really upset about leakage from the insertion site. We'be told them its normal and they should just wipe it away and reinforce with tape as nexessary. but When pts get up to walk, the fluid runs down their.

You don't need glue.

The reason it leaks is because there's an low-resistance tract from the catheter tip to the skin.

Make that tract a high-resistance one by adding loops of your catheter into the subcutaneous tissue and muscle. If you are coming across the vastus medialis you should be able to leave a loop or two in the body of the muscle. Voila, less leakage.

 

[stonemd]

Tunnel the cath 8-10cm and leakage will be reduced

 

[Oggg]

1. I don't see how adding loops in the subcutaneous/muscle will reduce leaking. The fluid might have to take a longer route to exit through the insertion site, but extra loops aren't going to bunch up and block the exit hole. Anyways, I've been threading the extra loops to aim for better catheter position retention, and I am getting leaks. I'll keep doing it for the retention issue.

2. If you tunnel, won't the fluid leak out of your initial insertion site still? We have an 18g hole and a 20g catheter. I thought tunneling was purely for retention. It seems like a lot of ppl don't tunnel, so I currently don't tunnel.

 

[stonemd]

When I tunnel I insert the touhy stylet next to the touhy though the same skin puncture site, and tunnel sq 6-8cm. The remove touhy, ramrod touhy over end of stylet, drive through, remove stylet and run catheter though touhy and remove the needle. Now when you take the slick out there will be no skin bridge and the catheter will not be visible at the original puncture site. I then see less fluid leak with infusion.

 

[Jay K]

When I tunnel I insert the touhy stylet next to the touhy though the same skin puncture site, and tunnel sq 6-8cm. The remove touhy, ramrod touhy over end of stylet, drive through, remove stylet and run catheter though touhy and remove the needle. Now when you take the slick out there will be no skin bridge and the catheter will not be visible at the original puncture site. I then see less fluid leak with infusion.

I appreciate your offer of explanation, but can't visualize what you're doing. Any links/pics from other sites with this technique?