Dear Editor,
Continuous peripheral nerve block (CPNB) using an indwelling catheter is an established technique for managing pain in both acute and chronic settings.[1] However, clinicians are often faced with catheter dislodgement, which hampers the effectiveness of CPNB, leading to unsatisfactory pain relief. The dislodgement rate of perineural catheters has not been extensively studied but may vary from 15% to 55%.[2,3] The causes for dislodgement can vary. The narrow gauge and smooth surface of the catheter allow free movement through the larger needle puncture site (in catheter-through-needle systems). Accidental traction on the catheter or the infusion tubing can frequently occur during the hospital stay. The catheter insertion site may also contribute, with shallower sites (such as out-of-plane interscalene) reporting much more frequent dislodgements.[4]
Various techniques have been proposed to resolve this issue, including subcutaneous tunnelling, suturing, sterile skin glue (2-octyl cyanoacrylate), and the use of anchoring devices, which are sometimes bundled with catheter system sets.[5] However, each of these has its drawbacks. Subcutaneous tunnelling can be traumatic and painful (particularly in awake patients if local anaesthetic is not infiltrated adequately). The 2-octyl cyanoacrylate glue, although effective, may not be readily available in all centres and is considerably expensive. Similarly, anchoring devices can add to the cost of the catheter kit and may not always be available. Other recent developments aimed at addressing this issue include the use of catheter-over-needle sets.[6] To overcome this problem, we have developed a simple and effective technique for securing the perineural catheter, which we refer to as the ‘adhesive-flag’ method. This technique holds the catheter in place and resists dislodgement, even after deliberate traction is applied.
The technique involves placement of the perineural catheter by using the desired method (either ultrasound or peripheral nerve stimulator guidance). For this fixation method, the catheter is held straight upwards. A small transparent adhesive dressing (Tegaderm 1624W, 3M India Limited, Bangalore, India) is placed in such a way that the catheter lies on the middle of the adhesive side of the dressing, leaving equal parts of the film on either side of the catheter near the insertion site [Figure 1a]. The dressing is then wrapped around the catheter so that both adhesive parts meet, sandwiching the catheter in between [Figure 1b and c], avoiding any wrinkles. The lining frame is then slowly removed [Figure 1d]. The catheter with the adhesive film now resembles a flag, hence the name ‘adhesive-flag’ for this method [Figure 1e]. The adhesive flag is then placed against the skin, and a final, large-sized transparent dressing (Tegaderm HP 8526IN, 3M India Limited, Bangalore, India) is positioned and centred over the adhesive flag, ensuring that the catheter entry site is within the borders of the larger dressing [Figure 1f and g]. The frame of the Tegaderm is removed while smoothing the borders of the film and applying gentle pressure [Figure 1h]. Care is taken to dry the skin thoroughly before applying the larger adhesive film. The part of the catheter (along with the connector and the filter) extending beyond the borders of the larger adhesive film is then carefully coiled to avoid kinking and secured with sterile adhesive tape close to the dressing [Figure 1i].
Figure 1.
Steps of adhesive-flag dressing. 3M Tegaderm 1624W (small) and 3M Tegaderm HP 8526IN (large) adhesive dressings were used in these images
The adhesive side of the large-sized dressing adheres strongly not only to the non-adhesive side of the smaller film encasing the catheter (the adhesive flag) but also to the skin surrounding the smaller film. The bond between the two dressings is strong enough to withstand considerable traction forces that might otherwise dislodge the catheter. The application of a single large dressing over the catheter entry site without the ‘adhesive-flag’ is less effective, as the bond between the adhesive film and the skin along the length of the catheter is weak, leading to easy dislodgement. The ‘adhesive-flag’ addresses this problem by securely wrapping around the catheter and increasing its surface area.
This technique has several advantages over others. It is simple, atraumatic, and does not require special training. Transparent adhesive dressings are universally available, comfortable when applied, and do not add any bulk to the dressing or limit movements. One major disadvantage of this fixation method is that, being so effective, any attempt to remove the dressing will also result in the removal of the catheter. Thus, it may not be suitable for situations where frequent dressing changes are desired. We have been using this technique regularly for the last eight years at various sites and have not witnessed any accidental catheter dislodgement to date. Strong traction on tugs on the catheter is unlikely to displace the adhesive complex. This technique can also be used to secure epidural catheters. Overall, we propose the adhesive-flag method as a simple and effective method for securing perineural catheters.
Conflicts of interest
There are no conflicts of interest.
Presentation at conferences/CMEs and abstract publication
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Study data availability
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Disclosure of use of artificial intelligence (AI)-assistive or generative tools
The authors confirm that no AI tools or language models (LLMs) were used in the writing or editing of the manuscript, and no images were manipulated using AI.
Declaration of use of permitted tools
The figure is copyrighted and appropriate permission has been taken.
Authors contributions
AM: Original idea/concept regarding this fixation technique, investigating the feasibility of this method and describing the fixation technique. RK: testing the stability of this fixation method and manuscript preparation. AA: editing the manuscript.
Supplementary material
Nil.
Acknowledgements
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Funding Statement
Nil.
REFERENCES
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