Practice guidelines provide checklists to decrease complications during central venous introducer placement.1  Fixation of introducers should rely on institutional practice, which may include suturing, stapling, or an adhesive method.1,2  Our institutional practice uses a two-point suture securement technique: one at the suture wing and a second wrapped around the introducer’s hub (Panel A).

Panel B illustrates a 9Fr ARROW Percutaneous Sheath Introducer (Teleflex, USA) with an inadvertent retention suture through the sheath. The practice guideline checklist recommends securement after aspiration and flushing.1  Before fixation, the sheath was immediately aspirated, revealing venous blood. After fixation, repeat aspiration revealed an air-filled venous blood mixture within the side port tubing and fluid leakage at the insertion site.

Introducer damage during fixation may be secondary to various factors: limited visibility, restricted neck rotation, emergent access, etc. Although practice guidelines remain ambiguous regarding fixation techniques, ARROW specifically recommends sutures remain outside the immediate sheath area.3  Considering the manufacturer’s recommendations, placing a skin suture beside the venous introducer (Panel A) followed by circumferentially wrapping around the hub’s ring is preferable to a suture trajectory posterior to the sheath.

Prompt identification of a venous introducer integrity breech remains critical in preventing potential air emboli, blood stream infections, insufficient intravascular volume resuscitation, and vasoactive drug administration. The current practice guideline checklist recommends flushing the catheter prior to securement only.1  Considering Panel B, integrity checks involving aspiration and flushing should be considered after sheath fixation and before use.

The authors declare no competing interests.

Practice Guidelines for Central Venous Access 2020: An updated report by the American Society of Anesthesiologists Task Force on Central Venous Access
Suturing central venous catheters.
Br J Anaesth
Teleflex Incorporated: Arrow percutaneous sheath introducer product: Safety and efficacy considerations
Available at: Accessed September 1, 2020.