Br.J. Anaesth. (1979), 51, 805
CORRESPONDENCE BRUXISM
Sir,—Grinding and gnashing of the teeth (bruxism) is a habit that can occur consciously or unconsciously and also during sleep. Although the aetiology of the disorder is unknown, it has been found to occur more frequently in nervous, hyperactive and mentally retarded children. Bruxism in children older than 2 years of age, who are undergoing mechanical ventilation for prolonged periods of time with nasotracheal intubation or tracheotomy, should be observed carefully. On occasion a child may attract the nurse's attention by making a grinding noise with the teeth, but in addition, it has been our experience that bruxism is an early, audible sign of distress caused by hypoxaemia or incorrect ventilation of the lungs. A child who practises bruxism should beobserved carefully to avoid erosion of the teeth. S. GARCfA-TORNEL Barcelona
A.
GILSTON
London REFERENCES
Eltringham, R. J., and Dobson, M. B. (1979). Cardiorespiratory arrests—a diurnal variation ? Br. J. Anaesth., 51, 72. Gilston, A., and Resnekov, L. (1971). Cardio-respiratory Resuscitation. London: Heinemann. Sir,—Thank you for the opportunity to comment on Dr Gilston's letter. I was interested in the points he makes, but I must point out that it was not our intention to go into the philosophical or semantic aspects of cardiopulmonary resuscitation. In addition, we did not use the words "unexpected" or "death". M.
DOBSON
Gloucester
CENTRAL VENOUS CATHETER DESIGN AND MAINTENANCE COMPLICATIONS
Sir,—We read with interest the report of Drs Parulkar, Grundy and Bennett (1978) concerning the fracture of a float catheter. This prompted us to review similar complications which had been observed at this hospital over a period of 1 year with one type of conventional central venous catheter (Vygon Surcath Long-line 174.17). The catheters had been inserted by a variety of medical personnel and used for either central venous manometry or parenteral nutrition. Fracturing of the catheter shafts with leakage of infusion fluids and subsequent colonization with Candida albicans was noted on several occasions (fig. 1A). In two patients, Candida was cultured from blood. This fault occurs following repeated flexion of the catheter by movement of the patient, inadequate fixation to the skin, or simply the weight of the attached infusion lines. In one case, the nursing staff had attempted to stop the leak by wrapping adhesive tape around the catheter (fig. 1B). Separation of the catheter from its hub occurred on five occasions. This was associated in two instances with the development of clinical symptoms and signs suggestive of bacteraemia (fig. 2A). These complications occurred between 12 h and 10 days after insertion and all catheters were removed upon detection of these problems. Such events, although infrequent, emphasize the importance of constant vigilance in the maintenance of central venous lines after insertion. The problem of sepsis and the integrity of central venous catheters is well known. The danger of air embolism via a fracture in the catheter hub or faults in the i.v. infusion line has been reported (Ordway, 1974; Armstrong, Peters and Cohen, 1977). Catheter embolism has occurred following repeated flexion of the shaft. Sprague and Sarwar (1978) recently reported a case of catheter embolism occurring from faulty bonding of the catheter shaft to the hub. They demonstrated, furthermore, separation of the hub and shaft in a number of "Angicaths"
Downloaded from http://bja.oxfordjournals.org/ at University of Bath Library & Learning Centre on July 4, 2015
DIURNAL VARIATION IN CARDIAC ARREST
Sir,—The report by Eltringham and Dobson (1979) on the apparently diurnal variation in cardiac arrest is most interesting. One of the main problems with their information is the nature of their distinction between "cardiac arrest" and "death". Some definitions of cardiac arrest use such phrases as "unexpected cessation of heart action", "previously fit" or, more recently "apparently fit person", "not expected to die" and so forth. Such definitions are quite obsolete, like the "ABCD" resuscitation sequence (Gilston & Resnekov, 1971), although all are still widely propagated. The practical difference between cardiac arrest and death depends on whether or not resuscitation is attempted, or if attempted, subsequently abandoned. In an Intensive Care Unit (where a large proportion of their patients were treated) "cardiac arrest" is another way of saying the heart has finally stopped beating in a desperately ill patient, hardly an "unexpected" event! In other words, are patients more likely to die at certain periods of the day, or is it simply that during those hours there is a high chance of someone saying "he isn't really dead, it's just that his heart has stopped" ? Despite the play on words, this is an important point, since, today, "death" is synonymous with "brain death". This is the root of the dilemma, "to resuscitate or not to resuscitate" a patient with a distressing or incurable lesion, for if his brain is not yet dead, although his heart has stopped, then truly he is still "alive", and not to initiate cardiac massage may, philosophically, be closer to a sin of commission than one of omission! Ethical euthanasia perhaps ? Equally interesting, but far more difficult to pursue, would be a record of the times of death outside hospital. Are their long-term survivors spread equally throughout the day? If so, then this would indicate a temporal emphasis on resuscitation. On the other hand, if the number of long-term survivors is largest at the peak periods of resuscitation, then we would need to add further questions to their already considerable list.
806
BRITISH JOURNAL OF ANAESTHESIA illogical that, having been improved by the advent of Luer-lock mechanisms (fig. 2B), the junction between the administration set and catheter has been replaced by a system in which the catheter can be disconnected from the hub at point " D " in the diagram (fig. 2c). In our opinion, the design of central venous catheters must be improved to render them resilient enough to withstand normal clinical usage. There is clearly a need for a catheter constructed in unity with the hub which will allow smooth subcutaneous tunnelling to be accomplished when prolonged parenteral nutrition is envisaged.
FIG. 1. A: Candida colonization of central venous catheter. B : Cracked and leaking catheter.
REFERENCES
Armstrong, R., Peters, J. L., and Cohen, S. L. (1977). Air embolism caused by a fractured central venous catheter.
Downloaded from http://bja.oxfordjournals.org/ at University of Bath Library & Learning Centre on July 4, 2015
J. L. PETERS S. MEHTAR C. J. VALLIS B. R. KENNING London
(Deseret) and "Quick-Caths" (Travenol) by incubating Lancet, 1, 954. them for several days in a water bath at 37 °C and 42 °C. Recently, skin tunnelling techniques for central venous Benotti, P. N., Both, A., Miller, J. D. B., and Blackburn, G. L. (1977). Safe cannulationof the internal jugular vein catheters have been described when total parenteral nutrition is required. In one such procedure, the plastic hub is grasped for long-term hyperalimentation. Surg. Gynaecol. Obstet., and drawn subcutaneously using an artery forcep (Benotti 144,4. et al o 1977). We feel that the junction between catheter hub Kiely, E. M. (1978). Placement of central feeding catheters. and shaft should not be subjected to such excessive stress. Br.Med.J.,2, 1123. In another subcutaneous tunnelling technique, the hub is cut off, the catheter tunnelled and the hub then reconnected Ordway, C. B. (1974). Air embolism via a CVP catheter without positive pressure—presentation of a case and (Powell-Tuck, 1978). Episodes of septicaemia have been review. Ann. Surg., 179, 479. observed following a similar technique when disconnection of the catheter shaft from the hub occurred (Keily, 1978). Parulkar, D. S., Grundy, E. M., and Bennett, E. J. (1978). Fracture of a float catheter. Br.J. Anaesth., 50, 201. The preservation of a closed infusion system is essential to minimize the risk of air embolism or bacterial or fungal Powell-Tuck, J. (1978). Skin tunnel for central venous catheters: non operative technique. Br. Med. J., 1, 625. contamination. New catheters are being marketed for the provision of parenteral nutrition, in which the shaft is Sprague, D. H., and Sarwar, H. (1978). Catheter embolization due to faulty bonding of catheter shaft to hub. simply pushed on to a metal hub (fig. 2c). It is surely Anesthesiology, 49, 285.
INFUSION LINE
LUER-LOCK
CENTRAL VENOUS CATHETER
FIG. 2. A: Hub disconnection, B and c: Current catheter hub designs.
CORRESPONDENCE BRUXISM
Sir,—Grinding and gnashing of the teeth (bruxism) is a habit that can occur consciously or unconsciously and also during sleep. Although the aetiology of the disorder is unknown, it has been found to occur more frequently in nervous, hyperactive and mentally retarded children. Bruxism in children older than 2 years of age, who are undergoing mechanical ventilation for prolonged periods of time with nasotracheal intubation or tracheotomy, should be observed carefully. On occasion a child may attract the nurse's attention by making a grinding noise with the teeth, but in addition, it has been our experience that bruxism is an early, audible sign of distress caused by hypoxaemia or incorrect ventilation of the lungs. A child who practises bruxism should beobserved carefully to avoid erosion of the teeth. S. GARCfA-TORNEL Barcelona
A.
GILSTON
London REFERENCES
Eltringham, R. J., and Dobson, M. B. (1979). Cardiorespiratory arrests—a diurnal variation ? Br. J. Anaesth., 51, 72. Gilston, A., and Resnekov, L. (1971). Cardio-respiratory Resuscitation. London: Heinemann. Sir,—Thank you for the opportunity to comment on Dr Gilston's letter. I was interested in the points he makes, but I must point out that it was not our intention to go into the philosophical or semantic aspects of cardiopulmonary resuscitation. In addition, we did not use the words "unexpected" or "death". M.
DOBSON
Gloucester
CENTRAL VENOUS CATHETER DESIGN AND MAINTENANCE COMPLICATIONS
Sir,—We read with interest the report of Drs Parulkar, Grundy and Bennett (1978) concerning the fracture of a float catheter. This prompted us to review similar complications which had been observed at this hospital over a period of 1 year with one type of conventional central venous catheter (Vygon Surcath Long-line 174.17). The catheters had been inserted by a variety of medical personnel and used for either central venous manometry or parenteral nutrition. Fracturing of the catheter shafts with leakage of infusion fluids and subsequent colonization with Candida albicans was noted on several occasions (fig. 1A). In two patients, Candida was cultured from blood. This fault occurs following repeated flexion of the catheter by movement of the patient, inadequate fixation to the skin, or simply the weight of the attached infusion lines. In one case, the nursing staff had attempted to stop the leak by wrapping adhesive tape around the catheter (fig. 1B). Separation of the catheter from its hub occurred on five occasions. This was associated in two instances with the development of clinical symptoms and signs suggestive of bacteraemia (fig. 2A). These complications occurred between 12 h and 10 days after insertion and all catheters were removed upon detection of these problems. Such events, although infrequent, emphasize the importance of constant vigilance in the maintenance of central venous lines after insertion. The problem of sepsis and the integrity of central venous catheters is well known. The danger of air embolism via a fracture in the catheter hub or faults in the i.v. infusion line has been reported (Ordway, 1974; Armstrong, Peters and Cohen, 1977). Catheter embolism has occurred following repeated flexion of the shaft. Sprague and Sarwar (1978) recently reported a case of catheter embolism occurring from faulty bonding of the catheter shaft to the hub. They demonstrated, furthermore, separation of the hub and shaft in a number of "Angicaths"
Downloaded from http://bja.oxfordjournals.org/ at University of Bath Library & Learning Centre on July 4, 2015
DIURNAL VARIATION IN CARDIAC ARREST
Sir,—The report by Eltringham and Dobson (1979) on the apparently diurnal variation in cardiac arrest is most interesting. One of the main problems with their information is the nature of their distinction between "cardiac arrest" and "death". Some definitions of cardiac arrest use such phrases as "unexpected cessation of heart action", "previously fit" or, more recently "apparently fit person", "not expected to die" and so forth. Such definitions are quite obsolete, like the "ABCD" resuscitation sequence (Gilston & Resnekov, 1971), although all are still widely propagated. The practical difference between cardiac arrest and death depends on whether or not resuscitation is attempted, or if attempted, subsequently abandoned. In an Intensive Care Unit (where a large proportion of their patients were treated) "cardiac arrest" is another way of saying the heart has finally stopped beating in a desperately ill patient, hardly an "unexpected" event! In other words, are patients more likely to die at certain periods of the day, or is it simply that during those hours there is a high chance of someone saying "he isn't really dead, it's just that his heart has stopped" ? Despite the play on words, this is an important point, since, today, "death" is synonymous with "brain death". This is the root of the dilemma, "to resuscitate or not to resuscitate" a patient with a distressing or incurable lesion, for if his brain is not yet dead, although his heart has stopped, then truly he is still "alive", and not to initiate cardiac massage may, philosophically, be closer to a sin of commission than one of omission! Ethical euthanasia perhaps ? Equally interesting, but far more difficult to pursue, would be a record of the times of death outside hospital. Are their long-term survivors spread equally throughout the day? If so, then this would indicate a temporal emphasis on resuscitation. On the other hand, if the number of long-term survivors is largest at the peak periods of resuscitation, then we would need to add further questions to their already considerable list.
806
BRITISH JOURNAL OF ANAESTHESIA illogical that, having been improved by the advent of Luer-lock mechanisms (fig. 2B), the junction between the administration set and catheter has been replaced by a system in which the catheter can be disconnected from the hub at point " D " in the diagram (fig. 2c). In our opinion, the design of central venous catheters must be improved to render them resilient enough to withstand normal clinical usage. There is clearly a need for a catheter constructed in unity with the hub which will allow smooth subcutaneous tunnelling to be accomplished when prolonged parenteral nutrition is envisaged.
FIG. 1. A: Candida colonization of central venous catheter. B : Cracked and leaking catheter.
REFERENCES
Armstrong, R., Peters, J. L., and Cohen, S. L. (1977). Air embolism caused by a fractured central venous catheter.
Downloaded from http://bja.oxfordjournals.org/ at University of Bath Library & Learning Centre on July 4, 2015
J. L. PETERS S. MEHTAR C. J. VALLIS B. R. KENNING London
(Deseret) and "Quick-Caths" (Travenol) by incubating Lancet, 1, 954. them for several days in a water bath at 37 °C and 42 °C. Recently, skin tunnelling techniques for central venous Benotti, P. N., Both, A., Miller, J. D. B., and Blackburn, G. L. (1977). Safe cannulationof the internal jugular vein catheters have been described when total parenteral nutrition is required. In one such procedure, the plastic hub is grasped for long-term hyperalimentation. Surg. Gynaecol. Obstet., and drawn subcutaneously using an artery forcep (Benotti 144,4. et al o 1977). We feel that the junction between catheter hub Kiely, E. M. (1978). Placement of central feeding catheters. and shaft should not be subjected to such excessive stress. Br.Med.J.,2, 1123. In another subcutaneous tunnelling technique, the hub is cut off, the catheter tunnelled and the hub then reconnected Ordway, C. B. (1974). Air embolism via a CVP catheter without positive pressure—presentation of a case and (Powell-Tuck, 1978). Episodes of septicaemia have been review. Ann. Surg., 179, 479. observed following a similar technique when disconnection of the catheter shaft from the hub occurred (Keily, 1978). Parulkar, D. S., Grundy, E. M., and Bennett, E. J. (1978). Fracture of a float catheter. Br.J. Anaesth., 50, 201. The preservation of a closed infusion system is essential to minimize the risk of air embolism or bacterial or fungal Powell-Tuck, J. (1978). Skin tunnel for central venous catheters: non operative technique. Br. Med. J., 1, 625. contamination. New catheters are being marketed for the provision of parenteral nutrition, in which the shaft is Sprague, D. H., and Sarwar, H. (1978). Catheter embolization due to faulty bonding of catheter shaft to hub. simply pushed on to a metal hub (fig. 2c). It is surely Anesthesiology, 49, 285.
INFUSION LINE
LUER-LOCK
CENTRAL VENOUS CATHETER
FIG. 2. A: Hub disconnection, B and c: Current catheter hub designs.
