Correspondence AGUIDE FOR REPLACINGTHE LEAKYEll To rhe E&or:-1 read with interest the letter by Dr Nakhgevany et al entitled “A New Technique for Emergency Endotracheal Intubation in Trauma Patients” (AJEM 1989;7:664-666.). Recently I had the opportunity to apply a modification of their technique while treating a medical patient. An elderly woman presented to the emergency department in respiratory failure resulting from congestive heart failure and emphysema, and required ventilatory support. Nasotracheal intubation proved to be technically difftcult in that multiple attempts were required to pass the tube through the glottis. The procedure was ultimately completed without additional complication and the patient improved rapidly. A slow leak from the cuff of the endotracheal tube was discovered, requiring replacement with a second tube. The proximal, connecting end of a 16F nasogastric (NG) tube was cut off, and the distal end passed through the endotracheal tube to approximately the level of the carina. The defective endotracheal tube was then rapidly withdrawn over the NG tube and replaced with a new endotracheal tube, using the NG tube as a guide. The NC tube was then withdrawn. This procedure required between 10 and 15 seconds and was accomplished without change in the patient’s vital signs. STEVENROSENZWEIG, MD Delaware County Memorial Hospital Drexel Hill, PA
HEPARINLOCK USE To the Editor:-The heparin lock has been used since the early 1970s for the purpose of maintaining access to the venous system, and for the intermittent infusion of intravenous (IV) medications. Although several studies have demonstrated its simplicity, effectiveness and reliability, it has yet to gain widespread use in the hospital.‘-5 Recently, the heparin lock was shown to be a safe, convenient and cost-effective method of maintaining IV access in the prehospital setting.’ However, the majority of patients entering the hospital through the emergency department still have conventional IV fluid lines established. The purpose of this study was to determine the percentage of patients in the emergency department who could benefit from a heparin lock rather than a fluid line, and to determine the potential cost savings of using heparin locks in the emergency department. The source of patients for the study was the emergency admitting area of the emergency department at the Los Angeles CountyUniversity of Southern California Medical Center. The emergency admitting area cares for all adult critical and nonambulatory sick and injured patients, and pediatric trauma. All charts of patients seen in the emergency admitting area over a 2-week period were retrospectively reviewed. Charts indicating that an IV line was ordered were selected for the study. Data collected from each chart included patient identification number, presenting chief complaint, initial vital signs, type of IV fluid and the ordered rate of flow, emergency department diagnosis and disposition. For purposes of study, we arbitrarily chose a rate of 125 mL/h as a dividing line between those who required IV fluids for therapeutic
_ The American Journal of Emergency Medicine invites correspondence, commentary, and criticism in the form of letters to the editor. Please address correspondence to the Editor: The American Journal of Emergency Medicine, 3800 Reservoir Rd, NW, Washington, DC 20007.
purposes and those who did not. With the exception of trauma cases, all patients who had IV fluid lines established and operated at flow rates less than or equal to 125 mL/h, without regard to diagnosis, were considered appropriate candidates for use of a heparin lock. Over the 14-day period, data were collected on 907 patients in whom 976 IV lines were established. Classification was made according to the type and rate of fluid ordered. The number and percentage of trauma patients in each category were also determined (Table 1). Of 233 patients receiving IV fluid lines of DSW, 227 (97%) were at a rate ~125 mL/h, and 222 (95%) were “to keep open” (TKO) lines. There were no D5W lines established in trauma cases. Of the 82 patients receiving IV D5 % NS lines, 55 (67%) had rates =S125 mL/h and only three of these patients were trauma cases. Of 20 patients in whom Ringers lactate fluid lines were ordered, 10 (50%) had rates ~125 mL/h; however, half of these in the low flow rate category were trauma cases. There were 506 patients who received a single IV fluid line of normal saline. Of these 506 patients 272 (54%) had rates s 125 mL/h, and 47 of these were trauma cases. Sixty-three patients received two normal saline fluid lines. Of these, 30 (48%) were ~125 mL/h, and nearly all (26 of 30) were trauma cases. There were three patients who each received three IV normal saline lines. All three were trauma cases and all had rates greater than 125 mL/h. During this 14-day study period, there were 907 patients who had IV fluid lines established. In accordance with our assumption that emergency department patients receiving fluid at a rate cl25 mL/h do not require urgent or emergency therapeutic hydration, 513 of these 907 patients (57%) may have benefited from a heparin lock instead. Ideally, when chief complaint, general appearance, and vital signs are used as determining factors of the necessity for IV fluids rather than an arbitrary cut-off rate, patients with clear indications for fluid lines are those who require emergency fluid resuscitation, continuous medication infusion, and urgent therapeutic hydration (such as dehydrated, or preoperative surgical patients). Intravenous fluid lines are also more appropriate than heparin locks in trauma patients to allow for any need of fluid replacement. Candidates for heparin lock use include those who have TKO fluid lines, those receiving single or multiple dose medications, and those who are able to take oral medications and are receiving IV fluids at less than maintenance rates. When there is no indication for intravenous fluid administration in the emergency department, the heparin lock has several advantages over the more commonly used “TKO” or low rate fluid line. It TABLE 1. Total IV Lines Ordered All Patients
Fluid
n
Trauma
Rate (mL/h) G125 >125 N (%) N (%)
D5W D5.5NS R/L NS x 1 NS x 2 NS x 3
233 82 20 506 63 3
227 55 10 272 30 0
Totals
907
594 (65%)
(97%) (67%) (50%) (54%) (48%) (0%)
6 27 10 234 33 3
(3%) (33%) (50%) (46%) (52%) (100%)
Patients
Rate (mL/h) >125 ~125 N (%) N (%) 0 3 5 47 26 0
(0) (4%) (25%) (9%) (41%) (0%)
0 0 0 10 21 3
(0) (0) (0) (2%) (33%) (100%)
313 (35%)
95
AMERICAN JOURNAL OF EMERGENCY MEDICINE l Volume 9, Number 1 n January 1991
96
allows freedom of movement for the patient and ease of patient transportation. It avoids the need to monitor IV fluid volume, and eliminates the possibility of inadvertent fluid overload. In addition, it provides easy access to the venous system for patients who require frequent blood sampling, thus avoiding the discomfort of multiple venipunctures. Finally, if the need for continuous infusion subsequently arises, it can easily be given through the existing heparin lock. It was apparent from our data that a large number of IV lines were established in patients who did not really require IV fluids. Although many of these may represent caution on the part of physicians, one must consider the influence of reflex and habituation in such physician behavior. The ready availability of a safe and simple alternative technique for access to the vascular system could serve to usefully alter such behavior. Previous studies have addressed concerns as to whether the heparin lock can reliably maintain patency, and whether there is a higher incidence of complications associated with its use.2s3 They concluded that the heparin lock is as reliable as the TKO line for providing a patent IV route, and that there was no significant difference in their complication rates. The question of whether the amount of heparin used to maintain patency would alter coagulation studies has also been addressed. It was found that a standard solution of 10 USP units of heparin in I mL normal saline reliably maintains patency and does not significantly alter systemic blood clotting factors including clotting time, prothrombin time, and activated partial thromboplastin time.6 More recently it was suggested that an injection of normal saline alone may be effective for maintaining heparin lock injection sites.7.8 This would avoid the possibility of heparin-related drug compatibility problems, and would also reduce both the cost of the flush solution, as well as the time necessary for routine maintenance of the system. In addition to the aforementioned benefits, the heparin lock offers an opportunity for substantial cost reduction to both patients and medical care providers. The hospital cost for intravenous cannulation equipment at our institution is detailed in Table 2. Over our 2-week study period, if heparin locks were ordered instead of fluid lines in all patients considered appropriate candidates, the savings in equipment alone would have been $651. Assuming these 2 weeks represent an average 2-week patient sample, the yearly savings on supplies would be approximately $17,000, a savings of 55%. Obviously these detailed figures are unique to both this study period and our institution. However, it is clear that in reducing the cost of supplies, not to mention costs involved in purchasing, inventory and storage, there is an opportunity for substantial cost reduction universally. The dollar savings to patients are proportionately much greater. Previously reported data comparing patient charges for IV cannulation equipment indicate a charge of $45.20 for a conventional IV D5W infusion, compared with $10.07 for a heparin lock.’ This results in a net decrease of $35.13, or 78% savings per patient. Other published cost-comparison data report a total cost of $14.80 for an IV DSRL infusion, compared with a cost of $2.99 for a heparin lock.’ This represents a difference of $11.81 per patient or an 80% savings. Clearly these numbers will vary geographically as both hosTABLE 2.
Cost of Supplies to Hospital
Angiocatheter (18 g) IV administration tubing IV solutions: Normal saline Dextrose 5% Ringers lactate D5 ‘/z NS Heparin lock adapter Heparin flush solution (10 U)
$0.45 1.14 0.60 0.55 0.74 0.71 0.45 0.08
pital costs and patient charges differ. At our medical center patients are not charged for specific medical supplies; however, it is easy to realize the potential for enormous reduction in charges at most hospitals where this does occur. In summary, the heparin lock has been demonstrated to be a safe, effective and reliable method for maintaining access to the venous system. It affords the advantages of enhanced patient comfort, increased freedom during transportation, minimal monitoring requirements, avoidance of inadvertent fluid administration and major cost reduction. It is therefore our recommendation that heparin locks replace IV fluid lines whenever appropriate in the emergency department . CLAUDIA R. GOLD, MD JOSEPHE. MORALES,MD LAC-USC Medical Center Los Angeles. California
REFERENCES 1. Schwarzman P, Rottman S: Prehospital use of heparin locks: A cost-effective method for intravenous access. Am J Emerg tvled 1987;5:475-477 2. Hanson R: Heparin-lock or keep-open I.V.? Am J Nurs 1976;76:1102-1103 3. Hanson R: A Comparison of the rate of complications with heoarin-lock and keeo-ooen I.V.‘s. Comm Nurs Res 1977:8: . . 1S&200 4. Levitt D: Use of the heparin lock on an outpatient basis. Cancer Nurs 1981;4:115-119 5. Basil W: The use of heparin locks (PRN Adapters) vs. intravenous therapy in outpatient surgery. Insight 1988;13:13, 15 6. Hanson R, Grant A, Majors K: Heparin-lock maintenance with ten units of sodium heparin in one milliliter of normal saline solution. Surg Gynecol Obstet 1976;142:373-6 7. Lombardi T, Gunderson B, Zammet L, et al: Efficacy of 0.9% sodium chloride injection with or without heparin sodium for maintaining patency of intravenous catheters in children. Clin Pharm 1988;7:832-836 8. Epperson E: Efficacy of 0.9% sodium chloride injection with and without heparin for maintaining indwelling intermittent injection sites. Clin Pharm 1984;3:626-629
AN UNUSUAL DIAGNOSIS FOR ACUTE RIGHT-SIDED GROIN PAIN IN A 39-YEAR-OLD WOMAN To the Edifor;-Pelvic pain is a common presentation to the emergency department. When pelvic pain is associated with a pelvic mass, the emergency physician should take into consideration a specific differential diagnosis. Although extraskeletal Ewing’s sarcoma is an exceedingly rare cause of pelvic mass and pain, the possibility of a tumor must be considered in this setting. A 39-year-old gravida 1 para 1 Hispanic woman presented to the emergency department at 4 AM complaining of acute right-sided groin pain radiating to her knee. She stated that the pain had awakened her from sleep. She further denied any trauma, injury, previous episodes of similar pain as well as history of low back pain. She denied dysuria, urgency, frequency, vaginal discharge, hematuria, or anorexia. No recent history of fever, chills, nausea, vomiting, or diarrhea was elicited. Her last menstrual period was 6 days before the emergency department visit and was described as normal. Past medical history was significant for hypertension for which she was prescribed atenolol. Past surgical history was significant for an appendectomy as a child. On examination, the patient was noted to be resting comfortably and appeared to be in no acute distress. Blood pressure was 164/110 mm Hg, pulse rate, 68 be.ats/min; respiration rate, 18 breaths/min; oral temperature 36.5”C. Breath sounds were clear. Heart rate and rhythm were regular with no murmurs, rubs, or gallops. The abdomen was noted to be obese, soft and nontender to palpation. No
HEPARINLOCK USE To the Editor:-The heparin lock has been used since the early 1970s for the purpose of maintaining access to the venous system, and for the intermittent infusion of intravenous (IV) medications. Although several studies have demonstrated its simplicity, effectiveness and reliability, it has yet to gain widespread use in the hospital.‘-5 Recently, the heparin lock was shown to be a safe, convenient and cost-effective method of maintaining IV access in the prehospital setting.’ However, the majority of patients entering the hospital through the emergency department still have conventional IV fluid lines established. The purpose of this study was to determine the percentage of patients in the emergency department who could benefit from a heparin lock rather than a fluid line, and to determine the potential cost savings of using heparin locks in the emergency department. The source of patients for the study was the emergency admitting area of the emergency department at the Los Angeles CountyUniversity of Southern California Medical Center. The emergency admitting area cares for all adult critical and nonambulatory sick and injured patients, and pediatric trauma. All charts of patients seen in the emergency admitting area over a 2-week period were retrospectively reviewed. Charts indicating that an IV line was ordered were selected for the study. Data collected from each chart included patient identification number, presenting chief complaint, initial vital signs, type of IV fluid and the ordered rate of flow, emergency department diagnosis and disposition. For purposes of study, we arbitrarily chose a rate of 125 mL/h as a dividing line between those who required IV fluids for therapeutic
_ The American Journal of Emergency Medicine invites correspondence, commentary, and criticism in the form of letters to the editor. Please address correspondence to the Editor: The American Journal of Emergency Medicine, 3800 Reservoir Rd, NW, Washington, DC 20007.
purposes and those who did not. With the exception of trauma cases, all patients who had IV fluid lines established and operated at flow rates less than or equal to 125 mL/h, without regard to diagnosis, were considered appropriate candidates for use of a heparin lock. Over the 14-day period, data were collected on 907 patients in whom 976 IV lines were established. Classification was made according to the type and rate of fluid ordered. The number and percentage of trauma patients in each category were also determined (Table 1). Of 233 patients receiving IV fluid lines of DSW, 227 (97%) were at a rate ~125 mL/h, and 222 (95%) were “to keep open” (TKO) lines. There were no D5W lines established in trauma cases. Of the 82 patients receiving IV D5 % NS lines, 55 (67%) had rates =S125 mL/h and only three of these patients were trauma cases. Of 20 patients in whom Ringers lactate fluid lines were ordered, 10 (50%) had rates ~125 mL/h; however, half of these in the low flow rate category were trauma cases. There were 506 patients who received a single IV fluid line of normal saline. Of these 506 patients 272 (54%) had rates s 125 mL/h, and 47 of these were trauma cases. Sixty-three patients received two normal saline fluid lines. Of these, 30 (48%) were ~125 mL/h, and nearly all (26 of 30) were trauma cases. There were three patients who each received three IV normal saline lines. All three were trauma cases and all had rates greater than 125 mL/h. During this 14-day study period, there were 907 patients who had IV fluid lines established. In accordance with our assumption that emergency department patients receiving fluid at a rate cl25 mL/h do not require urgent or emergency therapeutic hydration, 513 of these 907 patients (57%) may have benefited from a heparin lock instead. Ideally, when chief complaint, general appearance, and vital signs are used as determining factors of the necessity for IV fluids rather than an arbitrary cut-off rate, patients with clear indications for fluid lines are those who require emergency fluid resuscitation, continuous medication infusion, and urgent therapeutic hydration (such as dehydrated, or preoperative surgical patients). Intravenous fluid lines are also more appropriate than heparin locks in trauma patients to allow for any need of fluid replacement. Candidates for heparin lock use include those who have TKO fluid lines, those receiving single or multiple dose medications, and those who are able to take oral medications and are receiving IV fluids at less than maintenance rates. When there is no indication for intravenous fluid administration in the emergency department, the heparin lock has several advantages over the more commonly used “TKO” or low rate fluid line. It TABLE 1. Total IV Lines Ordered All Patients
Fluid
n
Trauma
Rate (mL/h) G125 >125 N (%) N (%)
D5W D5.5NS R/L NS x 1 NS x 2 NS x 3
233 82 20 506 63 3
227 55 10 272 30 0
Totals
907
594 (65%)
(97%) (67%) (50%) (54%) (48%) (0%)
6 27 10 234 33 3
(3%) (33%) (50%) (46%) (52%) (100%)
Patients
Rate (mL/h) >125 ~125 N (%) N (%) 0 3 5 47 26 0
(0) (4%) (25%) (9%) (41%) (0%)
0 0 0 10 21 3
(0) (0) (0) (2%) (33%) (100%)
313 (35%)
95
AMERICAN JOURNAL OF EMERGENCY MEDICINE l Volume 9, Number 1 n January 1991
96
allows freedom of movement for the patient and ease of patient transportation. It avoids the need to monitor IV fluid volume, and eliminates the possibility of inadvertent fluid overload. In addition, it provides easy access to the venous system for patients who require frequent blood sampling, thus avoiding the discomfort of multiple venipunctures. Finally, if the need for continuous infusion subsequently arises, it can easily be given through the existing heparin lock. It was apparent from our data that a large number of IV lines were established in patients who did not really require IV fluids. Although many of these may represent caution on the part of physicians, one must consider the influence of reflex and habituation in such physician behavior. The ready availability of a safe and simple alternative technique for access to the vascular system could serve to usefully alter such behavior. Previous studies have addressed concerns as to whether the heparin lock can reliably maintain patency, and whether there is a higher incidence of complications associated with its use.2s3 They concluded that the heparin lock is as reliable as the TKO line for providing a patent IV route, and that there was no significant difference in their complication rates. The question of whether the amount of heparin used to maintain patency would alter coagulation studies has also been addressed. It was found that a standard solution of 10 USP units of heparin in I mL normal saline reliably maintains patency and does not significantly alter systemic blood clotting factors including clotting time, prothrombin time, and activated partial thromboplastin time.6 More recently it was suggested that an injection of normal saline alone may be effective for maintaining heparin lock injection sites.7.8 This would avoid the possibility of heparin-related drug compatibility problems, and would also reduce both the cost of the flush solution, as well as the time necessary for routine maintenance of the system. In addition to the aforementioned benefits, the heparin lock offers an opportunity for substantial cost reduction to both patients and medical care providers. The hospital cost for intravenous cannulation equipment at our institution is detailed in Table 2. Over our 2-week study period, if heparin locks were ordered instead of fluid lines in all patients considered appropriate candidates, the savings in equipment alone would have been $651. Assuming these 2 weeks represent an average 2-week patient sample, the yearly savings on supplies would be approximately $17,000, a savings of 55%. Obviously these detailed figures are unique to both this study period and our institution. However, it is clear that in reducing the cost of supplies, not to mention costs involved in purchasing, inventory and storage, there is an opportunity for substantial cost reduction universally. The dollar savings to patients are proportionately much greater. Previously reported data comparing patient charges for IV cannulation equipment indicate a charge of $45.20 for a conventional IV D5W infusion, compared with $10.07 for a heparin lock.’ This results in a net decrease of $35.13, or 78% savings per patient. Other published cost-comparison data report a total cost of $14.80 for an IV DSRL infusion, compared with a cost of $2.99 for a heparin lock.’ This represents a difference of $11.81 per patient or an 80% savings. Clearly these numbers will vary geographically as both hosTABLE 2.
Cost of Supplies to Hospital
Angiocatheter (18 g) IV administration tubing IV solutions: Normal saline Dextrose 5% Ringers lactate D5 ‘/z NS Heparin lock adapter Heparin flush solution (10 U)
$0.45 1.14 0.60 0.55 0.74 0.71 0.45 0.08
pital costs and patient charges differ. At our medical center patients are not charged for specific medical supplies; however, it is easy to realize the potential for enormous reduction in charges at most hospitals where this does occur. In summary, the heparin lock has been demonstrated to be a safe, effective and reliable method for maintaining access to the venous system. It affords the advantages of enhanced patient comfort, increased freedom during transportation, minimal monitoring requirements, avoidance of inadvertent fluid administration and major cost reduction. It is therefore our recommendation that heparin locks replace IV fluid lines whenever appropriate in the emergency department . CLAUDIA R. GOLD, MD JOSEPHE. MORALES,MD LAC-USC Medical Center Los Angeles. California
REFERENCES 1. Schwarzman P, Rottman S: Prehospital use of heparin locks: A cost-effective method for intravenous access. Am J Emerg tvled 1987;5:475-477 2. Hanson R: Heparin-lock or keep-open I.V.? Am J Nurs 1976;76:1102-1103 3. Hanson R: A Comparison of the rate of complications with heoarin-lock and keeo-ooen I.V.‘s. Comm Nurs Res 1977:8: . . 1S&200 4. Levitt D: Use of the heparin lock on an outpatient basis. Cancer Nurs 1981;4:115-119 5. Basil W: The use of heparin locks (PRN Adapters) vs. intravenous therapy in outpatient surgery. Insight 1988;13:13, 15 6. Hanson R, Grant A, Majors K: Heparin-lock maintenance with ten units of sodium heparin in one milliliter of normal saline solution. Surg Gynecol Obstet 1976;142:373-6 7. Lombardi T, Gunderson B, Zammet L, et al: Efficacy of 0.9% sodium chloride injection with or without heparin sodium for maintaining patency of intravenous catheters in children. Clin Pharm 1988;7:832-836 8. Epperson E: Efficacy of 0.9% sodium chloride injection with and without heparin for maintaining indwelling intermittent injection sites. Clin Pharm 1984;3:626-629
AN UNUSUAL DIAGNOSIS FOR ACUTE RIGHT-SIDED GROIN PAIN IN A 39-YEAR-OLD WOMAN To the Edifor;-Pelvic pain is a common presentation to the emergency department. When pelvic pain is associated with a pelvic mass, the emergency physician should take into consideration a specific differential diagnosis. Although extraskeletal Ewing’s sarcoma is an exceedingly rare cause of pelvic mass and pain, the possibility of a tumor must be considered in this setting. A 39-year-old gravida 1 para 1 Hispanic woman presented to the emergency department at 4 AM complaining of acute right-sided groin pain radiating to her knee. She stated that the pain had awakened her from sleep. She further denied any trauma, injury, previous episodes of similar pain as well as history of low back pain. She denied dysuria, urgency, frequency, vaginal discharge, hematuria, or anorexia. No recent history of fever, chills, nausea, vomiting, or diarrhea was elicited. Her last menstrual period was 6 days before the emergency department visit and was described as normal. Past medical history was significant for hypertension for which she was prescribed atenolol. Past surgical history was significant for an appendectomy as a child. On examination, the patient was noted to be resting comfortably and appeared to be in no acute distress. Blood pressure was 164/110 mm Hg, pulse rate, 68 be.ats/min; respiration rate, 18 breaths/min; oral temperature 36.5”C. Breath sounds were clear. Heart rate and rhythm were regular with no murmurs, rubs, or gallops. The abdomen was noted to be obese, soft and nontender to palpation. No
