Extracorporeal membrane oxygenation line-associated complications: in vitro testing of cyanoacrylate tissue adhesive and securement devices to prevent infection and dislodgement

Abstract

Background: Extracorporeal membrane oxygenation (ECMO) delivers cardiac and/or respiratory support to critically ill patients who have failed conventional medical therapies. If the large-bore cannulas used to deliver ECMO become infected or dislodged, the patient consequences can be catastrophic. ECMO cannula-related infection has been reported to be double the rate of other vascular devices (7.1 vs 3.4 episodes/1000 ECMO days respectively). The aim of this study was to assess the ability of cyanoacrylate tissue adhesive (TA) to inhibit bacterial growth at the ECMO cannulation site, and the effectiveness of TA and securement devices in securing ECMO cannulas and tubing.

Methods: This in vitro study tested the (1) antimicrobial qualities of TA against standard transparent dressing with ECMO cannula; (2) chemical compatibility between cannula, TA and removal agent; (3) pull-out strength of transparent dressing and TA at the cannula insertion site; and (4) pull-out strength of adhesive bandage and commercial sutureless securement devices (SSDs) on circuit tubing. Fisher's exact test was used to evaluate differences in bacterial growth observed between the transparent dressing and TA groups. Data from mechanical testing were analysed using one-way ANOVA, followed by Tukey's multiple comparison test or t test as appropriate. Statistical significance was defined as p < 0.05.

Results: No bacterial growth occurred under TA-covered cannulas compared with transparent dressing-covered cannulas (p = 0.002). Compared to plates lacking TA or transparent dressing, growth was observed at the insertion point and under the dressing in the transparent dressing group; however, no growth was observed in the TA group (p = 0.019). TA did not weaken the cannulas; however, the TA removal agent did after 60 min of exposure, compared with control (p < 0.01). Compared with transparent dressing, TA increased the pull-out force required for cannula dislodgement from the insertion point (p < 0.0001). SSDs significantly increased the force required to remove the tubing from the fixation points compared with adhesive bandage (p < 0.01).

Conclusions: Our findings suggest that the combined use of TA at the cannula insertion site with a commercial device for tubing securement could provide an effective bedside strategy to prevent or minimise infection and line dislodgement.

Keywords: Catheter-related infections; Cyanoacrylate; Extracorporeal membrane oxygenation; Securement; Tissue adhesives.

Fig. 1

Simulated ECMO cannula insertion site. Cannula secured with a tissue adhesive, Histoacryl (n = 6), and b transparent dressing, Opsite (n = 6)

Fig. 2

Skin with ECMO tubing attached and secured. a Grip-lok (n = 6). b MultiFix (n = 6). c Tensoplast adhesive bandage (n = 6)

Fig. 3

Microbiological test results. a Control plate: S. epidermidis growth on pH indicator agar. b TA applied at insertion site: TA inhibits S. epidermidis growth along the TA edge to the insertion point. c Transparent dressing applied over insertion site: S. epidermidis growth under the dressing, at the cannula insertion point and along the cannula dressing tunnel. d TA + transparent dressing: S. epidermidis growth under the dressing but inhibited beyond the TA edge. TA, tissue adhesive

Fig. 4

Mechanical test results. a Cannula securement comparing transparent dressing (Opsite) with TA (Histoacryl). b Tubing securement comparing adhesive bandage (Tensoplast) with SSD (Grip-lok and MultiFix). TA, tissue adhesive; SSD, sutureless securement device