introduction / clinical conundrum

A patient is admitted in transfer with a kinked introducer catheter (shown above).  Does this catheter need to be removed, or can it somehow be salvaged?

a few words about the introducer catheter

Introducer catheters (a.k.a. “cordis” or “sheath”) are traditionally popular for hemorrhagic shock resuscitation because they have high flow rates.  However I dislike this practice for several reasons:

• They get kinked a lot.
• In order to avoid getting kinked you need to put another catheter through them – which decreases the flow rate (thus defeating the whole purpose of using the catheter in the first place).
• They aren't designed as a stand-alone device, so when inserted alone they have sharp-ish ends which could irritate vessels and possibly increase the risk of thrombus formation.
• They don't get you a lot of lumens.
• They aren't pressure injectable, so you can't use them for a CT angiography (seriously – this may cause the catheter to explode).

Personally I'd prefer *any* of the following options for large-volume resuscitation:

• Hemodialysis catheter (two lumens, never kinks, enormous flow rate).
• Trialysis catheter (hemodialysis catheter with three lumens)
• MAC introducer.
• Quad lumen pressure-injectable central line (generally disparaged for large-volume resuscitation, but if you attach this to a Belmont or Level-1 infuser you can get very decent flow rates).

how to salvage a kinked introducer catheter?

This can be fixed by gently advancing a catheter within the introducer to stent open the introducer (eliminating the kink).  The key here is that the inner catheter should be specifically designed for this use, so that it fits snugly within introducer (example above).   If you use a standard central line, there may be a gap between  the central line and the introducer which leads to bleeding or air embolism.  A specifically designed inner catheter also locks onto the introducer, keeping things clean.  If the inner catheter doesn't pass with gentle pressure, don't force it – in that case you may need to just remove the introducer.

This solution won't get you a large-bore lumen for rapid infusion of volume.  So if your patient is dying of hemorrhagic shock this won't get you out of trouble.  However, if you just need vascular access, then this is a simple way to convert a kinked (and totally worthless) introducer into a triple-lumen catheter.

• Using an introducer catheter for access to provide large volume resuscitation probably isn't a great idea – there are numerous better options.
• Don't stick any old central line into an introducer catheter – if there is any gap between the central line and the introducer this will cause bleeding and/or air embolism.
• A kinked introducer can be salvaged by gently advancing a specially designed inner catheter through it, to stent it open.