In vitro testing of cyanoacrylate tissue adhesives and sutures for extracorporeal membrane oxygenation cannula securement

Abstract

Background Extracorporeal membrane oxygenation (ECMO), an invasive mechanical therapy, provides cardio-respiratory support to critically ill patients when maximal conventional support has failed. ECMO is delivered via large-bore cannulae which must be effectively secured to avoid complications including cannula migration, dislodgement and accidental decannulation. Growing evidence suggests tissue adhesive (TA) may be a practical and safe method to secure vascular access devices, but little evidence exists pertaining to securement of ECMO cannulae. The aim of this study was to determine the safety and efficacy of two TA formulations (2-octyl cyanoacrylate and n-butyl-2-octyl cyanoacrylate) for use in peripherally inserted ECMO cannula securement, and compare TA securement to ‘standard’ securement methods. Methods This in vitro project assessed: (1) the tensile strength and flexibility of TA formulations compared to ‘standard’ ECMO cannula securement using a porcine skin model, and (2) the chemical resistance of the polyurethane ECMO cannulae to TA. An Instron 5567 Universal Testing System was used for strength testing in both experiments. Results Securement with sutures and n-butyl-2-octyl cyanoacrylate both significantly increased the force required to dislodge the cannula compared to a transparent polyurethane dressing (p = 0.006 and p = 0.003, respectively) and 2-octyl cyanoacrylate (p = 0.023 and p = 0.013, respectively). Suture securement provided increased flexibility compared to TA securement (p < 0.0001), and there was no statistically significant difference in flexibility between 2-octyl cyanoacrylate and n-butyl-2-octyl cyanoacrylate (p = 0.774). The resistance strength of cannula polyurethane was not weakened after exposure to either TA formulation after 60 min compared to control. Conclusions Tissue adhesive appears to be a promising adjunct method of ECMO cannula insertion site securement. Tissue adhesive securement with n-butyl-2-octyl cyanoacrylate may provide comparable securement strength to a single polypropylene drain stitch, and, when used as an adjunct securement method, may minimise the risks associated with suture securement. However, further clinical research is still needed in this area.

Extracorporeal Membrane Oxygenation Cannulae-related Infection: Diagnostic Difficulties and Potential Prevention

“…Research indicates that TA inhibits bacterial growth and migration of Staphylococcus epidermidis , 17 particularly down cannulae insertion tunnels in vitro , whereas increasing the force required to dislodge cannulae compared with transparent, polyurethane dressings ( P = 0.003). 16 The application of TA to peripherally-inserted ECMO cannulae insertion sites may therefore be a potential bedside strategy for preventing CRI. However, further safety testing is required before this is translated into clinical practice.…”

“…Although there is a lack of research around optimal cannulae securement techniques, emerging evidence suggests n-butyl-2-octyl cyanoacrylate tissue adhesive (TA) may be a useful adjunct for peripheral ECMO cannulae securement 16 and infection prevention, 17 as it has been successfully used for such indications in smaller intravascular devices. [18][19][20][21] Winiszewski's study highlights that coagulase-negative Staphylococci was one of the pathogens most frequently responsible for CRIs.…”

“…14 Furthermore, unpublished point prevalence data from the Australia and New Zealand ECMO cohort demonstrate whereas 83% of ECMO centers have a local ECMO cannulae dressing and securement guideline, only 10% of cannulae were dressed in accordance with local guidelines. 15 This suggests further dressing and securement technique/guideline compliance research is needed to inform clinical practice and ensure uniformity in global practice.Although there is a lack of research around optimal cannulae securement techniques, emerging evidence suggests n-butyl-2-octyl cyanoacrylate tissue adhesive (TA) may be a useful adjunct for peripheral ECMO cannulae securement 16 and infection prevention, 17 as it has been successfully used for such indications in smaller intravascular devices. [18][19][20][21] Winiszewski's study highlights that coagulase-negative Staphylococci was one of the pathogens most frequently responsible for CRIs.…”

Adhered ECMO cannula in COVID-19 related severe acute respiratory failure

“…However, known complications of ECMO cannulation include migration, dislodgement and inadvertent decannulation. Thus, various tissue adhesives have occasionally been utilized to secure the cannula at the insertion site [ 2 ]. Additionally, infection with COVID-19 has been shown to cause multisystem derangements, including systemic arterial and venous thromboembolism [ 3 ].…”