You're Putting that Needle Where?!
Case: 34 year old with history of extensive IV drug abuse and insulin-dependent diabetes presents to the ED in hypovolemic shock from DKA. Multiple attempts at IV access in the field failed. Once transitioned from the EMS stretcher to the bed, the ED team immediately starts an assessment. While the MD progresses through the A-B-Cs, the nurses start to look for IV access and the techs disrobe him. Nursing is unable to identify an veins on exam that would be amenable to IV placement. One of the tech’s jokingly points out that the patient has multiple penile veins that could be used for large bore placement.
Clinical Question: Is it safe and effective to place intrapenile or intracavernosal catheter to achieve access?
Anatomy
The venous vessels of the male penis form two primary systems - the superficial system involving the skin which ultimately drains into the superficial dorsal vein and the sinusoids of the corpora cavernosa draining into the deep dorsal vein. There are many communications between the superficial and deep systems facilitating rapid drainage.
https://en.wikipedia.org/wiki/Corpus_cavernosum_penis#/media/File:Gray588.png
Animal Studies
The canine penis is anatomically and physiologically similar to the human penis, and these authors conducted a small prospective comparative study (3 male dogs) to assess the clinical utility of intracavernosal (IC) access for fluid resuscitation and drug administration. A standard intravenous catheter was placed (gauge and location not named) to serve as the control for the 19-gauge butterfly needle placed in the penile corpora cavernosa. Placement of the intracavernosal catheter was confirmed by the aspiration of blood. The infusion pressure of all fluids was controlled by a pneumatic infusion device.
Three primary tests were conducted:
- A normal saline infusion by IV and IC catheters were started at various pressures and flow rates were compared (see Table 1).
- Each dog was exposed to epinephrine (0.5 mg IC) and monitored for 5 minutes, then atropine (600 mg IC) and monitored again with HR, MAP, CVP recorded.
- The dogs were bled down to a MAP of 60 and then each resuscitated with a different fluid (normal saline, Haemaccel [colloid], autologous whole blood) while MAP and CVP were recorded.
The IC catheters infused normal saline slower than the control IV catheters but were relatively comparable. See Table 1 for details. Both epinephrine and atropine given via the IC route increased the MAP and HR, respectively, with the peak effect occurring within 1 minute (no control to compare). Lastly, all dogs were successfully resuscitated as indicated by a CVP that that was equal or greater than pre-bleeding levels and a MAP that was the same or within 10% of the pre-bleeding pressures.
Conclusions: Intracavernosal access in the canine model can facilitate moderate volume infusion rates and administration of vasoactive medications with systemic effects. Although more research is warranted, it can be considered as an alternative means of vascular access when more traditional methods fail.
This small experimental study was conducted to evaluate the utility of transfusing blood and/or resuscitation via the intracavernosal route. The authors elected to use 2 different animal models to analyze transfusion rate: the donkey and dog.
A total of 3 donkeys underwent 3 separate sessions of IV blood withdrawal (2 units each session) and IC auto-transfusion (in the same session) with each session separated by 1 week. The transfusion was performed via 18-gauge IV cannula with the site changed for each unit transfused. Times blood transfusion and establishment of corporeal access times were recorded. The rate of transfusion for each unit was calculated. Manual compression was applied to the site of the needle puncture for a maximum of 5 minutes after completion of the blood transfusion. The penile shaft was observed throughout the procedure and 1 hour afterward. A total of 3 dogs had blood withdrawn until a MAP of 60 mmHg was achieved. The same blood was transfused back into the dogs using a 19-gauge butterfuly needle inserted into the corpora cavernosa using a pressure bag to maintain infusing pressure at 150mmHg.
In the donkey cohort, the average time to establish IC access was 22 seconds with a range of 14 to 48 seconds. The average time to transfuse a unit of blood was 14.2 minutes with a range of 13.2 to 16.1 minutes. The average rate of transfusion was 31.7 mL/min. In all donkeys, the penis returned to its pre-transfusion state by the end of the transfusion. Complications including extravasation, hematoma formation, or color changes were not seen.
In the dog cohort, the average rate of transfusion was 35.2 ml/min with a range between 33.1 and 37 mL/min. All dogs had been successfully resuscitated with a return of their MAP close to baseline.
Conclusions: “Every point along the corpora cavernosa of that precious organ—the penis—may offer potential vascular access to rescue a man’s life and replenish his blood in some critical situations.”
Human Studies
This study started as a retrospective review of 33 cases of males being evaluated for impotence. During evaluation, a tourniquet was placed at the base of the penile shaft preventing venous outflow from the penis. A recorded volume of normal saline was injected into the corpus cavernosum through a 19-gauge scalp vein needle. The changes in penile circumference and pressures inside the corpus were recorded simultaneously. Then the tourniquet was released, and the time between the release of tourniquet and return of pressure and tumescence to the preinjection level was recorded. This time represented drainage time of the fluid injected from the corpora cavernosa into the penile venous system.
The drainage time from corpora cavernosa was recorded in 10 patients, and the volume drained in the first two to four seconds ranged from 27% to 85%, with an average of 56%. The average peak drainage per second was 13.4 cc per second, with a range Of 4 cc to 22 cc per second. One patient was noted to have subcutaneous hematoma which resolved the next day. Patients did not report any pain.
Conclusions: An intracavernosal catheter has several advantages. It is always available in male patients, obviates the need for venous cutdown, and can facilitate high capacity resuscitation. In male patients with hypovolemic shock with no other IV access, the IC route may be a useful alternative.
Shafik A, El Sibai O, Shafik IA, Shafik AA. Corpora cavernosa as an alternative route for transfusion. Front Biosci. 2006 Sep 1;11:2535-7.
This is a small prospective case series of 15 men with difficult venous access due to burns (7), scarred veins from repeated injections (6), or extensive trauma (2). After multiple failed attempts to obtain IV access, the providers placed an intracavernosal catheter for access. An 18-gauge intravenous cannula was inserted into the shaft of the penis. Blood was aspirated to verify that the needle was in a sinusoid. The thick and fibrous tunica albuginea encasing the corpus facilitated anchoring of the cannula during blood or fluid infusions. During infusion of blood or normal saline, the penile shaft elongated which disappeared after termination of infusion. To prevent hematoma, following termination of the blood transfusion and withdrawal of the needle, the penile shaft at the site of needle insertion was compressed between fingers for 1-2 minutes.
In shock states, it took only few seconds to insert the cannula into the corpus (compared to femoral access or saphenous cut down which requires a mean of 3.18 to 5.63 minutes). Not once did a failure to successfully cannulate the corpus occur. No difficulties were encountered by varying rates of intracavernosal infusion from slow to rapid or repeating the infusion during the same or subsequent days. Subcutaneous penile hematoma occurred in 2 patients but disappeared spontaneously.
The ability to obtain an erection was followed in 5 men for mean period of 6.3±1.4 SD months (range 4-8) after discharge. All patients reported normal sexual activity after the catheters were discontinued. No changes in the flaccid or erect penis, swellings or curvatures of the shaft, or pain/discomfort during erection or coitus were reported. Additionally, fibrosis of corpus cavernosum or priapism which might occur after repeated injection did not occur.
Conclusion: “In conclusion, the CC can serve as a simple, easy, rapid, and safe method for vascular access in conditions for administration of fluid or blood when other conventional routes are inaccessible.”
BOTTOM LINE: While it may not be first, second, or even third line, intracavernosal cannulation is a potential means to facilitate rapid access in a male patient with limited options; and although intraosseous access is typically the mainstay for emergent vascular access in resuscitation, intracorporal access can be an option when an intraosseous needle is not available, such as in a resource limited or mass casualty situation. Although the risk of hematoma formation or other penile injury was low in these studies, their small sample size makes it difficult to draw strong conclusions regarding potential complications.
Submitted by Dr. Danny Kolinsky, PGY-4
Edited by Dr. Phil Chan (@PhilChanEM), PGY-4
Faculty reviewed by Dr. Rose Naunheim