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Centrel Venous Catheterization
Centrel Venous Catheterization
CENTRAL
VENOUS
CATHETERIZATION
(CLINICAL ASPECTS)
,c
by
THE GOTHENBURG eve-GROUP
(Ioan eurelaru, M.D.,Ph.D., Lars-Erik Linder, M.D.,Ph.D.,
Sven-Erik Ricksten,M.D.,Ph.D., Erik Hultman, M.D., and
Peter Nitzescu, M.D.)
Gothenburg University- Departments of Anaesthesiology,Sahlgren's
and stra Hospitals, Gothenburg, Sweden
September - 1987
DEFINITION
Central venous catheter (CVC): a catheter the tip of which is located in a great
intrathoracal vein, usually the superior caval vein, or the right atrium (Fig.J.) but also
in the innominate (brachiocephalic), and even the subclavian veins.
HISTORY
(MILESTONES)
Bleichrder ..; Germany, Uriivershy
of Berlin (1905): catheterization of
arteries in man. Unger - Germany, University. of Berlin (1912): catheterization of the inferior vena cava in human
subjects (among thern- Dr. Bleichrder ) .
- \ '\. Cal~eto<
1
\~top
Forssman - Germany - Eberswalde Univer sity (1931): insertion of a well oiled
\
\
4 French ureteric catheter into his 0~ 1
l
heart: (Nobel prize for Medicine, 1952 ) .
AubagnH;.c - University of Alger (19L..l )
percutaneous pur.cture of the subclavian
vein; 1952 - first technique of the sub
clavian vein catheterization with stee l
Fig. l. Diagram showing the usual locations of the
needles (considered as the founder of
central venous catheter tip in the superior caval
central venous catheterization). Seldin1
vein, or 1-4 cm in the right atrium.
- University of Stockholm (1953): inser
tion of a catheter over a guide-wire ("the seldinger technique"). This technique revolutioned
not only diagnostic radiology, but also the technique of catheterization of all cavitary organ:
and Seldinger's name became a legend. Mayer- USA (1945): first insertion of a plastic, nylon
catheter into a peripheral vein. Schaeffer- Egypt University of Alexandria (1953): first central venous catheterization for measurement of the central venous pressure (CVP). Wilson -USA
(1962) - technique of catheterization of the subclavian veins with plastic catheters. Wilson' s
work spread the technique of central venous catheterization all over the world.
BASIC ANATOMY
OF
THE
CENTRAL
VEINS
The central (intrathoracal' veins may be divided in: l) the great, and 2) the small
intrathoracal veins.
,c)
2)
I) THE GREAT INTRATHORACAL VEINS (Fig. 2): i) Suclavian veins: continue the axillary
veins from the lateral border of the first ribs to the ipsilateral sternoclavicular joints .
Length: mean = 6-cm, range = 4-7 cm. 2) Innominate (brachiocephalic)veins continue the
junction of the respective subclavi~ and i~temal ju~lar ve~ns. R~*ht: extends from the
sternoclavicular joint to the cran1al marg1n of the first, r1ght r1 . Length: mean = 2.5
cm; range = 1.5-6.0 cm. Diameter:
mean = 1. 5 cm. Left: extends from the
ipsilateral sternoclavicular joint to
the superior margin of the first,right
rib where it joins the right inneminate vein to form the superior caval vein.
WILSOH POINT
AU8A.GHIAC POINT
Length: mean = 5.5 cm; range = 4.5-8.7
cm. 3. Superior caval vein: extends from
the superior edge of the first, right
rib to the cranial margin of the 3rd ,
right rib. Length: mean = 7.0 cm; range
= 3-10 cm. Diameter: approx. 2-cm in
the adult patients. 4) Right atrium: its
surface projection is represented by the
3rd, right intereastal space, parasternally . The right atrioventricular orifi ce
can be represented by a line, 4-cm long,
commencing in the median plane opposite
the 4th eostal cartilage, and passing
downwards and slightly to the right. The
Fig.2: Diagram. Basic anatomy of the great intracentre of this line should be opposite
thoracal veins .
the middle of the 4th intereastal space.
II) THE SMALL INTRATHORACAL VEINS (Figs. 3,4,5). Accidentally, a central venous catheter
tip may harbour i n a small intrathoracal vein, and this location is considered as a malposition. However, in the last years such locations (e.g . in the great_azygos vein) have been
In f. lhyroid -"''
lnf. Thyroid
;
L Brachiocepholic v.
vCU\ i
__j_ ~~ R. Brachiocephalic
v.
l~ ~~'"'"'"'"'~
U U/ 1 \
\
W.~o~
"'~<o'Oo'o<
/,
). l
-
-?~" :LJ
l :J
' \
3)
3) Right superior intereastal vein. This vein drains the 2nd, 3rd, and 4th intereastal
veins before entering the posterior azygous arch. In the case of its accidental catheterization, the catheter will be seen on the frontal film as proceeding cephalad. On the
lateral film, the tip of the catheter will be seen going cephalad at the posterior tum
of the azygous arch. 4) Left superior intereastal vein. The diameter of this vein ranges
from l to 5-cm- On the lateral film, the catheter will be seen coursing from the anterior
left brachiocephalic vein posteriorly towards the spine. Its course on the lateral view
is somewhat analogous to the azygous arch. 5) Pericardiophrenic vein. A catheter positioned in the pericardiophrenic vein appears as a line following the lateral border of the
heart. This unusual catheter position may be seen on the frontal thoracic radiographs.
Accidental catheterization of the small intrathoracal veins is a very rare--but possible-event because of their small diameters. Such a catheterization is more likely to occur
with the catheters inserted from the left side (particularly via the externa! and intemal
jugular veins).
CENTRAL VENOUS
CATHETERS
MATERIALS. In historical order, the following materials have been used for manufacturing of central venous catheters:
1. Steelneedles: their use has been associated with mechanical injuries to the veins
and infiltration of the infusates.
2. Plastic materials:
i) Nylon: this is a very stiff and thrombogenic material, and presently it is not
used anymore.
ii) Polyyinylchloride (PVC): this is a thermoplastic material, thrombogenic,
leaks safteners (e.g. phtalate esters) and binds some drugs (e.g. nytroglycerin).The use
of this.~terial i~ presently very restricted.
.
111) Teflon
(polythetrafluoroethylene). This is a carboresin, and a very st~ff material. The stiff TeflonR-catheter has eaused many deaths by perforation of the central veins
and heart cavities, particularly with the catheters inserted from the left side (externa!,
or intemal jugular, and subclavian veins) (Fig. 6).
iv). Polyethylene: this is chemically and physiologically inert material. It does not contain and
does not leak any softeners, but it is rather stiff
and thereby thrombogenic.
v) Silicone elastomer is the softest material
presently on the market. The silicone elastomer
has a low thrombogenicity (thrombus formation),
but also a low mechanical resistance, and eauses
a high thrombophlebitis rate with the catheters
inserted via the basilic and cephalic veins.
vi) Polvurethane is chemically and biologically
inert, and 10-12 times mechanically more resistant
than the silicone elastomer with the catheters
having identical geometrical properties (i.e identical diameters). The polyurethane is as thrombogenic as the silicone elastomer regarding thrombus formation on catheter surface, but eauses a
thrombophlebitis rate 5-6 times lower than that
registered with the silicone catheters when inserted via the basilic and cephalic veins.
vii) Hydrogel-coated catheters. ~ecently, some
Fig. 6. Diagram illustrating perforation
campanies (CardioSearch, British Viggo) have begun
of the superi~r caval vein by a
manufacturing central venous catheters consisting
stiff (Teflon ) catheter inserted
of a silicone elastomer or polyurethane "core"-via the left external jugular v.
(According to Molinari et al.1984)
the so ~alled "~ubstr~te"--coated on the inner and outer surface with a "hydrogel", i
a plast~c mater~al wh~ch absorbs water. Such a "hydrogel"--chemically a nitro(poly-vi
pyrro lidone) (N- PVP) is "Hydromer"R. (fu:.ll. One believed--and present ly one be lieves
that the HydromerR capacity to absorb water (Fig.8) may inhibit thrombus formation on
INSERTION TECHNIQrn
.T here are two -techniques for insertic
central venous catheters: percutaneous i
tiot:t, and surgical cut-down of the vein
approach.
I) PERCUTANEOUS INSERTION. Thi
Fig. 9. SEM. Degenerated outer HydromerR
be classif1ed in : catheter-over-the nee
layer (arrow) after indwelling.
catheter-through the needle (the needleducer may be manufactured of steel, or a plastic material, catheter-over-guide wire (Seld
technique), and earobination of the above mentioned techniques (e.g. Desilets technique, a
R
McMihan's technique).
l) Catheter-over-the needle technigue. Stiff, Teflon (e.g. Viggo Secalon-T), or pol:
ethylene catheters are used with this technique. Their insertion is similar to that of Ve r
peripheral cannula. Advantages: quick insertion, suitable for acute situations; thereafteJ
these catheters must be exchanged because of high risk to cause perforation of the centra :
or eveR heart cavities (see the figure 6). Disadvantages: i) stiff catheter. manufactured
Teflon , or polyethylene; ii) long, och therefore instable needle, and consequently iii) c
cult appreciation of the puncture depth (injuries to the neighbouring organs, e.g. arterie
nerves, pleura, lungs, etc.) may occur.
2) Catheter-through needle technigue. This t~chnique is very popular in West-Germany
preferentially used with Braun-Melsungen and Triplus polyurethane catheters. Advantages: t
~s a technique suitable for insertian of the lang, soft catheters made of soft polyvinylch
silicone elastomer, and polyurethane. Disadvantages: i) possibly higher risk for mechanica
ries to the neighbouring structures (e.g. arteries; cases of hemiplegia after accidental P'
tures of the earotid arteries were reportedfrom West-Germany);ii) bleeding at the inserti o
because the diameter of the needle introducer is larger than the outer diameter of the catl
iii) high risk for catheter transeetian and embolism when needle-introducers made of stain:
steel are used, and when the edges of the neele bevel is not provided with heels (Fig. 10Ql; iv) the introduce r must be ~ept in-place, over the catheter; thus, the blood accumulat i
between the cathete r and introducer may facilitate infection; to avoid this, splitting ("pe
away") introducers have b~en developed (Figs. 11,12).
3) The Seldinger t echnigue. With this technique, a guide-wire (Fig.l3) is passed along
introducer (needle, or cannula ) lumen, and the introducer is removed. The catheter is then
over the wire, and the wire r emoved (Fig. 14). Advantages: i) Avoiding laceration of thorac
S)
Fig lO
Fig.l2.
iii) Permitting "switching" of the catheters (e.g. if an intemal jugular line needs
to be replaced with a Swan-Ganz catheter, a
wire can be inserted through the central vein
catheter, the catheter removed, and an insertian sheath with a vein dilator inserted over
the wire; thereafter, the Swan-Ganz catheter
is inserted through the sheath, and the sheath
is withdrawn); iv) Increasing the rate of successful central venous cannulations from the
external jugular vein; v) Permitting unknatting
of loosely knotted catheters; vi) Greater relia
bility (the seldinger technique offers greater
reliability in placing the c~al venmrs cathe
ter tip in the superior caval vein);. vii) Indi
cating malposition of the catheter (the geometry of the guide-wire at withdrawal is an indicator of correct, or incorrect catheter tip position - see later in this compendium); viii)
lower risk of catheter damage and catheter embolus (this is particularly tru
when the seldinger technique is
campared with catheter-throughneedle technique, or catheterover the needle technique); ix )
Permitting replacement of cathe
ter in the case of malposition
(see Jater in this compendium );
x) Lower risk of air embolism
and supage of blood (this is ex
lained by the fact that the cat
ter calibre matehes the cathete
hele created in the vein wall.
Disadvantages: i) Less, or not
suitable for too soft (e.g. si l
cone elastomer) catheters (if t
soft catheter is too thin and
must ne2ociate a tum, it may
kink,Use of thicker catheters
obviates this problem; ii) More
expensive (Lhe guide-wires rang
in price from $ 10 to 20 each wire, needle, and vein dilator
included); iii) The seldinger
technique is a relatively ~or7
'
THE GOTHENBURG eve-GROUP
6)
This means that the equipment (guidewire and catheter) comes in centact with
operator's hand. Thus, insertion of a
central venous catheter with the seldinger
technique requires asepsy and antisepsy
conditions satisfied only by the operating
room environment. These requirements made
the seldinger technique even more expensiv
than those already mentioned before.Furthe
the seldinger technique is not adequate f e
emergency situations, e.g. insertion of ce
tral venous catheters at the spot of acci dents, battle field, or ward departments.
'
4) Desilets & Hoffman's technigue con
bines the Seldinger technique With the US E
of a vein dilator and a large-bore sheath.
This technique is used for insertian of
large-bore catheters (outer diameter >2 . 5
mm) e.g. dialysis catheters, and pulmonar ;
(Swan-Ganz) catheters (Fig. 15).
5) McMihan's technigue is practicall
identical to the Desilets & Hoffman's
technique and has similar indications.Th
McMihan's'technique is largely used in US
~i?:.~ . . :step 1: performing the venipuncture. Step 2: cnfir- for ressuscitation with insertian of larg
ming effective venipuncture by free aspiration of blood. Step bore cannulas as that presented in the
3: removing the syringe, and introducing the guide-wire,soft figure 15-7.
tip first, through the introducing-needle. Step 4: removing
the needle-introducer. Step 5: threading the catheter over
guide wire. Step 6: removing the guide-wire from the inserted
catheter.
4)
S)
lO IV
Fig. 15. Schematic representation of Desilets & Hoffman's technique: l) venipuncture; 2) insertion
of the guide-wire; 3) withdrawal . of the needle-introducer; 4) enlarging skin orifice; 5)
inserting the vein dilator with a movement of rotation; 6) advancing the vein dilator to
enlarge the orifice at the. vein wall; 7) the vein dialtor was withdrawn and a large-bore
cannula was inserted inte the vein, and the guide-wire was withdrawn.
'
CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS
7)
VEIN APPROACHES
We classify the vein approaches in the "long-way", "short-way", and "half-way" venous
approaches.
I. THE "LONG-WAY" APPROACH. The catheter entry site is located long away from the
thoracic cage, e.g.: i) basilic and cephalic veins punctured at the cubital fossa; ii) femoral
veins punctured at the groin, etc.
II. THE "SHORT-WAY" APPROACH. The central venous catheter is inserted into a vein
locating in the vic1nity of the thoracic cage, e.g.: i) axillary vein; ii) subclavian vein;
iii) external jugular vein; iv) internal jugular vein.
III. THE "HALF-WAY" APPROACH (The Gothenburg eve-Group) . The catheters are inserted
via the basiiic or cephl1c vein approached percutaneously or by cut-down at the cubital fossa,
and have the tip located at the border between the peripheral and central veins ( in the vicinity
of the lateral edge of the first rib).
THE BASILIC AND
CEPHALIC VEIN
CATHETERIZATION
( ''LONG-WAY''-CATHETERS)
'
8)
fewer sinuousities than the cephalic vein, and continously increasing diameters.
2. Between the left and right basilic vein, the left basilic vein should be preferred.
The reason is a lower risk for malposition of the catheter in a cervical vein (the ipsilateral
intemal jugular vein), and a significantly lower risk of thrombophlebitis occurr5nce.
3. Insertion of the catheter should be performed with patient's arm in 90 abduction.
In such away, one straightens the vein course and facilitates advancement of the catheter,
avoiding its arrest at the axillary fossa (with the basilic catheters), or at the deltopectoral
groove, under the clavicle (with the cephalic catheters).
4. The cephalic vein is a seeond choice for insertion of central, "long-way" or "shortway" venous catheters because of: i) the vein irregular course and presence of multiple valves;
ii) the presence of the arch formed before the vein ending into the axillary or subclavian vein;
iii) the multiple anastorneses between the cephalic vein and the superficial veins of the shoulder
and neck (the catheter tip may easily harbour in these veins); iv) small ostium (sometimes less
than 3-4 mm) at its termination. Because of all these anatomical factors, a catheter inserted via
the cephalic vein may easier be malpositioned than one introduced via the basilic vein (41% vs 20%
malpositions, respectively ) .
5. The tip of the "1ong-way", bas i l i c and cephalic catheters must be located approximately
2-cm below the jugular notch, i.e. in the inneroinate {brachiocephalic) veins (Fig. 16). This recommendation is based on a physiological finding: with
movements o the arm, the tip of the catheters--when
located in the superior caval vein--may be displaced
into the right atrium, or even into the right ventricle and trigger very severe heart arrhythmias. The
displacement of the catheters downwards may reach
up-to 7 cm (the mean length of the superi or caval
ve in is 7 -cm) , and the total ( upwards and downwards )
displacement up-to 12-cm. The distance from the cubi
tal fossa to 2-cm below the jugular notch may be
calculated according to the equation:
(L x 0.25) + c
(l)
----Basilic (n-200)
Y=4.0478 + 0 .2402x
55
55
50
45
40
165.
170
175
180
185
190
195
200
Regression diagram (nomogram) constructed by the Gothenburg evegroup permitting correct location of the "long-way" brachial cateters in the innominate veins (2-cm below the jugular notch).
rl-OlYUR!TAH
~0"-'IUII(TAN U.e.. ..-N....en41
nl1
~OL'IYIN'ILKLOIIIO
"ll
'Ol.'f'll'YUM
na12
,.,.
SlliKON-ILAS TOlllUt
'OLY(TYl(N tllriiM-11111
natl
"
20
10
TROMBOFLEBIT-INCIOENS ('!!.)
(cvk frn armvecket)
40
100
(/)
!
o
a:
i!:
u.
DURATION
Qf .. CATHETERizATION (OAYS)
Fig. 20. Absolute incidence of superficial thrombophlebitis with the "long-way" basilic and cephalic
catheter in relation to duration of catheterization (The Gothenburg eve-Group results)
._..__...
0-C-CI
220
200
"
,_
tO
- 180
l5 "
10-4 "...
.,
P<O.O$
>
ffi 12
~-
l5
a:
w
...
60
40
20
o
DURATION OF CATHETERIV.TION (DAYS)
Fig. 21. Bar diagram:thrombophlebitis incidence in relation to duration of catheterization. (The Gothenburg
CVC-Group's results)
38
8.9
7.8
'Mnti"IIYartll(""'*"'....rel
'Mnl" l
ca,_- thoTill
~&""'*"'....re!
P<Q05
.JjoJ
. . . .. el- . ..
l .f t U
P'.'C
SE
(n a14)
(na9)
P\J
(ne24)
H"J
(n.8)
22.7
CEPHALIC VEIN
CATHETERIZATION
( ''HALF-WAY'' -CATHETERS)
I. DEFINITION
Catheter inserted via the basilic or cephalic vein at cubital fossa, having its
tip located in the_proximal axill~,or distal subclavian vein, about 3-cm medial, or
lateral to the external edge of the first rib (Fig.26). The distances from the cubital
fossa (on the line joining the epicondyli of the humerus) to the lateral edge of the ipsilateral first
rib correlate with the patients'
\
body heights and may be estimated
~~
by the equation (2)'
-3~~=~~~~~::::::::::::::::11~1
De
2
( )
(L x 0.2) + c
where:
- De
"HALF-WAY'-POSITION
::r:::
5I
7S
100
fLO~WITCH
125
150
115
10
201
,,:JJ
CONICATH
20
CONICATH
Fig. 27
. Diag-ram lllustrating the idcalized loc.ation ar the proximaJ edge of the fint ribof a ''haJf-way'' cachet: tip inxr1cd by the right builic YCin . The
''haJf-way '' catheter is introduccd by a conc shaped , low traumatic introdu:r (ConKa.th ), anJ ptovKkd with a flow interruptcr (FioSwitch ).
1be com:ct location of the catheter tip in relation to patient' s body hcight (c .g. 175 cm) ls indiatcd by the hu b of the Oow intcrrupter on an in vend y
__ ,
EX AMPLE : patient' s body heig,t
A)
B)
Fig. 28. Nomogram used fcr correct location of the tip of a basilic
catheter in the "half-way" position. A) Frontal view. B)
Dorsal view (The Gothenburg CVC-Group's results).
ONTA:I:NER
t----,:::11....--ROTATING
KNOB
MARK
GRADUATION
A)
B)
Fig. 29. Diagram: "Drum-Cartridge" used for correct location of a basilic catheter in
the "half-way"-position. A) Frontal \'iew (note the window where the units of
the inserted catheter lenght may be read). B) Lateral view with the window
where the tenths of the inserted catheter length may be read (The Gothenburg
CVC-Group's results).
III. INDICATIONS:
The "half-way"-catheters have all the indications of the central venous catheters,
measurement of the central venous pressure included. The central venous pressure correlates with the pressure in the proximal axillary vein, in both the spontaneous and controlled
ventilation (Fig.30). Further, the curves of the pressures in both the proximal axillary
vein and the superior caval vein have an identical appearance (Fig. 3l).The difference between the proximal axjllary venous pressure and central venous pressure is of approx. l-cm
tl2Q (higher in the proximal axillary vein).
0
15
:l!
UJ
~
[2 10
(/)
a:
Q.
(/)
5z
,_>
UJ
a:
<
...J
...J
-o.99
<
...J
<
P< 0.001
:l!
x
o
g:
5
10
15
IV. CONTRAINDICATIONS
l) Infusion of strongly irritant solutions (e.g. cytostatics, hydrochloric ~cide)
because of higher risk of axillary/subclavian vein thrombosis. 2) In patients with haemathological diseases (for the same considerents). 3) For total parenteral nutrition at home
(more difficult catheter care by the patient self, and higher risk of axillary/subclavian
vein thrombosis).
V. ADVANTAGES
l) The "half-way"-catheters fulfill all the functions of the central venous catheters, measurement of the central venous pressure included.
2) The routine, radiological control of the "half-way"-catheter tip is not neces~ if the catheter was inserted via the basilic vein, and if the insertian was uncomplicated.
3) There is no risk for severe mechanical injuries to the neighbouring anatomical
structures during the manipulations necessitated for insertian of the catheter, as well as
during its indwelling.
4) No risk for triggering of heart arrhythmias, the catheter tip being located long
away from the superior vena cava/right atrium junction, right atrium, and right ventricle.
5) Relatively low thrombophlebitis rate (4-7%) up to 50 days after insertion.
6) Low thrombogenicity ( thrombus formation) regarding both the "catheter" and
"mural" thrombi, similar to that recorded with the soft, "long-way", polyurethane, silicone
THE AXILLARY
I.
VEIN
CATHETERIZATION
HISTORY
Introduced by Ayim, 1977 (Kenya- University of Nairobi).It was very seldom used
by some groups, particularly in France.
the teres major and from 10 to 19-mm at the lateral border of the first rib.
The axillary vein is erossed anteriorly by the pectoralis minor which divides the
vein in 3--topographically distinct--parts: i) an upper portion which is proximal to
the muscle, ii) an intermediate portion lying posterior to the muscle, and ii) the
distal part which is distal to the muscle. This distal portion--situated between the
lower border of the pectoralis major and the lower border of the teres major is theonly
on~ approachable, and thereby of particular interest for catheterization (Fig. 32).
l"'
!" i'
" Ic
i'
"i
: ;\
f !";
c
~
~~
t
~
lf
't
l.. ~i
.
5 ;'
l
'Il
"'i'i
t
l;
iE
,.
[
f
i
~
..
"
ll lt
r
,.
'
\\
'Il
"i
I
:<
.~
llp
i"
Ii~
hi
~...
i !" i
..{
ui
l
'?:
"l "[
!
l
F
!:"
ic
l
Fig. 32. Diagram showing the cubital fossa with the insertian points for
the basilic and cephalic vein cannulation/catl1eterization, and
the origin of the axillary vein at the teres major and ending
of the vein at the lateral edge (middle of the clavicle} of the
ispilateral first rib (black points and arrows) .
. _Here the vein runs, relatively superficially, with its anterior covering consisting of
fascia, a varying amount of fat and areolar tissue, and skin, but even these structures
make palpation of the vein difficult in ooese individuals.The axillary vein lies relati vely superficially to the axillary artery and its accompa~ying nerves. The nerves can be
felt as hard cords in comparison to the softer and more pliable consistency of the axillary vein. The axillary artery can be distinguished by its pulsation.
IV. INDICATIONS
Very rare, possible indications: l) No approachable basilic, cephalic, and external
jugular veins; 2) No experience with the "short-way" (subclavian and intemal jugular)
approach; 3) Durations of catheterization of up-to a month.
V. CONTRAINDICATIONS
l) Obese subjects (difficult, or impossible vein approach); 2) Local conditions,
e.g. infection, ganglionated mass in the axilla (metastases),painful shoulder joint, etc.
VI . ADV ANTAGES
l) No risk for severe mechanical complications, e.g. pneumothorax, haemothorax, or
chylothorax during venepuncture (as these occur with the subclavian catheterization); 2) Lower
risk of thrombophlebitis when campared with the "long-way" (basilic and cephalic) catheterization.
EXTERNAL
JUGUL.AR.
VEIN
CATHETERIZATION
I. HISTORY
Introduced by Hentschel, 1964 (Germany- University of Berlin)."J"-wire technique
-Blitt et al., 1974 (USA- University of Arizona).
SOLO(R(O~
S'ltiNG GUlD(
t 4S a c
o} . . .
~'t
IV. INDICATIONS
V. CONTRAINDICATIONS
l. No approachable (visible, or palpable) external jugular veins. 2. Thrombosis of t~e superiorvena
caval system. 3. Local conditions making approach to
the extemal jugular veins impracticable, e.g.: previous cut-down of the vein, previous cannulation eausing
occlusion or thrombosis of the vein, hypertrophic supraclavicular lymph nodes. vicious scars (keloids) after
previous radical neck dissections, ulcerations, fistulas,
pharyngostomies, etc.4. Mediastinal tumours compressing:
the central venous and making their approach impracticable.
THE
CATHETERIZATION
I. HISTORY
Goldstein (1949): first description of percutaneous approach to the intemal jugular
vein. English et al. (1969): percutaneous catheterization (lateral technique).
Diuxrom of SMpuficial disuct ion of th ~ right sid~ of th~ ntck - itlt tlrt lttad
turn~d to tlrt ltft. Tht intunal jugulor vdn is indirotrd b) do lltd fints . Arro-.s A and B
indira tt tht d irrrtiun u[ titt nttdlt fur l't lltptmcturt h_v thr 't lnt it ' nnd 'altrnto t i,t'
tuhniquts roru lirly .
III. CATHETERIZATION
TECHNIQUE
1 0 Pati ent's position: Trendelenburg
~~-~~~ ~~n:c~u~~~~~e~~~=4~go~~~~dsand
the gpposite side and in "neutral position"
(180 ). in relation to the ho::-izontal plane.
OBS. DO NOT TRY PUNCTURING OF THE INTERNAL
JUGULAR -VEIN WITH PATIEN~'S NECK AND HEAD IN
FLEXION!!!
23)
iv) no resistance was opposed to the guide-wire or/and catheter advancement; v) free
in-and backflow from the catheter, without trepidations of the catheter, or aspiration
of air-bubbles, was obtained.
IV. INDICATIONS
l) Central venous catheterzation during 11 <Y.l-going" surgery (procedures under
the neck). 2) Infusion of strongly irritant solutions, e.g. cytostatics, hydrochloric acide
etc. (lower risk for occurrence of thrombosis of the central veins than with the catheters
insertedvia the subclavian veins). 3) Patients with pathologic obesity needing a central
venous catheter (e.g.those operatedwith gastroplasty).Paradoxally,the puncture of the
intemal jugular vein is not difficult in these patients if it is performed at Brinkman's
point and a longer introducer (approx. 10-cm) is used. The reason is the probably larger
diameter of the intemal jugular vein eaused by the high intrathoracal pressure exerted
by the abdominal content, high position of the diaphragma, Trendelenburg position, and
application of PEEP. 4) Patients with coagulation disturbances, particularly those with
acute leukemia and thrombocytopenia providedthat the Seldi~ger technique is used (reduced
bleeding at the puncture site). 5) Patients with contraindications to subclavian vein
catheterizationwith no other approachable veins, e.g.: women with large breasts, asthma,
bullous emphysema (in all these conditions there is greater risk for occurrence of pneumothorax with the subclavian vein approach), tracheostomy (cannulation from the Conso's point
should be preferred) associated with a high risk for catheter-related infections and sepsis
with subclavian vein cannulation.
V. CONTRAINDICATIONS
l. Local conditions in the neck making the approach to the intemal jugular vein
hazardous, or even impossible, e.g.: vicious scars after radical neck dissection, presence
of hypertrophic lymph nodes (cancer adenopathy), struma,- oeso.-pharyngos.tomy_, burn sequeale,
etc. l) Pathological conditions in the thorax (mediastinum) making the approach to the superiorvena caval system impossible, e.g.: thrombosis of the great intrathoracal veins, tumours
campressing the central veins, etc. 3) Each time when the approach to another vein (e.g .
basilic, cephalic, externa! jugular,etc.) is apparently easier (superficial, visible, large
veins).
24)
(when thrombosis in the ipsilateral innominate vein exists), right intemal mammary
vein (radiologically may be confounded with a catheter laying in the superior caval
vein,on frontal thoracic radiographs), opposite innominate vein.
b) Left intemal jugular vein. Abberant locations in the small,
mediastinal veins (left superior intercostal, left intemal mammary, and pericardiophrenic veins) are exceptional,but possible. Usually, these locationsare indicated
--before radiological control--by a resistance opposed to the guide-wire/catheter advancement, not-free aspiration of blood from the catheter (the aspiration eauses catheter trepidations and aspiration of air-bubbles), and low infusion flow-rates. In exceptional situations, a catheter inserted from the left intemal jugular vein in a
persistent, left superior caval vein.
THE
SUBGLAVIAN VEIN
CATHETERIZATION
I. HISTORY
Aubagniac (University of Alger), 1941: topographical anatomy of the subclavian vein; 1952: first description of subclavian vein catheterization with steel-needles.
Wilson (USA) - 1962: subclavian catheterization with plastic catheters; spreadning of the
technique all over the world.
Fig. 42. Diagram: scalenus anterior separates the subclavian artery {behind the
muscle) from the subclavian vein (in front
of the muscle).
The subclavian vein is in relation, jn front, with the clavicle and subclavius muscle,
separated from it by scalenius anterior muscle, and--on the right side, the phrenicus
nerve. Below, it ~s in a shQllow groove on the first rib, and upon the pleura. The
subclavianvein usually has a pair of va ves situate abou 2-cm above its termination.
At its angle of junction with the int~rnal jugular vein,the left subclavian vein receives
the thoracic duct,and the right subclavian vein - the right lymphatic duct.
Thus, the subclavian vein is found within the costo-clavicular-scalene triangle
(Fig. 43-a,b) which is formed by the medial end of the clavicle anteriorly, the broad surface of the first rib below, and the scalenus muscle posteriorly (Fig.44). The subclavian
vein is covered by the medial 5-cm of the clavicle, and is joined by the intemal jugular
vein near the medial border of the anterior scalene to form the brachiocephalic (innominate )
vein. The distance between the subclavian vein and the subclavian artery (separated by
the anterior scalene muscle) is of approx. 1.5-cm in adult subjects (Fig. 43-a).Behind the
subclavian artery are pleura, plexus brachialis cords, ductus thoracicus, ganglion stellatum,
etc ... , anatomical structures ~hich may be accidentally injured during the subclavian
venepuncture.
Ant scalene m
'"""""_"V . .
Srernocledomostotd m .
C,sro-=too~culor-scolene
fl
Cl.l11iclr
m.
l_
1cK
________. ..\.'
.
~n
. .
/
~'
A)
Fig. 45. Diagram representin the angle formed by the subclavian and intemal
jugular veins at their junction: A) Right side; B) Left side. ACcording to
Henegouwen et al., 1980).
TIIE GOTHENBURG
CVC-GROUP
26)
1965 -
AUBAGNlA G -
Ca theter
in Lumen
Fig. 46
We do not recomrnend the supraclavicular
approach because of substantially higher risk of
injuries to the pleura and lungs, subclavian
artery, plexus brachialis cords, stellatum,
ductus thoracicus (Fig.47).Fur_~e r, the supraclavicular approach imposes no limitati on to
movements of the puncturing needle. In addition, the supraclavicular approach is not applicable in patients with stiff shoulders that
are crunched up, or elevated toward the head
in a defensive attitude. The infraclavicular
approach is safer for the beginners than the
supraclavicular venepuncture because it limits
the range of movements of the needle between
the clavicle and the 1st rib .
Cos to el avieular
Ligament
Clovicol
Scolene
Anticus
Sterum
Campressed Cotheter
Fi g. 47
i) higher risk for injury to the subclavian artery and median, radial, and ulnar nerves
adjacent to the subclavian vein (Fig.49); ii) substantially lower rate (approx. 7S%) of
successful venipuncture at the first attempt when campared with the Aubagniac's approach
(approx. 9S%) .
-~-/-~~--\- - ...
/
.....
\ \,,_,_to
9. Inserting the catheter. Steps: i) Estimating tbe lengtb of tbe catheter following;t
be inserted intravenously, The distance from the
insertian site to the superior edge of the 3rd,
right eostal cartilage (tip location in the lower
part of the superior caval vein), or to the 3rd,
right intereastal space (right atrium) is m~sured
with a disposable metric tape (Viggo's Seldy -catheters) or either by the catheter or its stylet
(Braun-Melsungen and Triplust catheters). Altematively, a standard length of catheter may be inserted: 12-cm (women) and 14-cm (men) on the right side,
and 15 - cm (women) and 18- cm (men) on the left side.
ii) Inserting the catheter over the wire poses no
problem with the stiff (Teflon) catheters. With the
Patient wi t h the neck. and head in straight posi t ion .
relatively safter, polyurethane catheters, these
The cathetec- tip h Nlpositioned i n the lpsllateral i nterna!
must be advanced and concomitantly rotated to overJusubc vein (CureLaru et al. unpublished res ults)
pass the natural resistance encountered at the skin
(puncture site) and vein wall. iii) The catheter
Fig. 52-B. According to Fischer et al.,l977 must not encounter any other resistance during its
threading into the central venous system. If such
is encountered, this may point out
position into patientts central venous system. ato:r esistance
extravenous
location of the guide-wire; kin~
However, one should stress that turning the
ki
ng
of
the
wire
and its location in the intemal
patientts head and neck towards the side of
jugular vein; actvancement of the wire into a sma f l
cannulation may facilltate entering of the
mediastinal vein, usually the intemal mammary, or
cannula into the intemal jugular vein, or
azygous
vein; presence of thrombi in the central
even its k1nking, thereby making insertian
veins. iv) Withdrawal of the guide-wire from the
of the guide-wire impossible, or directing
catheter . The catheter is gently held with the
its tip into the internal jugular vein (Eig .
great and forefinger at the insertian site (avoill).
ding occlusion of the catheter), and the guidewire ~ s withdrawn. If resistance to withdrawal of
the guide-wire is occurring, the wire must be
withdrawn concollfthantly with the catheter (this
may indicate kinking or knotting of the wire, and
attempt to a forceful withdrawal may be followed
by decoiling of the wire--see later--,its rupture,
and embolization of the ruptured fragment, and
damage to the catheter). The withdrawal of the
guide-wire is performed with the hub of the catheter ~der the level of the right atrium (midaxillary
line) to prevent air-embolism. Suplemmentary, the
patients who can cooperate may keep breathing (alternatively PEEP of 2.5-5.0 cm water may be applied
in the intubated patients). iv) Interrupting the
flow through the catheter. This is d~~e by s~itchiug
the f~ow interruptor ("Flowswitch") vith Viggo's
Seldy -ca theters, or by capping the hub with a standard plastic plug. ~e flow is automatically interrupted with Triplus catheters. v) Checking the
guide-wire for bending (kinkjngl If the guide-wire
Fig. 53. Schematic representation of actvan- is bent approxim. 5-6 from the tip, this is a
suspicion for harbouring of the catheter tip
cement and kinking of the introducing-sheath strong
into
the ipsilateral intemal jugular vein iEig.
into the intemal jugular vein with rotation
54). vi) Checking patency of the catheter. A 10-20
of patientts head and neck toward the side of ml
syringe half filled with isotonic saline is
insertian (the Gothenburg t s CVC-Group t s unpub- connected
to the catheter hub, and patency of the
lished resul ts) .
catheter is checked by free in-and backflow through
the catheter. If blood can be freely aspirated,
!herefore, presentelv we do not recommend anymore without trepidations of the catheter and aspiraturning of patientts head and neck towards the in- tion of air bubbles, this indicates correct posisertion side, but only maximal lifting of the
tion of the catheter in the central veins (the
shoulder during the insertian of the guide-wire,
catheter is not kinked, curled, knotted, and its
alternatively catheter (with catheter through can- tip is not located against a vein wall).
nula technique). ii) Inserting - the guide-w i re~
length egual with the distance from the puncture
10. Fixing the catheter and dressing the
site to approx. 2-cm below the sternoclavicular
insertian site. steps: i) The catheter is fixed
joint: thereby actvancement of the floppy end of
by two monafilament sutures (Dermalon-00, or
the wire inta a small mediastinal vein is preNovafil-00) applied over a silicone or rubber
vented, as well as the subsequent catheter malsleeve within the first cm from the insertian
site. Supplementary, other 2 identical sutures
positions. A standard length of approx. 10-cm
are applied over the catheter hub (through the
is usually adequate . iv) Withdrawing of the
hales of the "Floswitch" with Viggo's Seldy cathe introducer (needle or plastic cannula) over the
ters). ii) Checking once again the catheter for
guide-wire, from the vein. v) Cleaning of guide
patency after application of the sutures (to avoid
wire from blood with a dry gauze compress.
A)
2)
1)
Fig. 54. Schematic representation of kinking of guide-wire at withdrawal . l) Two positions of the central venous catheter: A) Subclavian vein; B) Intemal jugular vein.
2) Two shapes of guide-wires from central venous catheters: A) Subclavian position;
B) Internaljugular position (according toKern & Fischer, 1983).
accidental occlusion of the catheter by too
at the base of the neck.
hardly knotted sutures). iii) Dressing the
insertian si~ 6 A trans~arent polyurethane
12) Radiological control of catheter
film (Tegade~' - Opsite ) is usually _
tip location. a) This may be given up if
applied on the insertian site . This is substhe following reguirements have been satistituted with an absorbent compress in the
fied: i) The local anesthesia at the inserpatients with bleeding tendency and blood
tian site was performed with a short needle
oozing at the insertian site.
(2-cm long) and no "pre-venepuncture" was
performed (thus no risk of clinically silent
11) Clinical checking for catheter tip
location .. In spite of a trouble-free. ~nsertion, pleura puncture and occurrence of later pneumothorax); ii) Successful venepuncture at the
the catheter may be nevertheless located in
first attempt during advancement of the introthe ipsilateral intemal jugular vein. This
ducer (thus no laceration of the subclavian
location can be clinically detected by: i)
vein and injuries to the neighbouring struca buzzing sensation in the ipsilateral ear
tures); iii) The guiding wires ana the catheaccused by the patient when a. rapid injection
ters were inserted the recommended lengths
of saline into the catheter is given;
(see above) and no resistance was opposed to
ii) loud bruit at auscultation under the
(during)their advancement and withdrawal;
_mastoid process undera forceful injection of
iv) The guide-wire did not present any bend,
20 ml saline via the catheter (Fig. 55); this
ki~, or decoiling when inspected after withdrawal; v) The blood may be aspirated freely
from the catheter (without air-bubbles and
trepidations of the catheter); vi) No bruit
CMA..c; 14 1'0
N.OK!OH
at auscultation over the intemal jugular
vein (under the mastoid process) with the
- ;
IIUolf"'s.fiiOHIO
patient in apnoe, during forceful injection
.. ft:tNAl
of 20-ml of isotonic saline.(The requirements
_.__..
iii-vi refer to correct location of the
catheter tip in the central venous system).
,...- .\\.
b) The radiological control must be performed :
i) each time when only ONE of the above requirments is not satisfied (experienced doctors ) ;
ii) always (doctors at the beginning of their
clinical training). c) If radiological control
is performed, the radiograph is taken best with
the patient's arm abducted so that the cathe t er
The auscultatory test rOf predcung internat juoular vein malposition. A
{s not obscured by superimposition of the clavi syringe of blood is injected tapidly into the catheter, and a brult is heard over the ip~ latet"al
cle.
neck ~te with a stethoscope if the tip lies in the internatjugulat vein.
--
:/C'fCt
;\ ....
t#~
Fig. 55.
IV . INDICATIONS
l. Long - term catheterization (e.g. for
total parenteral nutrition at home, intermit t ent chemotherapy regimens, etc.). With this
approach, the patient self can take care of
his catheter (e.g. dressing the insertian s i t e,
changing the infusion bottles, flushing the
.32)
2. Aspinte blood to
FlG. %. 1ne IMthod ~ whkb the po&it.ion o( a cratr&l wnout c:athtur can be oo~ A) A emtnl W'OOIW c:a&.bd.u il: iuened via richt
-..bdavian win and ia auspl.-ed in t.hrt richt ju.cul.ar win.. A 12 Fopny at.heur ia ta.erted throuch tJw ~ ttatnl ftDOUa catbd.u and
the }J.&Iloon ia inn.ted.. 8) Both Fop..rty and centra.! wnou. eathctcn are withdnwn ~r (.e the black anowa). Cl Only the Foprty at.het.eT
.V. ~. inO.t.ed beUoon W puahed forward (indicated hy anow). 0) TM central wnou. cat.lwur il puaed o.a t.hc Foprty catbet.tr and
coiT- 'l.IY po&itioned. in the euprerior wna cava. OnJy the Fopn.y nt..bd..lrt a rcmowd and t.tw tip o( tht c:eatnl ~ c:at.hdn rtmaia. conw:tly
po.itioned in tM superi wna e.va.
THE
FEMORAL VEIN
CATHETERIZATION
I.
FtGUAE 2 : The auscultatory test for repositionino malpo~t~oned cathetets. A. The
catheter is wtthdrawn until the btuit is no longer heard. B. The cathetet isthen redirected
into the superior vena cava .
HISTORY
INGUINAL
LIGAMENT
_;_ ' ;~
~-:_ ~
\ '.
' /~y: ;,.,.,~.~
\Nffoooosuo .
""''"''"'
- -~- c-
- -'' . \
----------
should be preferred; Viggo's 16G/1.7 mm 0/60mm long introducer is adequate for venipuncture in the great majority of cases, excepting
the obese subjects; v) The venepuncture is performed under continuous aspiration with a S-ml
plastic (disposable) svringe containing 2-ml of
sterile, isotonic saline;vi)If the puncture is
performed with the patients doing valsalva maneuver (altematively, PEEP 5-10 cm H O is applied on the intubated patients), blo~d is aspirated into the syringe during the advancement
of the introducer; vii) In the patients who-for one or another reason--can not perform
Valsalva maneuver, the vein may be collapsed,
and no blood at aspiration is obtained. In such
a situation, the needle-introducer is advanced
until bony resistance is encountered. Then,
with the left hand of the operator braced
against the patient's thigh, the needle-introducer and the syringe is gradually withdrawn,
applying simultaneausly gentle traction on the
plunger; when venous (dark) blood returns freely,
the operator's left hand grips the handle of the
sheath and advances it 3-4 cm into the vein.Thereafter, the steel-needle and the syringe are withdrawn, and the sheath (cannula) is caped.
7. _ Inserting the guide-wire. The IeflonRcannula is decaped, and the guide-wire (approx.
llS cm long) is introduced 10-lS cm into the
vein. Thereafter, the cannula is withdrawn from
the vein over the guide-wire.
8. Inserting the catheter. For usual cath~
terizations, we recommend Viggo'a Secalon-CathR
universal catheter, 6S-cm long, 1.2/1.8 mm I/OD.
This catheter may be inserted by a genuine
Seldinger technique. Insertion of large-bore
catheters requires skin incision at the puncture site after insertion of the guide-wire,
and possible use of a vein dilator and a largebore cannula (Desilets & Hoffman's technique).
The skin incision may cause injury to the small
subcutaneous vessels (very numerous in the region
and subsequent bleeding. The catheter is thread ed
approx. lS-cm over the guide-wlre. Thereafter,
the guide-wire and the catheter together are advanced until the level of the right atrium (projected at the 3rd, right, eostal interspace).
The distance from the insertion site to the
right atrium is roughly estimated by l/4 of
patient's body height. A more correct estimation,
avoiding further manipulations for relocation
of the catheter, is obtained by measuring the
distance on patient's body with a measure tape.
However, the most correct location is obtained
by fluoroscopy: a coin is applied and attached
to the skin (with tape) at the 3rd intereastal
space, parastemally, and the guide-wire together with the catheter is advanced until the
the coin.
9. The next-following steps are identical
to those performed with the other vein approaches.
10. Particular aftercare. Immediately after
the insertion, the patient should stay in bed fo~
at least l hour. If the patient sits or stands
immediately after insertion of the catheter, the
insertion site may bleed because of increased
venous pressure. Patients with inferior vena cava
catheters should be instructed to either lie down
or walk, and to avoid sitting and ~ding at all
times. Sitting and standing increase venous pressure in the inferior vena cava.
IV. INDICATIONS
1. Ressuscitation (e.g cardiac arrest,chock
2. Lack of competence with insertion of subclavia
and intemal jugular lines. 3) Emergency haemodia
lysis. 4) Thrombosis of the superior caval vein .
s. Battle-field conditions (field hospitals).
6. No other venous approaches accessible.
7. Short-term (up-to 72 hours) catheterization.
8. Advantageous in children (safer than subclavian and intemal jugular vein approaches, with
no risk for life-threating respiratory and
cacdiovascular complications).
V. CONTRAINDICATIONS
l. Relative: paralysis of the lower extrem i ties and confinement to bed (higher risk for
thrombosis); no palpable femoral pulse (difficul t
venepuncture); history of pulmonary embolus and
old age (higher risk for thrombosis).
VI. ADVANTAGES
1. Suitable in emergency and battlefield conditions. 2) Safer (no risk for immediate, lifethreatening ~espiratory and cardiovascular complications. 3) May be performed by non-expert personal (trained nurses).
36)
Peritaneal ""tents
a)
Right atrium
b)
LATERAL THORAClC V.
Fig. 65. Cut-down and inserting a central
venous catheter via the lateral thoracic
vein (according to Parsa & Tabora,1985).
II. INTRA/EXTRA-ABDOMINAL
1. Inferior vena cava under the renal
vein was performed in patients with thrombosis of both superior and inferior caval
vein (under the renal veins).
2. Portal vein. Approaches to the por- _
tal vein through the following brances: middle colic vein, gastric coronary vein, branches of superior mesenteric vein an~ inf~rior
mesenteric vein, stump of the splen~c ve~n
following splenectomy, and right gastroepiploic veins, an intra-hepatic vein approached
by transhepatic catheterization. -
PARTICULAR
INSERTION
TECHNIQUES
a..)
b)
PARTICULAR CATHETERS
I. MULTI-LUMEN
CATHETERS
CENTRAL VENOUS
Usually, catheter with double-and triplelumen are used, but CVC with 4, and even 5
lumina have been manufactured (Fig. 68-a,b).
Disadvantages of the single-lumen catheters:
l. Inadvertent injection of drug residua! in
the infusion system during CVP-measurements;
2. Incompatibility of drugs, or infusates
given by the same lumen, favoring precipitation
and occlusion;
THE GOTIIENBURG eve-GROUP
38)
drugs.
Insertian of multi-lumen eve
The catheters are usually inserted by
the seldinger technigue. With very largebore (OD = 4.5-6.4 mm) catheters, Desilets
& Hoffman's techniaue, or "peel-away"-introducer technique were used.
Advantages of the multi-lumen cve
l. Preservation of venous puncture sites.
2. Complications created by mult~ple_ puncture sites are lessened. Burn patients particularly benefit from only one puncture site invasion.
3. Incompatible drugs, or drugs at different
flow rates may be infused simultaneously.
4. A line for total parenteral nutrition is
available, undisturbed by blood sampling, or
other drug administration.
5. The risk of inadvertent bolus administra-
tion of Concentrated solutions during flushing of
the lines, or administration of "push-out" doses
of other injectates into the same infusion line
is avoided.
Disadvantages of the multi-lumen eve
l. Larger diameter (e.g. Raaf Dual Lumen
Catheter = 4.5-mm; Hickman Double Lumen Catheter
= 6.4-mm), and consequently larger veins are necessary for insertian of the catheters (e.g. subclavian, intemal jugular, and femoral veins)
2. More traumatic insertian because of large
diameters.
3. Probably higher risk of cardiac tamponade. This complications was related (Mashke &
Rogove, 1984) with catheter stiffness, its tapered,
or beveled tip (shaped to facilitate the insertion)
and catheter tip location: the disadvantage of the
multi-lumen catheters is the necessity to advance
them somewhat further than a normal (i.e. singlelumen) catheter to ensure that the proximal opening
of the multilumen catheter is within a central vein.
Thus, the beginners must realize that the design and
construction of some multi-lumen catheters (e.g.
Arrow-Howes) may be associated with a higher risk of
perforation of the central veins and heart cavities
when it is placed by a person unfamiliar with its
proper use.
4. Probably higher risk for air-erobolism
(eonahan, 1979). Insertian of a multi-lumen catheter
requires usually a large-bore (approx. 2.5-mm) introducer. Air-erobolism may occur between the removal
of the wire and dilator from the lumen of the introducing-sheath (cannula)and insertian of the multilumen catheter through the introducing plastic cannula. More than 8% of patients present clinically
silent air-erobolism during insertian of multi-lumen
catheters. An introducer of of 2.5-mm may accept
potentially fatal air-flows at clinically attainable
pressures. Is has been showed that a fatal airerobolism may occur at a flow of l ml/kg/sec.Hence,
a 4-torr g'adient would be sufficient to induce airerobolism in an adult patient.
5. Higher risk of thrombosis of the central
veins explained by: i) larger diameters (reducing
blood flow around the catheters), an~ ii) higher
stiffness (because of larger diameters) even if
the catheters are made of a sqft material (polyurethane).
~
~
Fig. 69. Vaccess-4000 Subclavian
Catheter used for haemodialysis
subclavian vein, but also used for cannulations via the right intemal jugular
and subc lavian ve in. The cannula is made
of aliphatic, thermoplastic and hydrophilic polyurethane becoming softer once
inside the vessel.
The "anatomy" and "physiology" of
the cannula are presented in the figure
70. The cannula is divided into two
rnarate lumens ( arterial and venous)
by a septum. The arterial lumen is located outside and it is provide.d with
6 side orifices near the tip. The orifices are arranged in spiral fashion.
The catheter (15, or 20-cm long) is
prolonged by a Y-piece made of soft
polyurethane, and provided with female
luer connection. The connection may be
capped with p lastic plugs.
2) INSERTION TECHNIQUE
a) ehoosing the vein .. The vein
approach ~hould be preferred 1n the following order: i) Right subclavian (the
best); ii) Right intemal.jugular (when
attempt to puncture the nght subclav~an
vein was unsuccessful, or the subclav1an
vein was unapproachable; iii) Left subcclavian vein (more inconstant anatomy,
smaller diameter, high risk for ~erfora- _
tion of the superior vena cava :1ght wal .
during advancement of the relat1vely
stiff and large-bore polyurethane catheter); iv) Right femoral; v) _Left femoraL
~
~~.,G~53.~~H~f{~~~::.~-~-~~~o..=~,,.~~~'!.~-~~~~-'==l
"-.,, .
~.
-~
F\g. 71. Diagram. The extensions of the doublelumen, dialysis catheter were caped with p1astic plugs provided with silicone bottoms permitting repetated administration of heparin
injections into the catheter lumens (according
to Uldall et. al., 1982).
j) eappingthe extensions of the catheter
after their clamping.
j) ehecking if the venous lumen, as indicated by the blue clamp is orjenced cephalad.
If not, rotate the catheter to obtain the wanted position.
k) ehecking if bleeding is occurring at
the insection site. If so, apply a "strippurse" suture w1th a 2-00 monafilament thread
arou~d the puncture site and tie it just sufficiently to stop the bleeding, but avoiding oc~
lusion of the catheter.
l) Suturing the wings. The wings are
oriented to the skin surface, and sutured into
place wi~ two 2-00 wonofilament sutures (e.g.
Derrnalon or Novafil ).
m) Dressing the site. A thin polyurethane
film, ~ransparent ang self-adhesive (e.g.
Opsite , or TegadermK) is applied over the skin
at the catheter entry site, if no bleeding is
occurring at the site. In the case of blood
oozin~at the site, an absorbant compress (e.g.
Mepore ) is used instead.
n) The dialysis catheter is now ready
for use. (Fig. 72). The arterial lumen of the
3) POST-OPERATIVE CARE
i) Changing of the dressing each time it
is dirty, otherwise once a week.
ii) Heparin-lock (see above) each 42-72
hours. The injection of a new "heparin-lock"
should be proceeded by aspiration and discharge
of the old heparin solution (3-5 ml of aspirate,
i.e. heparin and blood, should be discharged).
iii) ehanging the catheter. Exchanging the
catheter once a week, or at least once a month,
was recommended by some authors. In our opinion,
there is no evidence that the rates of thrombosis
or catheter-related sepsis might be reduced by
periodic exchanges of the catheter. Furthermore,
the exchange may cause new complications (e.g.
air-erobolism and bleeding), and it is expensive.
Thereby, we recommend to exchange the catheter
only in the case of ics malfunction (e.g. occlusion).
4. INDieATIONS
for
insufin the
of
41)
r ,~
42)
This is explained by the fact that the sideholes of the arterial lumen are preponderantry occluded by fibrin deposits located outside the catheter arterial lumen. Further,
attempts to declotting may be dangerous,
favoring bleeding, and clot-and air- embolism.
Therefore, we st~ongly cecommend exchange of
the catheter in the case of its occlusion.
A rate of 16% catheter clotting was reported
in large statistical materials.
v) Tear in catheter wall. This was usually eaused by repeated clamping of the extensions of the catheter with roughly edged
forceps. This complication may cause severe
bleeding and air- embolism.
vi) Accidental catheter withdrawal. This
was occurred in unconscious or agitated patients, during sleep, and were eaused by unsufficient catheter fixation. This complication may also cause bleeding and air-embolism.
vii) Laceration of arteries (e.g. earotid
and subclavian arteries, and even of the
aorta) .was reported. The complication was usually eaused by a nonchalant~ "cavalier" actvancement of the stiff, Teflon -made, vein dilator. Prophylaxis: not to advance the veindilator more than 2-cm after the seeond resistance ( vein wall) opposed to ca theter advancement has been overthrown.
viii) Perforation of the right wall of the
superior caval vein (and fu~ther of the mediastina! pleura, and even of the right lung). This
complication is typical for L~e dialysis catheter inserted From the left subclavian vein.
Symptoms and ~i~s: Resistance to advancement
of the catheter is encountered app~ox. 10-12
cm from the insertian point.Next, the patient
complains of dull, substernal pain during advancement of the catheter indicating the centact of the tip with the wall of the superior
caval vein, or even perforation of its wall.
Finally, haemoptysis may occur when the tip
has perforated the lung. On a frontal thoracic radiograph one may see impingement to the
right of the rigqt ~all of the superior vena
~ , and distorsion of the mediastinal silhouette. Treatment: if the right wall of the
superior caval vein is not yet perforated
(the tip is sti 11 intravascular), the catheter should be withdrawn 1- 2 cm until the tip
is located in the left in~ominate vein and
free blood at aspiration is obtained. If the
superior cava! vein was perforated, a pleural
(Bullow) drain should be inserted after ~omplete
withdrawar of the catheter, and a new dialysis catheter should be inserted by the right
intemal jugular vein, of a femoral vein.
ix) Higher rate of thrombosis of the
central veins than with the usual (singlelumen) catheters.
x) Severe bleeding reaching rates of
0.64% with the subclavian approach, and 0.64%
with the femoral approach, in large bodies
of statistics exceeding 2 , 000 observations.
xi) A lethality of 0.12% (approx . 1/1,000)
was reported with the dialysis catheters inserted by the subclavian veins .
8) WITHDRAWAL
OF DIALYSIS CATHErERS
III. PORT-A-CATHETERs
DEFINITION
Port-A-Cath is an implantable drug delivery
system designed for safe, P4sy, and repeated access to the centrar .rE!"nous system con sisting of 3 parts: i) an injection chamber
(the "portal") provided with a silicone
disk for repeated injections; 2) a soft
(silicone elastomer, or polyurethane) catheter , and 3) a lock system connecting the
previous two items (Pharmacia Port-A-Cah~
(Fig. 75). In some models (e.g. Infusaid )
TO P\JMP
CONNE<TION
SW:IN SUttfACE
SUBCUTANEOU\
fiSSuE
MUSCU FASCIA
4.3)
INSERTION TECHNIQUES
l) Cut-down (particularly used in
children ) of the the cephalic vein at
deltopectoral groove, externa! jugular
above the clavicle, and the great saphenous vein at the groin. Cut-down of the
axillary, subclavian, intemal jugular,
and femoral veins was performed only
in very exceptional situations (Figs.76~.
44)
Fig. 77.
POSTOPERATIVE CARE
l) Prevention of bleeding at the implantation site (incisions, tunnel, and pocket):
i) Sand sack for 4-8 hours; ii) Infusions of
platelet enriched plasma (in patients with
bleeding tendency).
2) Antibiotic prophylaxis for 3 days .
3) Thrombosis prophylax (Macrodex, coumarine derivates) in patients with history of
thrombosis and coagulation disturbances.
4) Port-A-Cath may be used immediately,
but best after 10 days (a eve may be i n$erted
in the patients needing a free vein way for
injections and infusion treatments). Conti-
GENERAL TECHNICAL
ASPECTS
In the following, same general, technical aspects, regarding all types of
the catheters and venous approaches will
be discussed.
sa
49)
Fig. 71. Diagram illustrating a HickmanBroviac catheter inserted via the ri~t
subclavian vein (A). Note the Dacron -cuff
(C) placed above the tunnel exit . (B).
(According to Gauderer et al.,l982)
begin by construction of the tunnel, and
ends with insertian of the catheter; if
insertian is unsuccessful, the t~~el
becomes unutilizable); ii) Bleeding & infections in the tunnel; iii) Ruptures of the
catheters in their subcutaneous tunnel at
forced irrigation with saline to clear the
lines (because of the poor mechanical properties of silicone elastomer); iv) Catheter
embolism eaused by rupture; v) Cumbersome,
painful, and traumatic withdrawal, with no
possibility to reuse the tunnel after insertian of a new catheter.
2) Viggo's Secalon-UniversalR-Catheter.
This catheter was constructed by British
Vigge in cooperation with the Gothenburg
CVC-Group. The catheter is 65-cm long, 1.2/
1.8 mm ID/OD, and made of thermoplastic polyurethane. The catheter is provided with a
removable stylet made of polyamide (to facilitate insertion) and a removable hub functioning also as a flow interruptor called
_:__ "Floswitch" (Fig. 82-a,b). The catheter
may be inserted by a special introducer
("catheter-through-cannula"-technique)
giving the possibility to occlude the catheter during its advancement inte the veins,
and avoiding air-embolism. Alternatively,
the catheter may be inserted by a genuine
seldinger technique using a 115-120 cm x
0.89 mm 0 guide-wire. A metric tape helps
50)
3.
--
purse string
suture
Fig. 82-b. Diagram. Hub and flow interroptar ("Floswitch") of Viggo's SecalonUniversal catheter: a) Flow through the
catheter - the 2 black marks are visible; b) Interrupted flow - the marks
are not visible.
streptokinase/urokinase).
B. CONTRAINDICATIONS
l) Infection at the insertian site
or in the tunnel. 2) Scar at insertian site .
C. EXCHANGE TECHNIQUES
The following clinical conditions
may be encountered, and the following techniques to exchange the catheters may be used:
l) Not-occluded - not-tunneled catheter. In this condition, 2 techniques are
available:
a) Exchange within the first 2
weeks after insertion: the catheter can be
exchanged over a guide wire (Seldinger
technique) (Fig. 83-a,b).
~!~~~~e~
floswit c h
----..
\
a.)
l . Dr~ing and anat:stht:tic infiltration.
FloswitCh
A--
b)
eter.
Ocduded C..cl\eter
Nor.-Ocduded
Wcheler 5.-gr~Mnt
~~..d~~~ - ~.
POSTOPERATIVE
THE
. ~uded C~h'
Cutde Wite
CENTRAL
CARE OF
VENOUS
CATHETERS
(DISPUTABLE TOPICS)
I. USE OF THE CVC-LINES
We recommend to use the lines for all
its purposes: infusion, transfusion, bloods~ling. The earlier recommendations not
to give blood through--or sampling blood from-the line are presently not valid.
l
4. Removal of the occludcd cathctcr.
~ tiffened
with another
floSWit Ch
ss)
b) Volume of the "heparin-lock". No more
volume than the catheter (and stop-cock) volume
should be injected. The same volume should be used,
no matter if the catheter is intended to stay
in place for one day, or one year. For instance.
with Viggo's catheters (without three-way stopcocks) a volume of 2-3 ml is adequate, and of 5-ml
when a three-way stop-cock is aclded to the line.
With Port-A-Catheters volumes of 1.0 ml are
used with the pediatric model (low profile portal
+ pediatric sized catheter) in small children,
2.0-ml in older children (standard portal + pediatric sized catheter), and 3-5ml in adults (stan_dard portal + adult sized catheter).
c) Rhytm of injections. i) CVC: once a
day in the majority of patients. and 2 times a
day in those with trend to hypercoagulation.
ij) Port-A-Catheters: once a month.
d) Maximal heparin-dose at a single . .
administration: i) New bom and infants: 500 IU~
il) Older children (3-8 years): 1,000; iii) Children from 8 to 12 ~ears: 2,500 units; iv) Adults:
5,000 IE.
e) Precaution. The line should be flushed
with isotonic saline (2-20 ml) before leaving the
heparin-lock.
GENERAL
COMPLICATIONS
OF
CENTRAL VENOUS
CATHETERIZATION
TREATMENT
a) Heparin. An injection of
5,000 IU heparin/2-3 ml isotonic saline
is injected into the catheter. Thereafter ,
the catheter is clamped (or the "Flowswitch" is commutated to the "off" posi~
tion). One waits 30 minutes, and thereafter one flushes the line with 5-20 ml
isotonic saline. The method may be
effective in the case of intraluminal
occlusion by clots.
b) Administration of thrombolytic
agents:
i) Urokinase. Mechanism of
action: urokinase is a thrombolytic agent
acting directly to convert plasminogen to
a proteolytic enzyme,plasmin. Plasmin
~~en digests fibrin, and ~educes pla~ma
concentrations of fibrinogen,and decrease:
levels of fibrinogen degradatlon products
Technigue of desosbtruction: a final concentration of 2,500 IU/ml in 0.9% saline
is prepared. Of this solution, 2.5 ml
(6,250 IU urokinase) is injected slowly
into the catheter (in adults), and the
catheter is clamped for 3 hours. Further,
a syringe containing heparin (100 IU/ml)
is attached to the CV.C, the clamp on the
catheter is released, and 25-ml (2,500
IU heparin) of this solution are slowly
injected into the catheter (in a~ults).
Thereafter, the catheter is clamped, the
continuity with the infusion system is
re-established, and the clamp is removed.
The pr9cedure may be repeated twice in
adult patients. Efficiency: highly efficient (up-to 100%) when occlusion if caus
by tip thrombi. Advantages: obviates
surgical removal of the thrombus, exchang
or implantation of a new catheter; disper
the thrombus, making the bacteria which
have been shelterd by it mc~e accessible
to the action of systernie antibiotics and
body's own defence mechanisms; the method
is particularly indicated in the occlusions associated with catheter-related
sepsis. Disadvantages: urokinase acts indiscriminately, dissolving not only
pathological thrombi, but also static
clots as well, leading to serious haemorrha&ic complications; urokinase is effective particularly in patients with acute
occlusion,i.e. acutely formed thrombi,
the older thrombi being endothelazed
and not attacked by urokinase; small
effects in patients with low plasminogen
levels, e.g. infants and children, and
in those with low functional activity of
plasminogen, and presence of an urokinas e
or plasmininhibitor.
ii) Streptokinase is a thromboly.tic enzyme obtained .from the cultures
of Beta-Haemolytic Streptococci (Lancef~ e
group-C). Mechanism of action: similar t o
that of urokinase. Technlgue of desobstruction. Three techniques were reported
to-date: Laufer's
et al. technique (19 7
and Hurtubise et al. technique (1980), an
56)
Fig. 83. Phlebograph showing total occlusion (black arrow) by thrombus of the
right subclavian vein (according to Smith
& Hall et, 1983).
the patient to the risk of radiation.
f) Digital substration angiography
(Fig. 84). Advantages: i) the amount of
fL
CLINICAL ASPECTS
59)
6) PROGNOSIS
a) Axillo/subclavian vein thrombosis.
The development of axillarv vein thrombosis
is usually clinically not-significant. However,
like the subclavian vein thrombosis, the process
may extend to the innominate veins and the superior caval vein. Immediate and late sequelae
of the catheter-associated thrombosis of the
axillosubclavian vein are minimized by: i) prompt
removal of the catheter; ii) systernie administration of heparin to prevent propagation of the
clot,and iii) arm elevation to reduce early
oedema of the upper extremity. The symptoms are
usually resolving within a period of days to 2-4
weeks after removal of the catheter, even without
anticoagulation. Phlebographic investigations
showed that--after complete obstruction--the recanalization starts 3 months afterwards. The striking feature in patients with axillosubclavian
vein thrombosis is that all patients become asymptomatic. This evolution is completely different
from that of the patients with subclavian or/and
axillary vein thrombosis eaused by extrinsec compression who very often have same residua! symptoms
(pain, arm stiffness, oedema, and collateral circulation of the thorax aperture and shoulder). The
danger of pulmonary embolism is low, but real.
Occurrence of suppurative thrombophlebitis is
a life-threatening complication needing massive
antibiotic therapy and surgery (resection or ligature of the vein, fasciotomias, plastic reconstructive surgery, etc .. ).
b) Innominate vein thrombosis has a
definetly more severe prognosis - particularly
when extended to the interna! jugular vein eausing exophtalmos and cerebral oedema. Lethal
casualties have been reported. The risk of pulmonary embolism appears to be higher, and the
approach to the superior vena cava system is
blocked. Thus, a patient needing a CVC for continuous infusion, or total parenteral nutrition
or/and cytostatic regimens may harbour in a lifethreatening condition.
c) Thrombosis of the superior vena cava
has even a more severe prognosis because of associated respiratory and ~rdiovascualar complications.
III. AIR-EMBOLISM
l) PREDISPOSING FACTORS
a) During the insertian of CVC:
i) Insertian of CVC with the patient
in harizontal supine, or even head-up positions.
ji) The patient does not perform
Valsalva maneuver (or PEEP is not arplied on the
intubated patient) during the steps of central
venous catheterization establishing a communication between atmosphere and patients' central
venous system (e.g. inserting the guide through
the introducer, or insertian of the catheter via
a steel, or plastic cannula).
Markedly decreased
left ventricular output
Failure of pulmonary
circulation
Hypoxia or anoxia
(myocardial qnd cerebral)
failure
Miocardial ischemia
Death
Fig. 85. Diagram illustrating the relationship of the pathophysiologic mechanisms
triggered by air-erobolism (according to Alvaran et al., 1978)
maneuver, if the patient is awake and can cooperate,while inserting the needle into the vein;
v) Immediately thereafter, the physiciail occludes
the h~b of the introducer (needle, plastic cannula
with the thumb, and the patient is allowed to
breath and relax, whilst the operator prepares next
step of catheterization; vi) The patient performs
a seeond Valsalva maneuver, and the guide-wire
and catheter are inserted; vii) The catheter hub
must be plugged with a plastic cap when the catheter is inserted by "catheter-through-cannula"
technique; viii) Supervising patient 1 s respiratory
pattern during the whole procedure of catheterization; ix) Informing the male patients having inser
ted eve via the external/intemal jugular veins
and using a razor-blade for shaving about the risk
of cutting-off the eve with the razor blade.
b) After insertion and during indwelling of
eve: i) Use of secure Luer lock type connections
between the catheter and infusion system; ii) Avoi
ding use of razor-blades ( male patients having
the catheter inserted via the external/internal
jugular veins); iii) At the time of catheter dressing and change of infusion sys~em, the_same ~re
cautions should be taken as dur1ng the 1nsert1on,
to prevent air-embolism; iv) Inspection ~f eve and
infusion system for eraeks or defects wh1ch could
lead to air-embolism; v) Air-embolization from the
infusion system can be avoided by using ~umps _ with
in-line air-detectors; vi) "Pyggy-back" 1nfus1ons
should not be administered distal to the detectors
of the infusion pumps; vii) The connecti~n between
the eve and infusion systems should be f1xed belo~
the level of the patients heart when gravity
systems are used.
c) At and after eve-withdrawal: i) Apply ~o~
ression with a gauze-compress proximal to th~ 1nsf
tion site during withdrawal of the eve (part1cula1
with the subclavian line and large-bore catheters :
ii) eover promptly the insertion site with an occ
lus i ve dressing af ter withdrawal of the eve to pn
vent aspiration of air--from the atmosp~ere,_ ..
through the tunnel--into the central ve1ns; 111)
Apply a suture at the insertion site, to close
it, and seal the entrance of air into the subcuta
neous tunnel, and further into the eve-syste~
catheters.
iv) Catheters developed to be inserted
by "tubing-though-steel needle technigue" e.g.
Bard-I-Cath- catheters (Bard Co), and DrumCartridge catheters (Abbott Co). Because of
the sharp edges of the bevel of the steel
needle, the catheter may be easily cut during
its inadvertent withdrawal from 'the needle.
b) Operator's experience. The complication
is directly related to the experience of the
operator.
c) Insertian technigue. Here frequent
with the CVC inserted by "catheter-throughsteel - needle technigue"
d) Vein approach: Peripheral (basilic
and cephalic) veins (with "Bard-I-Cath
and Drum-Cartridge catheters) : 65% of all
reported casualties. Subclavian veins (with
soft, large-bore, silicone elastomer, e.g.
Hickman-Broviac's catheters). Catheters
inserted from the left side in patients .
submitted to median thoracotomy (sternotomy):
accidental injury of the left inneroinate
vein and trans-seetian of the catheter by
the electric sternotomy saw was reported
(Fig. 87).
Fig. 87. Digram representing accidental cutting off of a CVC inserted via
the left intern jugular vein in a patient submitted to median thoracotomy
(sternotomy). (According_ to Krier et al .
1983).
PC
Fig.89. Radiograph showing a double catheter embolism (according to Burri & Ahnefeld,
1978).
iii) Paradoxical locations, e.g. the embolized catheter fragment may reach the arterial
circulation migrating through a right/left communication (persistence of a foramen ovale).
5) COMPLICATIONS
The type of corrplications is depending on
the site of embolism:
a) Embolism of peripheral localization.
Circulation. disturbances in the affected extremity, and a lethality of 4.1% were reported.
. All patients died after thoracotomy.
b) Embolism of central localization. The
following complications were reported:
i) Perforation of cardiac wall;
ii) Septic endocarditis and pericarditis;
iii) Therapy resistant heart arrhytmias;
iv) Thrombosis of the central veins and
right atrium;
v) Pulmonary embolism;
vi) Septic thrombo~hlebitis;
vii) Lethality of 32%.
6) PROPHYLAXIS
a) Before insertion
i) Use CVC made of materials with superior mechanical properties (e.g. soft, polyurethane catheters);
ii) Use only radio-opaque catheters permittL~g radiologic localization of the erratic
fragment in the case of embolization;
iii) Avoiding using CVK-kits developed to
be inserted by "catheter-over-needle" technique
(e.g. Viggo's Secalon-T catheters made of TeflonR)
or by "catheter-through-steel-needle-technique"
(e.g. Bard's Bardic-1-Cath, or Abbott's DrumCartridge-Cath).
b) During the insertion
i) Record the length of the catheter
before insertion;
ii) Use preferentially the Seldinger
technique;
iii) Concentrate your attention during
all the steps of the insertion procedure;
iv) Iosert the catheter preferentially
via the right side veins (significantly lower
risk for cutting-off of the catheter during a
median thoracotomy with median sternotomy);
v) Have a fast grip on the catheters
provided with removable hubs (e.g. Viggo's
Secalon-Universal provided with a Flowswitch)
how long the hub is not in-place, screwed to
the shaft);
vi) Fasten securely the catheter to tl1e
sl:iP- at the entry site with one--or better two-00-monfilament sutures applied on a silicone or
rubber cuff, and by two other sutures fixing
the hub of the catheter, or the wings of the
hub (with Viggo's catheters) to the skin.
vii) Do not withdraw a catheter when
obstacles during its advancement are encountzred and the catheter is inserted by an
"over-the-needle" or "through-steel-needle"
technique. Withdraw concomit. the CVC & needle.
c) During the indwelling
i) Sedation,and supervising of the agitated and unconscious patients by instructed,
expeLienced personnel;
ii) Early removal of soft, large-bore,
silicone elastomer (e.g. Hickman-Broviac)
Fig. 92. Hooked instruments: Left - coronary catheter according to Judkins; Centre
- "pigtail" catheter; Right - ~oronary ca~e
ter according to Senes (accord1ng to Burr1
& Ahnefeld, 1978).
and subclavian veins; subclavian and inneminate veins; in the right atrium to the motion
of heart contractions; therefore, a rigid cather tip reaching the atrium oppesing the wall
may be driven through the wall, eausing infusion into the pericardial sac and cardiac tamponade; when the tip of the catheter faces the
. posterior wall of the superior caval vein, or
of the right atrium, and erodes through the
wall, it may penetrate the mediastinum, or the
pleural space, because a part of the posterior
wall of the vein and atrium is not inside the
pericardial sac.
2) TYPE OF ENDOCARDITIS
a) Nonbacterial endocarditis eaused
by injury to the endocardium from the intracardiac catheter with subsequent nonbacterial
thrombotic vegetation formation. This type
of nonbacterial endocarditis is the precursor
of bacterial endocarditis. Bacteria are thought
to "seed" the endocardial lesions during epi2) PROPHYLAXIS
sodes of bacteremia eaused by infectious foci
i) Avoiding the use of stiff evc.
(e.g. suppurative thrombophlebitis, pneumonia,
infected wounds,etc.).
ii) Recognizing location of the catheter
tip against the vein wall by:
b) Bacterial endocarditis eaused by:i )
- absence of free aspiration of blood
Bacteria (Staphylococcus aureus is the most
from the catheter (the aspiration is associafrequent, practically always present in burn
ted with trepidations of the catheter);
patients; Gram-positive cocci; Gram-negative
- withdrawal of the catheter permits
rods). The predominance of staphylococcal endofree aspiration of blood from the catheter
cardial lesions in spite of more frequent occurrence of Gram-negative bacteremia in all bur
iii) Avoiding insertion of large-bore, stiff,
ned patients suggests a predilection of the for
with sharp bevel catheters (e.g. dialysis and
mer
microorganism to "seed" the endocardial
multi-lumen catheters)via the left side veins
(external/internal jugular and subclavain veins); thrombi of the burn patient. ii) Candida albic~
3) TREATMENT
4) PROPHYLAXIS
a) Location of evc-tip in the superic
rior vena cava in the high risk patients (burr.
immunesuppressed and transplanted patients). Cv
l) These are clinically represented as
tip location should be checked on a frontal
lymphangitis, cellulitis, and local suppuration.
thoracic radiograph.
2) Osteomyelitis of the clavicle has been reb) "Antibiotic-lock" ? (see later in
ported with the subclavian CVC.
this compendium). This might be a valid altera) Mechanisms: i) the needle or/and the
native to repeated catheter exchange.
catheter maytransmit infection from,or through
the skin ii) metastatic blood spread from anoc) Exchange of CVC at least once ever
ther foc~s in the body; iii) septicaemia precee- 72 hours. This recommendation is unreasonable
ding the subclavian venipuncture; iv) infected
because most of the patients considered as a
haematoma after perforation of the subclavian
high risk for endocarditis occurrence usually
vein and/or artery, abscess formation, and subse- do not have practicable vein routes. Furtherquent osteomyelitis; v) suppurative thrombophle- more, the exchange of the catheter performed
bitis of the subclavian vein.
through an infected region (e.g. burn area) ma ~
centaminate the new catheter.
l) RISK FAeTORS
a) Patient' s condition: bums, immunesuppresed and transplanted patients, thromboembolism, shock, existing infection (sepsis),
cancer, chronic alcoholism.
b) Catheter tip location: _right atrium,
5) TREATMENT
l) RAIES
3) BACIERIOLOGICAL FLORA
D
~
CATM(T(It
''~
ISOL,fr.f(J
2) ROUIES OF INFECTION
a) Skin: 75% of cases (migration of skin
bacteria throu~the subcutaneous tunnel into
the central venous system (Fig. 93).
.
o
Ou""' Menuhcture
- + - - - O u r+ng compoul'ldlt'IQ
inlus.at contl+rterl
Matlunc:tonf'l9 atr filef or
contam.,\att<laor
Y )unctons
IV PtCJiilyb.lC.._
CVP Medutemenu
lf'ltKitQnl . iHtg..l(I()OI
~mtn+St~+l\9
otood producu
otheT
Of' mt'doUtl()nS ,
Cnnula
=====-
OIO(~Itl)
..
Fig. 95. Bar diagram illustrating the bacteriological spectrum of the catheterrelated sepsis (according to Maki et al.,
1973).
ROUTES OF INFECTION
Cont~unuon
flf'ltflltSIC}
MinHmUraton Mt junthons
Cannuta echan4Je
Fig. 94. Diagram showing possible ways for contaroination of infusion fluids (according to
Maki et al., 1973)
67)
68)
69)
THE GOTHENBURG CVC-GROUP
. Other measures:
i) If infusate contamination is confirmed, save the implicated container and any remaining units in the same lot.
ii) If intrinsic infusate contamination
(contarnination during manufacturing) is suspected, prompt ly notify the local and state health
authorities.
9) PROGNOSis
The catheter-related sepsis is associated
with a high lethality rate ranging from 50%
(Collins et al., 1969) to 66% (Takala et al
1981) in absence of adequate therapy.
.,
CE~~RAL
VENOUS
TERIZATION
IN
70)
CATHE-
CHILDREN
(PARTICULARITIES)
I. GENERAL INDICATIONS
The general indications are identical to
those in adult patients. It appears that more
children (1.5%) than adults (0.5%) need central venous catheterization, when all the hospitalized patients are taken into consideration.
V. ANAESTHESIA
1. Local anaesthetic infiltration and
sedation may be used in older children.
2. General anaesthesia (often tracheal
intubation) is necessary in small children
uncapable of cooperation.
71)
72)
l) CATHETER FIXATrON
i) Suturing of the CVC is compulsory in
childrens for the following reasons:
- The children--particularly the small
ones--have a natural curiosity to explore and
pull-out all the new things coming in contat
with their body.
- The small children are uncapable of
coopertion. They do not understand ~~e importance of the CVC as a "life-line".
~(~a~p~p~r~o~x~-3~0~%~)~o~f~ma~l~p~o~s~i~t~i~o~n~s-=in~th~e~i~o~s~i~l~a~t~e~r~al
ii) Tunnelling has probably wider indicatiinternal jugular vein than in adults (approx. 13%) ons in children than in adults for the
following reasons:
- The tunnelling makes the fixation ot
6) FEMORAL VEIN
the CVK more secure;
- Thereby, the tunnelling might reduce
a) Technique and equipment: i) seldinger
the movements of the catheters, particularly
technique should be preferred; ii) Needle intro- with flexion of the neck and head (for the
ducers :1.1-1.3 mm 0, 4-cm _long; iii) Guide-wires catheters inserted via the external/intemal
0.53 mm 0, of appropriate length to child's
jugular veins) and their advancement into
body lenghth and catheter length (guide-wires
the right atrium, or even the right ventricle,
of 40 and 80-cm would be adequate for insertion and triggering of the severe arr~ythmias.
of 20-cm and 40-cm long catheters). iv) Catheters : polyurethane (or silicone elastomer to
2) LOCATION OF THE CVC-TIP
be insertedwith a "peel - away"-introducer);
It is strongly recomrnended to avoid location
length - 20 and 40-cm (for older children may
of
the eve-tips in the right atrium for the
be used adult catheters); diameters- 0.50/1.1
following reasons:
and/or 0.75/1.3-mm inner/outer diameters.
i) Higher risk of severe cardiac arrhythb) Venipuncture (see adults - pg. 33-35)
is performed 2-3 cm below the inguinal ligament. mias (particularly supraventricular paroxysmal
tachycardia) when the catheter tip is located
c) Inserting the guiding-wire: 5-10 cm (de- in the right atrium (approx. 30% in children vs
pending on child's body length.
approx. 2% in adults).
d) Inserting the catheter: a length equal
ii) Higher risk for formation of intrato the distance from the insertion site to the
atrial "ball-thrombi" because of lower leve l s
inferior edge of the 4-th, right eostal cartiof plasminogen in children {particularly in
lage is inserted.
the premature and new bom infants) than in
adults.
e) Catheter tip location. In frontal
7 -3 )
iii) Higher risk for perforation of the right atrium, even when soft CVC (silicone
elastomer, or polyurethane) are used because of the substantially thinner wall of the
right atrium, and higher tendency to develop intra- atrial thrombi than in adult (the
intra-atrial thrombi may involve the atrial wall eausing its erosion, and perforation).
The final results will be intrapericardial admnistration of the infusate, heart tamponade, and very often death of the child.
INSTEAD
OF
CONCLUSION
ALWAYS
BENEFIT
IN
CONsiDERATION
RATIO,..AND
THE
DO
NOT
TH:E
RISK-
FORGET - - -
C>C>C>0000C>C>C>
SELECTED
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61. Webre RD, Arens FJ. Use of cephalic and basilic veins tor introduction of central venous
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62. Weechsler JR, Byrne JK, Steiner MR . The misplaced thoracic venous catheters: detailed
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oooOOOOooo
.. .:.:
76)
THE GOTHENBURG CVC-GROUP
CONTENTS
CHAPTERS
PAGE(S)
..
77)
IV.
V.
VI.
VII.
VIII.
GOTHENBURG,
the
1st
OF
SEPTEMBER,
1987