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l)

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)

ONLY FOR INTERNAL, EDU'eATIONAL PROGRAMMEs

2)

THE GOTHENBURG CVC-GROUP

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
-

Fig. 3. Diagram. Schematic drawing of


the mediastinal venous anatomy
(frontal view).
L Brachiacepholic v.

-?~" :LJ
l :J

' \

Fig. 4. Diagram. Schematic drawing of the


mediastinal venous anatomy.Left
sagital view demonstrating the lef t
mammary artery and the pericardiophrenic vein.

accepted in some particular conditions (e.g.


thrombosis of both the superior and inferior
vena caval systems). The small intrathoracal
veins are: l) The intemal mammary veins
R. Sup.
\ \
lntercostol v. ~
(right, and left). On thoracic radiographs ,
the course of the right mammary vein may be
confused with that of the superior vena cava.
However,
the right intemal mammary ve in is
Azygosv. ~
lateral to both the superior vena cava and
azygous arch. Definite distinction from the
a zygous vein is made on the lateral radiographs
where the right intemal mammary vein is in the
anterior, retrostemal position. 2) Azygous
)
vein (arch) tums forward at the level of Th4Th5 vertebrae. Accidental catheterization of the
azygous arch is likely to occur in clinical con Fig. 5. Diagram. Schematic drawing of the
ditians increasing the flow in the vein, and dimediastinal venous anatomy. Right
sagital view illustrating the right lating it (e.g. congenital absence of the inieintemal mammary vein, right supe- rior caval vein, pregnancy, portal hypertension ,
rior intercostal vein, and azygous congestive heart failure, pericarditis, etc .

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS

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).

INDICATIONS FOR CENTRAL VENOUS


CATHETERIZATION
l. Insufficient peripheral veins. 2) Measurement of central venous pressure (CVP).
3) Infusion of strongly irritant solutions (e.g. cytostatics, hydrochloric acid ,etc.).
4) Haemodialysis. 5) Long-term, or permanent intravenous infusion, e.g. total parenteral
nutrition at home, or continous
intravenous drug (e.g. insulin) administration.

CONTRANDICATIONS TO CENTRAL VENOUS


CATHETERIZATION
There are no absolute contraindications to central venous catheterization.

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 GOTHENBURG CVC-GROUP


4

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

f.i&..:_l. SEM. Coated polyurethane catheter

(in the middle) with inner (curved


arrow) aRd outer (straight arrow)
Hydrorner layers.

Fig. 8. SEM. Swollen (hydrated) ir


HydromerR layer (arrow) af
intravenous indwelling.
catheter surface. In reality, HvdromerR
very brittle materi~l in both its dry a
forms. The Hydrorner -coating, particula
outer layer may be easily damaged duri
pulatians of the insertian (Fig. 9). By
out" phlebogr~phy, we could demoostrate
the "Hydrome~"-coated polyurethane catl
have a thrombogenicity similar to the w
tubings made of the same material.

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

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS

S)

cervical structures in intemal and subclavian vein catheterization by usjng introducers


having a diameter smaller than the catheter outer diameter; ii) "Stepping-up" the capability of the operator (the seldinger technique allows the safe, and simple percutaneous
insertian of very large-bore catheters using small-bare needles for their introduction);

Fig lO

A. CC'ossseetion of a stand.ard needle,dernonstt"atlng the part


which D.~Y transect a catheter, or a CUide - win. durin& retnction (at'row) .
8. s._ needle with this cuttlng edge rounded (nrov ). c. !n face view
of st-.ndard needle . The V (he:el) of the bevel caay transects the c:ath.eter (cuide-wire) with retraction (arrow) . D. Needle with rounded heel of
the bevel. The bevel edges vece rounded from the bottoa of the V fo["W'a~;d
to the point ind iu.ted by the saall arrows. E. Ratrutlon of a J-sh.aped
&uide-vire from .an unrounded needle uy cause cuttinc off of lts J-shaped
Up (According to IF lbvkins ' LP Elliott : Kodlfication of Intracath
needle to prevent catheter transection . R.adiol ogy 1973 : !2,Z : 695-697)

Fig.l2.

Schematic rep~esentation. Insertian of a


"half-way" catheter with a splitting lntroducer developed by the Gothenburg evegroup. The introducer is split under its
withdrawal by a "knife"applied on the
catheter hub. Thus, the splitting is
produc.,.d with onlv ""'~"" movf'J!lPnt..

Fig.ll. Schematic representation.


Insertian of a subclavian
central venous catheter
using a "peel-away" sheath.

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

Femoral vein set-up for simultane <


resuscitation and CVP monitoring .

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)

II) SURGICAL "CUT-DOWN" OF THE VEIN.


l) Approached veins: i) Superficial veins are usually approached: basilic and
cephalic veins at cubital fossa, the cephalic vein at sulcus deltopectoralis, extern.jug.v. at the
base of the neck (2 fingerbreadths above the clavicle), the great saphenous vein in front of the
intemal (tibial) mallealar process or at the groin (Scarpa's triangle). ii Profound veins: the
axillary, subclavian (exceptionally), intemal jugular (e.g. for insertian of Porta-catheters - see later in this compendium), femoral veins, and--in desperate situations, e.g.
-thrombosis of both the superior and inferior vena caval systems--vena epigastrica inferior
(intra-abdominally), azygous vein and right atrium (with right side thoracotomy).
2) Advantages: lower risk for severe mechanical injuries to the neighbouring anatomical structures (the cut-down is performed under sight control).
3) Disadvantages: i) Significantly higher rate -of catheter related-sepsis than with
the percutaneous techniques; ii) Time eraving and more expensive technique; iii) Necessity of
s~gical competence, particularly for cut-down of the profound veins.

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)

I. SITE OF APPROACH: the cubital fossa .


. II. INDICATIONS: l) approachable (visible) veins; 2) relatively short duration (up-to
a . month) of catheterization; 2) no experience with "short-way" (subclavian, intemal jugular)
catheterization; 3) Principially first choice alternative.
III. RELATIVE CONTRAINDICATIONS: l) Infusion of strongly irritant solutions (e. g.
cytostatics, and hydrochloric acide- higber risk for thrombosis of the central veins); 2) Longterm regimens of parenteral nutrition at home (it is difficult for the patients to care themselves their catheters).
IV. BASIC ANATOMY. l) THE BASILIC VEIN continues the cubital vein and is continued
by the axillary vein at the lateral border of the muscle Teres Major. Its diameter is continously increasing from the cubital fossa (mean = approx. 4-mm) to the axilla (mean = approx.
7-mm). The vein has usually a straight course, has few valves, and--in same patients--forms
a fold at the axillary fossa with subject's arm in maximal adduction. The lenght of the basilic
vein from fossa cubiti to the lateral edge of the Terres Major is approxirnately 24 cm (mean),
ranging from 20 to 28 cm in normal, adult people. 2) THE CEPHALIC VEIN is laying subcutaneously
on the lateral(radial) side of the arm. At the level of the shoulder, the vein is locating in the
deltopectoral groove,enveloped in a sheath which is a _prolongation of fascia deltopectoralis.The
vein has an irregular course, is provided with rnany valves and anastornases with the veins of
the shoulder and the neck (e.g. externaljugular vein and even intemal jugular vein), and
ends either in the axillary or subclavian vein, usually at the level of the first rib, by a
small (3-7-mm) ostium. Before ending, the vein forms an arch having a radius of approxirnately
3-cm (in the adult subjects). In some patients, the principal venous trunc is replaced by two
thinner ones.
The differences, and particularities of the anatomy explain why the basilic approach
should be preferentially used for insertian of the "long-way"--as well as for the "short-way"-venous catheters .
V. PARTICULARITIES OF CATHETERIZATION TECHNIQUE. The following details should
be respected for a successful and easy insert1on:
l. Catheterizat.ion via the basilic vein should be preferred each time this way is approachable. This recommendation is anatomically grounded: the basilic vein has a straight course and

'

THE GOTHENBURG eve-GROUP

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

Fig. 16. Diagram showing the correct


location of the "long-way"
brachial catheters (2-cm below
the jugular notch) in the inomminate (brachiocephalic) veins.

(l)

where:- De is the approximated distance (cm),


- (L x 0.25) - 1/4 of patient's body height,
- c - a constant, equal with 2-cm for the basi
lic, and 4-cm for the cephalic vein courses.
For quicker estimation of the distances, the regression diagram (nomogram) presented in the figure 17
mav be used.
Cephalic
Cephalic (n-200)-y
y-3.5414 0 .2538x

----Basilic (n-200)
Y=4.0478 + 0 .2402x

55

55

50

45

40

165.

170

175

180

185

190

195

200

BODY HEIGHT (CM)


Fig. 17.

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).

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS


9)

VI. ADVANTAGES: l) Easy, not-dangerous venipuncture (may be performed by


nurses, and even by trained firemen and soldiers; 2) Consequently, this approach
does not obligatory require medical competence; 3) May be performed in emergency
conditions (e.g. emergency rooms, spot of accidents, battle-field, ward departments) with minimal aseptic and antiseptic precautions, with the catheters developed to be inserted by a "non-touch" technique (e.g. from a protective plastic
sheath (Braun-Melsungen's catheters) , or a drum-cartridge (e.g. Abbott's catheters).
VII. DISADVANTAGES (DIFFICULTIES AND COMPLICATIONS):
l) DIFFICULT ADVANCEMENT OF THE CATHETER AND TIP MALPOSITION. i) Causes:
undulated trajectories of the basilic/cephalic-subclavian-innominate vein courses;
presence of valves (particularly in the cephalic, but also in the basilic, axillary,
and subclavian veins); right angle between subclavian and intemal jugular vein, particularly on the right side (approximately 18% of the inserted catheters harbour in
the ipsilateral intemal jugular veins); stiff catheters (e.g. polyethylene catheters)
which can not follow the undulations of the vein courses; insertian of the catheters
with patient's arms in adduction (in this position, the vein course forms a fold at
the level of basilic-axillary vein junction which hinders advancement of the catheter
towards the central veins). ii) Rates of malpositions:up-to 20% with the basilic, and
41% with the cephalic vein were reported. iii) Places of malpositions: the ipsilateral
intemal jugular vein (18% of all insertions); axillary veins (c:a 6% of all the malpositions);mediastinal veins (small intrathoracal veins) - c:a 2% of all the malpositions;
cervical veins etc. iv. Technical artifices to facilitate catheter advancement and
vrevent malpositions: insertian of the catheters with patients' arms abducted at 90;
using the "hydraulic insertion", i.e. flushing the catheter with saline during its advancement inta the vein; running continuously an infusion whilst advancing the catheters
towards the central veins; using soft catheters (e.g. silicone elastomer, or polyurethane
ca&heters6, and positioning the patients with the upper part of the body elevated from
45 to 90 to the harizontal (sitting position eneaurages gently bending of the soft
catheters and helps them to follow the contours of the great intrathoracal v8ins towards
the heart);turning patient's head toward the arm of insertian abducted at 90 , with the
chin touching the ipsilateral shoulder (this manoever decreased the rate of malpositions
by approximately 50%); using drum-cartridge units with the catheters coiled in the drums
(this decreased the rate of malpositions--in some reports--from 63% to 15%).
2) LARGE DISPLACEMENTS OF THE CATHETER TIPS DURING INDWELLING WITH MOVEMENTS OF THE
PATIENTS' ARMS. i) The direction of displacements is imprevisible for all, but the catheters inserted from the right cephalic veins which displace always downwards. However, the
most cathet8's are downwards displaced with both maximal adduction and abduction from the
neutral (90 abduction) position. 2) The size of the displacement may exceed 10-cm with
the stiff (polyethylene) catheters, and are somewhat shorter (up-to 7-cm) with soft (silicone elastomer and polyurethane) catheters. The downwards displacements are significantly
larger with both maximal adduction and abduction of the arm. 3) The main factors affecting
the direction and size of the displacements are: the anatomical relations of the basilic
and cephalic veins with caput -humeri; the biomechanical effects of the mov~ments in the
elbow, shoulder, and intervertebral joints on trajectories of the catheters; the degree
of the angle formed by the junction of the right and left innominate (brachiocephalic)
veins; the fastness of catheter fixation at the insertian site.
3) SEVERE HEART ARRHYTHMIAS. i) Etiopathogenesis: location of the catheter tip in
the right atrium, or right ventricle; displacements of the catheters with the movements of
the catheterized arm. ii) Rate: approximately 2% in adult patients, and 37% in small children (with the catheter located in the right atrium). iii) Prophylaxis: high location (in
the innominate veins - see above) of the catheter tips; secure (fast) fixation of the catheters at their entry site.
4) PERFORATION OF THE CENTRAL VEINS AND/OR HEART CAVITIES WITH SUBSEQUENT HEART
TAMPONADE. i) Etiopathogenesis: use of stiff (e.g. polyethylene catheters; too long adR
vancement of soft catheters provided with rigid, metal stylets (e.g. Abbott's Drum-Cartridge
catheters); displacements of a stiff catheter with movements (particularly abduction) of
the patient's arm; formation of "ball-thrombi" in the right atrium (e.g. in children),
with involvement of the atrium wall, and its secondary necrosis. ii) Prophylaxis: use of
only soft (silicone elastomer or polyurethane) catheters; high location, in the innominate
veins of the catheter tip (see above); secure fixation of the catheter at its entry site.
S) THROMBOPHLEBITIS OF THE SUPERFICIAL VEINS (BASILIC, OR CEPHALIC). i) Definition:
venous reaction eaused by physical (mechanical) or/and chemical irritation from the catheter
and infusate, andmanifestedas pain at palpation along the vein (tenderness), oedema
(swelling), erytema /redness), and palpable venous cord . ii) Rate: appoximately 20%, when
all catheter materials are considered. It appears that the rate of this complication is
largely dependent on the material the catheter is made of (Fig. 18). Thus, the rate is lowest
with polyurethane catheters, and highest with the stiff, heparinized polyethylene catheters .
Another factor affecting the rate is the vein used for catheterization:the incidence of
thrombophlebitis appeared to be significantly lower with the basilic than with the cephalic
vein catheterization (Fig.l9). iii) Dynamics of thrombophlebitis: the most cases of thrombo-

THE GOTHENBURG eve-GROUP


10)

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

phlebitis occur between 3 and 8 days


after catheterization (Fig. 20). After
10 days there is a significantly lower
risk for thrombophlebitis occurrence
(Fig. 21) and the curve representing
thrombophlebitis rate is practically
unchanged up-to 100 days (Fig.22). During
the first 10 days,one thrombophlbitis
casualty for 36 catheter-days was registered, and only one casualty for 181
catheter-days from 10 to 100 days after
insertian of the catheters. eonsequently,
there is no statistical basis to recommend
the prophylactic exchange of the "longway" brachial catheters 10 days after thei
insertian in order to prevent occurrence
of thrombophlebitis.

6. THROMBUS FORMATION (THROMBOGENieiT


All the central venous catheters, no matte
Fig. 18. Rates of superficial thrombophlebitis with which material they are made of, cause fonna
tian of thrombi. The thrombi may be divide
the "long-way" basilic and cephalic catheters inserted from the cubital fossa in re- in: i) "Catheter thrombi", called also for
lation to catheter material (The Gothenburg "fibrin sleeves",that form on and around
the catheters with no centact with the vei
eve-Group results)
wall (Fig.23). ii) "Parietal (mural) throm
--with, or without centact with the cathet
L.BASILIC/R.BASILIC
- P< 0.05
100
L.BASILIC/L .CEPHALIC - P< 0 .02
adherent to the vein wall (these thrombi
50
L.BASILIC/R .CEPHALIC - P< 0.01
are eaused by irritation of the vein intim
...o
from infusion of hypertonic and low pH sol
tians, or by its mechanical injury from
a stiff catheter tip). eontrary to the
catheter thrombi which have a very small m<
p< 0 .02
the mural thrombi are bulky and.may cause
very severe complications, and even ~eath
of the patient in the case of embolization
iii) "Total venous occlusion". In such a
case, the whole vein lumen is occluded, an
it is practically impossible to identify
the rate of participation of either cathet
or mural thrombi in the whole mass of the
o
veno-occlusive
thrombus (Fig.24). By "pull
Left basile
Riohl basile Lett cephalc Riohl cephalc
out"-phlebography, we have found that the
Cn51)
Cn38l
(no78)
(n.86)
7
7.5
size of the thrombi is apparently correlaL
with the catheter bending stiffness, no
matter the material the catheters are made
Fig. 19. Rates of super~icial_thrombo~lebitis (all.
of. The soft polyvinylchloride, silicone
catheter mater1als) 1n relat1on to the ve1n elastomer, plain-and heparin-coated polyapproached (The Gothenburg eve Group results)urethane catheters eaused formation of
smaller thrombi than the relatively stiffe
IN-PLACE CATHETERS (l
plain-and heparin-coated polyethylene cath
ters. ( Fig. 25) .
7. INTERRUPTION OF INFUSION FLOW-RATE
WITH FLEXION OF THE FOREAR."' is more likel y
to occur with the relatively stiffer (poly
;:::
ethylene and stiff polyvinylchlorde cve)
than with the safter silicone elastomer an
.....
Q.
polyurethane catheters (approximately 25%
o
vs 15%, respectively).
'Sl

(/)

!
o

a:

i!:

VII. PRESENT RECOMMENDATIONS

1. Use eve made of polyuerthane;


2. Insert the "long-way" brachial
catheters preferentially via the left
basilic veins;
3. Use only soft catheters;
4. Locate the eve-tips approx. 2
cm below the jugular notch.

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)

CENTRAL VENOUS CATHETERIZATION


11)

._..__...

0-C-CI

220

200

"

,_
tO

- 180

l5 "

10-4 "...

.,

P<O.O$

>

ffi 12
~-

l5

a:
w

...

60

Fig. 22: Curve indicating the cumulative incidence of


clinical thrombophlebitis (all materials)
in relation to duration of catheterization.
After 10 days of catheterization there is a
practically not-significant risk of thrombophlebitis occurrence. This means that there
is no statistical basis to exchange prophylactically the "long-way" brachial CVC in
order to prevent thrombophlebitis occurrence.
(The Gothenburg CVC-Group's results).

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)

Fig. 24: Schematic representation of the


"catheter" ("fibrin-sleeve") thrombi (the
catheter is not represented), "mural"
thrombi, and "veno-occlusive" thrombi.
(The Gothenburg CVC Group's results)

Fig. 23: Schematic representation of


the "catheter" and "mural" (parietal)
thrombi (the catheter is in-place).
(GothP~burg CVC-Group's results).
3

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

Fig. 25. Bar diagram: sizes of the


thrombi in relation to catheter materials and bending stiffness of the
cathet ers .. The stiffer, plain-and
hep~rin coated polyethylene catheters
cau~<e significantly larger thrombi
than the relatively safter polyvinylchloride, silicone elastomer, plainand heparin-coated polyurethane
catheters.

THE GOTHENBURG CVC-GROUP


12)

THE BASILIC AND

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

estimated distance (cm),


- (L x 0.2) - 1/Sth of patient's
body height (cm), and
- c - a constant, found experimentally, equal with 2-cm for the
basilic, and 4-cm for the cephalic
vein.

"HALF-WAY'-POSITION

Fig. 26. Schematic representation: "half-way"


position (3-cm medial, or lateral to
the external edge of the first rib).
(The Gothenburg CVC-Group concept).

II. INSERTION TECHNIQUES

l. OPTIMAL CATHETER LENGIH


By anthropometric, radiolographic,
and phlebographic measurements, the optimal catheter length was found to be equal with
42-cm.
2. INSERTION TECHNIQUES. i) Initially, the catheters were developed to be inserted
by a "touch" (Seldinger technigue). ii) At present, developmental work was finished to
insert the "half-way"-catheters by a "non-touch" technigue, using a splitting introducer
(see the figure 12). With this technique, the "half-way"-catheters may be inserted from
a protective plastic sheath (Fig. 27), or from a "drum-cartridge"-unit. The le.!'lgt..IJ. cf
the catheter intravenously inserted may be read on a nomogram (Fi~.28-a,b), or in the
windows of the drum-cartridge unit (Fig. 29-a,b). The drum-cartr1 ge was developed for
INSERTED CA THETER LENGTH (cm)

::r:::
5I

7S

100

fLO~WITCH

125

150

115

PATIENT'S LENGTH (cm)

10

201

,,:JJ
CONICATH

20

CONICATH

E.G. PATIENT"S LENGTH - 11s cm

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

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS


13)

c-..... u.-......... _., _

__ ,
EX AMPLE : patient' s body heig,t

=190 cm- "\

A)

HOW TO LOCATE THE CATHETER IN THE HALF-WAY' POStnON


1) With the patient's arm in 90 abduction punct~re the Basilie vein at the Cubital Fossa
The reference level is the Iine joining the Epicondyli of the Humerus .
2) Inser! the entire length of the catheter.
3) Locate the o edge of the Nomogram strip at the Cubital Fossa reference level, as
shown on the strip.
4) Withdraw the catheteter until the proximal end of i1s hub is level with the point
indicating the patient's height on the body height' scale.

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).

THE GOTHENBORG CVC-GROUP


14)
insertian of the "half-way"-catheters in critical situations (lack of medical expertise,
only minimal aseptic/antiseptic preeautians available),e.g. in emergency situations, at
accident sites, on the battle-field, etc. by anyone capable of performing venipuncture.
The insertian is intended to be practically as simple as that of an intravenous cannula.
The "scale-drum" may be used together with the nomogram (supplied with the container, or
printed on one of its sides), or by estimating the patient's body height and inserting a
catheter length equal to one-fifth of the height + 2 cm (2). Alternatively, simplerand
rougher, but sufficiently accurate for clinical use, a fixed catheter length (37-cm) may
be inserted in adult patients of normal (e.g. from 160 to 190-cm) body height. The desired
inserted catheter length is shown in the drum-container windows.
3. PREFERRED VEIN APPROACH. The basilic vein should be preferred for the anatomical
reasons already mentioned.

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

s_.taneous respiration (n26)


Controned

:l!

UJ

~
[2 10

(/)

a:
Q.

(/)

5z
,_>
UJ

a:

<
...J

...J

-o.99

<
...J
<

P< 0.001

:l!

x
o

g:
5

10

15

CENTRAL VENOUS PRESSURE (CM H,Ol

A linear regression analysis from one patient correlating


proximal axillary venous pn:ssures to central venous prc:ssures du ring
intermittent pressure ventilation (IPPV) at different levels (0-7 .5
cmH 20) of positive end-expiratory pressure (PEEP), and during
spontaneous respiration.

Fig. 30. (The Gothenburg CVC-Group's results)

Recordings of dectrocardiogram (ECG), proximal axillary


venous prc:ssures (AVP), and central venous pressure (?~P) during
intermittent positive pressure ventilation and zero postt!Ve end-~x
piratory pressure. Nate the two typical venous prc:ssure curves with
"a"- and "v"-waves. Paper rolling speed = 25 mm/s.

Fig. 31. (The Gothenburg CVC-Group's results)

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

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS


15)

elastomer, and polyvinylchloride catheters.


7) Lower rate of tip malpositions when compared with the "long-way"-catheters
(3% vs 30-60%, respectively).
8) Doctor expertise is not necessary for insertion of the "half-way" venous
catheters.
9) Thus, the "half-way" venous catheters may be advantageously used in critical
conditions: developing countries, spot of accidents, emergency, battle-field,etc.
10) Wider indications: e.g. ,the "half-way"-venous catheters may be routinely
used pre-, peri-, and post-operatively instead of peripheral venous cannulas (VenflonR)
when duration 0f catheterization longer than 3 days are deemed necessary. Thereby, the
necessity of changing the infusion site and repeating v~nipunctur~ every 12-72 hours,
as when peripheral steel needles or short, venous Teflon (Venflon ) cannulas are used
can be abandoned, thus reducing patient's inconvenience. Furthermore, the risk of thrombophlebitis is substantially reduced (from 100% at S days after insertion, with peripheral
venous cannulas, to 4-7% at SO days after catheterization with the "half-way"-catheters).
11) Lower rates of catheter related-sepsis: 0.3% with the "half-way", 0.4% with the
"long-way", 1-3% with the internal jugular, 3-7% with the subclavian, and S% with the
femoral central venous lines.

VI. DISADVANTAGES (LIMITS, PROBLEMS, AND COMPLICATIONS)


l) FUNCTION: i) "Half-way"-venous catheters demonstrated a satis~actorv function
jn 82% of cases for durations of catheterization of up-to SO days. This rate campares
favorably with those of the 11 long-way" (30%-83%) and "short-way", subclavian and internaljugular catheters (34%-94%). ii) However, with the "half-way"--as well as with
the "long-way" catheters, reduction or ternporarv interruption of the infusion flow rate
was recorded in 9% of the inserted catheters. This is eaused by kinking of the catheters
at the elbow (with forearm flexion), and changes in position of the tips, followed by
their occlusion by vein valves and walls (with shoulder movements).
2) LIMITATIONs: i) See contraindications; ii) Unsuitable for central venous blood
sampling, or for treatment of possible air embolism in which a tip lo~ation in the right
atrium is necessary. iii) Probably less suitable for blood sampling than the short CVC.
3) COMPLICATIONS: i) "Half-way"-catheter occlusion rate (12%) campares favorably
with _the occlusion rates of the "long-way"-catheters (14%-2S%). ii) Leakage of infusate
at the insertian site (l%) probably eaused by formation of "cap-thrombi" at the catheter
tip, and "fibrin-sleeves" around the catheters, and infiltration of the infusates between
the sleeves and the lines. This hypothesis is supported by the fact that the leakage
occurrs only with the "half-way"-catheters inserted via the thin-walled cephalic veins.
Th~s, the fibrin sleeve~ may occlude the whole vein lumen. iii) Pain along the vein during
infusion (l%) was observed with the "half-way" catheters inserted via the thin-walled
cephalic veins with infusion containi.ng strongly irritant drugs (e.g. potassium and cytos_tatics), and was probably eaused by venous spasm. iv) Catheter related-sepsis (0.32%, i.e.
l episode of sepsis for 2,429 catheter-days) was significantly- lower than witl1 the subclavian and intemal jugular lines (l episodefor 60, and 6S8 days, respectively). This difference is _probably explained by the difficulty in maintaining adequate dressing at the inser__ tion site, frequent (up-to 90%)catheter colonization by Staphyloccocus epidermidis from the
. patient's nose with the intemal jugular l:i.nes, or the vicinity of infectious foci, e.g.
from a tracheostomy (with the subclavian catheters), colostomy, urostomy, anus, and genitalia (with the femoral lines). v) Superficial thrombophlebitis of the basilic and cephalic
veins (7%). A similar rate (4.4%) was recorded with the "long-way", polyurethane catheters.
vi) Solitary thrombosis of the axillary/subclavian vein was observed in 2.S% of the patients.
This rate might be somewhat higher than that occurring with the "short-way" (subclavian and
intemal jugular) venous lines. This complication occurred when cytostatics and hydrochloric
acide solutions were gi ven through the "half-way"-lines. However, when similar infusates
were administered via the "short-way"-catheters, rates of axillary/subclavian vein thrombosis
ranging from 3.7% to 10% were reported.

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.

II. BASIC ANATOMY


The axillary vein begins, by definition, at the lower border of the teres major
muscle, as a continuation of the bas~lic vein, increases in size as it ascends, and ends at
the outer border of the first rib,where it becomes the subclavian vein. The axillary vein
has a length of approximately 12-cm (mean), ranging from 9-lS cm in adult, normal subjects.
The vein has a continuously increasing diameter rang_ing from 6-8 mm at the lower border of

THE GOTHENBURG CVC-GROUP


16)

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.

III. CATHETERIZATION TECHNIQUE


l) PATIENT'S POSITION. The patient is laying supine with the arm to be cathetezed abducted at 45 .
2) VEIN CATHErERIZATION: i) Aseptic precautions are taken, including shaving of
the hair. ii) Gompression is applied at the root of the arm to make the vein prominent.This
is obtained by placing a tourniquet as far proximal as possible in the axilla, and directing
the pull towards the lateral half of the clavicle. Anassistant holds thetourniquet firmly
in-place. In patients with pronounced hollow armpits, it is necessary to tuck a pack of gauze
under the tourniquet in order to achieve an effective compression. Alternatively, the operator uses the thumb of the left hand, or its seeond finger, to compress the vein medial to the
pulsatians of the axillary artery, and proximal where the vein is erossed by the pectoralis
minor (the latter can usually be feltas firm plate in the background). A pack of gauze can
also be used for applying pressure by fingers or hand to compress the vein against the neck
or head of the humerus. iii) Performing the venipuncture. This is usuually done without particular oroblems. iv) Inserting the catheter. Usually the catheter-through-needle technique was
preferentially used.The distance from the insertion site to the superior edge of the 3rd, right
rib is measured, and an adequate length of catheter inserted (approximately 25-cm in the adult,
normal sujects).
'

IV. INDICATIONS
Very rare, possible indications: l) No approachable basilic, cephalic, and external

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS


17)

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.

VII. DISADVANTAGES (PROBLEMS, COMPLICATIONS)


l) Difficult venepuncture in obese patients. A general rate of approx. 5% failures
was reported. 2) Thrombosis of the axillarv vein (4%). 3) A potentially high rate of accidental
puncture of the axillarv artery and arteriovenous fistula.4) Possible injuries to the plexus
brachialis nerves. 5) Potentially higher risk of catheter-related infeclions and sepsis.
THE

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).

II. BASIC ANATOMY


The externa! jugular vein is the principal, superficial vein of the neck, and it
is constituted by 2 branches: l) the posterior external jugular vein, and 2) the anterior
(ventral) external jugular vein. Under the skin, the posterior external jugular vein extends
from the angle of the mandible (gonion) towards the middle of the clavicle (Fig. 33) where
it forms a curve, penetrates the superficial fa~
cia, and finally discharges into the subclavian
or intemal jugular vein. In 75% of cases, the
posterior external jugular vein has 2-3 pairs of
valves in the main trunk. The anterior (ventral)
externa! jugular vein has only one pair of valves.
The centraJ. vein catheterization is usuallv performed via the posterior external jugular vein~ This
branch is topographically very constant, and relatively well developed, and easily found in children ,
even in the new-born and infants. In some cases, the
externa! jugular vein bifurcates before joining the
subclavian vein. In such situations, the medial
branch must be selected for cannulation (e . g. open
catheterization for insertian of portal catheters),
otherwise the catheter might end up in the axilla.
The externa! jugular vein has a sinuous ("bayonettshaped") cours e, mo re accentuated on the left than
on the right side. Usually the diameter of the vein
Suprah s chl. ~natoical relations of the pos ter io r
at the puncture (Brinkman) site is of approx. 3-5
uternd juaular vein (according to Surri ' Ahne feld}. "The
mm. This diameter may be significantly larger in the
C.vd Catheter". Spdnger - Ver hg, Berlln-Heidelbera New Yo rk .
1978 , PI 23) .
patients with heart insufficien~y.In these patients,
catheterization is substantially easier becuase of
incompetence of the valves.The length of the
vein course from the puncture site (Brinkman' point) to the junction between the superiorvena
cava and the right atrium is of approx. 20-cm in man and 18-cm in women, on the right side, and
of approx. 23-cm in men and 21-cm in women on the left side. When the vein is approached 2-fingerbreadths above the clavicle, the above distances range from 14-cm (women) and 16-cm (men) on
the right side, and 16-cm (women) and 18-cm (men) on the left one. In approximatelv 3% of the
subjects . the external jugular vein ends in an anastornetic venous network located behind the
clavicle, and making threading of the central venous catheters into the central veins impossibl e.
In such situations, the tip of the central venous catheter may harbour in the ipsilateral interna! jugular vein, or axillary veins, or in the superficial veins of the neck and shoulders.

III. CATHETERIZATION TECHNIQUE


1. Patient's position.The patient is placed 20 head-down with the head turned away

THE GOTHENBURG eve-GROUP


18)

from the proposed side of cannulation


and the arms placed by the side. The
suitability of the external jugular vein
for catheterization is assessed. If the
vein is neither palpable, nor vis~
cannulation must not be attempted.
2. Choosing the introducer. We strongl;
recommend to perform the venipuncture with
a 1.7 mm 0,4.5-cm long over-th~-needle
Teflon"-cannula (V1ggo Vent lon 1. 7). This
short over-the-needle-cannula should be used
for initial venepuncture as in 1/3 of the
patients repeated insertians of the guidewires are required. If one uses a steelneedle, vein perforation and haematoma formation are likely to occur during guidewire manipulations.
3. Choosing the catheterization techn i gue. The seldinger technique- -using a
Fig. 3.3. Schematic representation of the insertian "J"-tip shape guide-wire (Fig.34) is
point (Brinkman) used for catheterization of the
strongly recommended. Such a guide wire
external jugular vein.
can negociate easier the obstacles to
actvancement of the catheter, eaused by
the vein valves and sinuousities (Fig.35 ) .
4. Distending the vein. The vein is
distended by asking the patient to perform
Valsalva's manoever, or by keeping the
lungs in inflation, applying a positiveend-expiratory-pressure (PEEP) of 5-10 cm
water on the expiratory circuit of the
anaesthetic rnachine (with the patient in
narcosis, and tracheally intubated). Al ternatively, a finger can be placed on
the lower portion (above the clavicle)
of the vein.

SOLO(R(O~

S'ltiNG GUlD(

t 4S a c

o} . . .

~'t

Fig. 34. Diagram of a "J"-guide-wire

A. , Ctheter 1n vein. B. Jwire .ld v~ctng put hrst obsttuction. C. J W'Ite


complet~y ins.erted. O. Catneter actvancng over J-W1re. E. C.theter completely
ac:tvanc.ct. J-w1re reti\Oited.

Fig . 35. shernatic representation: insertian of


a eve from the left external jugular vein with

5. Performing the venipuncture.It is


essential that the cannula should only be
advanced a few (2-3 cm) inta the vein. If
the cannula is inserted a full lenghth, th
tip may enter one of the small contributory veins of the :iistal part of the externa! jugular vein, a position which effect i
vely impedes a guide-wiro from reachi ng
the intrathoracic position.
6. Inserting the catheter.- When a
"J"-tip shaped guide-wire is used, the
rate of successul catheterization may
reach up-to 90%, or even more. However,
even \;hen using "J"-shaped guide-wires,
failures of placement occuc when it is
impossible to advance the catheter beyond
the clavicle (Fig.36). In such a situation, the following artifices of insertian
technique may help: i) The guide-wire,
after a futile attempt, must be retracted
full y before a new atteJ!IPt is made. ii )
r f the catheter stuck in the region of
the clavicle, or finds its way into a
superficial vein, this can be remedied
by pulling the arm distally and press i ng
on the catheter tip from the outside.
iii) Inserting the cath~~~ ~over the
guide-wire till the obstRCJ1r. Thereafter ,
the guide-wire is withdrawn approximately
l-cm, and the catheter with the guide-wire
in-place are advanced into the central
veins. By this artifices, the l-cm tip
segment of the catheter without guidewire functions like a thicker "J"-wire,
and may negociate an obstacle easier than
the "J" of the wire, particularly when
the obstacle is represented by a vein valv

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS


19)
i v ) Using the "hydraulic technique". the guide-wire
is withdrawn from the catheter, and the ca theter
is forcefully flushed with 20-ml isotonic saline and
concomitantly advanced inte the central venous system .

7. Radlological control of catheter tip location


is obligatorv after central venous insertians from the
extemal jugular veins.

IV. INDICATIONS

Schem.a t.i c re present a t ion of the e xt e rna ! juguhr


ve1.n i ndi c ating the site o f veni punctu re (ar r o~,) v here the
v ein erosses t he posteri or edge of the s t e rnoc l eidocustoid
aNs cle ( .acco rd i ng to Bur ri &. Ahne f e ld : ''The Cava l Catheter"
Springe r - Verhg . Se rlin- Heide lbe:t'g Ne v - Yo rk'' 197 8 pg . 2J ) ,

Fig. 36. Schematic representation of the


externa! vein. Note the arrows at the
clavicle indicating the place where
actvancement of the guide-wire and
catheter is impeded by anatomical
obstacles (valves, sinuousities,
anastornetic network,etc.)

l. No approachable basilic and cephalic veins.


2. High risk for cannulation of subclavian (obese
patients, respiratory insufficiency, etc.) or
intemal jugular vein ("bull-neck" , bleeding tendency) .
3. No experience with central venous catheterization via the subclavian and intemal jugular veins.
4. Children (particularly by cut-down). 5. Visible and
easily catheterizable extema l jugular veins (e.g. in
patients with heart insufficiency and incompetent valves in the externaljugular veins). 6. Insertian of a
soft, Port-A-Catheter.

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.

VI. ADV ANTAGES


1. No risk for severe, mechanical injuries to the neighbouring anatomical structures .
2. No. needs of expertise with insertion of central venous catheters (as, e.g. with the subclavian
and internaljugular vein approach).

VII . DISADVANTAGES (PROBLEMs- AND COMPLICATIONS)


1. Relatively low rates of successful, central locations of the catheter t~ depending on anatomy oLthe vein,operat.or's skill, and the type of the guide-wire used to -insert the
catheter : _i) straight guide-wire - 29 - 60%; ii) "J"-shaped tip guide-wire - 76-92% . 2. l!igh r_isk
of caheter tip malpositions. This is explained by tortuous vein course, particularly on the left
side (catheterization of the right extemal jttgula_r vein must be preferred). "') Jime-consuming_
and cumbersame insertion (e.g. use of the "J-"guie- wire, "hydraulic technique", etc:.). 4) Not. suitable for emergency conditions-. 5} Necessity to check the tip locaticn on thoracic radiogr/!Ph .

THE

INTERNAL JUGULAR VEIN

CATHETERIZATION

I. HISTORY
Goldstein (1949): first description of percutaneous approach to the intemal jugular
vein. English et al. (1969): percutaneous catheterization (lateral technique).

II. BASIC ANATOMY


The intemal jugular vein emerges from the base of the skull, posterior to the earot i d
artery, and is included in the earotid sheath . As it descends through the neck, it becomes lateral--ru~d fir~lly anterelateral--to the i ntemal and common earotid arteries. It is erossed superficially by the posterior belly of the digastric, and by the omohyoid muscle. Through most of
ist course, it is overlapped by the stemocleidomastoid muscle (Fig. 37).The nerves and vessels
to the stemocleidomastoid also cros s ~e vein . The vein ends behind the medial edge of the ciavieular head of the sternocleidomastoid muscle, just above the medial end of the clavicle. This
is the most important surface mar~ing . The vein is under the deep cervical fascia :. Tributaries

THE GOTHENBURG CVC-GROUP


20)

1:-o T . L t-X r C AilOTIO


Alt TE UII S

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 .

Fig . 37 . Schemati c ~ epr e s entation of the relat i ons


of the internal jugular vein with the stentocleidomastoid musc le and earot i d arteries.

from the anterior jugular vein pass


through the gap between the two heads
of the sternocleidomastoid muscle. The
thoracic duct on the left, and the
right lymphatic duct enter the confluence of the int emal jugular and subclavian vei n posteriorly.
e relationship of the sternocleidomastoid muscle, the earotid artery,
and the intemal jugular vein is variable
depending on the degree of the rotation of
the head. However, as they are contained
in the earotid sheath, the relationship
between the intemal jugular vein and the
earotid artery remains eonstant regardless
of the degree of rotation of the head.
The right intemal jugular vein and
the right innominate vein, and further the
superior caval vein are almost in a straight
line , while the homonymous veins on the l e f t
side have a "bayonett- shaped" form. Thus ,
the right intemal jugular vein must be prefered for insertian of central venous catheters.
-----The length of the vein is of approx.
15-cm (mean values), and its diameter of
approximately 10-mm at the oriein. and
15- 20 mm at termi nation. With the patient
doing Valsalva's manoever or inflated lungs
(e.g. PEEP of 10-cm water). the vein can
reach. a diameter exceeding 30-mm (Fig.38).

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!!!

2. Vei~roach: i) Cut-<iown, e.g. f or


inserting thick, soft catheters (e.g. PortA-Catheters made of soft sil:i.cone elastomer) .
The rein is approached 2 fingerbread.t hs above
the clavicle by a 4-6 cm long incision extending from the lateral margin of the sternocleidomastoid muscle (clavicular head) to the
ipsilatera sternoclavicular joint. ii) Percutaneous approach (most used). Presently,
there are more than 17 points described for
puncturing the intemal jugular vein (Fi g.39 ).
More important than the choice of a c ertain
point is the respect for the 3 following principles: a. performing the venipuncture along
the line extending from the mastoid process
to the ipsilateral sternoclavicular joint;
b) puncturing preferentially the right interna! jugular vein, and c) choosing a point
located at--or better above--the middle of
the neck, the distance between the puncture
Fi g . 38 . "Pull -out" - phlebograph of the right
site and the ipsilateral sternoclavicular
i nte rnal jugu lar vein p e ~ formed with the pabeing at
l east 6-cm. The reason is that
tient doing Va l sa l va 's manoever. Not e that the
the needle- i ntroducers used to perform the
diameter of the i nternal j ugular vein is 3.2 cm, veni
punc ture have lengths varying from 5
exceedi ng the di amet er of t he superior caval
to 6-cm. If the distance between the puncvein (The Gothenburg CVC-Group's resu)ts)
ture site and the homonymous sternoclavicular
_ioint is l e s s than 6-cm, there is always a risk for accidental puncture of the pleural dome,or
even of the lung . The pl eura l dome ext ends 1.0-2 .5 cm above the clavicle (Fig . 40), and even

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS


21)

more in emphysematous patients. The 3


following points are recommended:
- English-Takagi's point (the middle
of the line extending from the mastoid
process to the homonymous sternoclavicular
joint). This point should be used each time
when the earotid artery is clearly palpable.
- Brinkman's point (where the extemal
jugular vein meets the dorsolateral edge of
the sternocleidomastoid muscle). This point
is recommended in the cases where the earotid
artery ~an.not be clearly palpated,as in the
patients with pathological obesity, and in
those with a "bull-neck".
- Conso's point (located on the dorsal
margin of the sternocleidomastoid muscle,
at the level of mandible angle). This point
is used when attempts to venipuncture at the
previously mentioned points resulted in accidental punctures of earotid artery and formation of haematoma in the neck.
3. Ask the patient to perform Valsalva's
manoever for a little while (if the patient
can co-operate), or set a PEEP of 5-10 cm H Q
2
Fig. 39. Schematic representation of the points on the intubated patients. These manoevers
increase
the
intrathoracal
pressure,
and
thereb)
used for puncturing of the intemal jugular vein
the pressure in the great (central) veins, and
(The Gothenburg CVC- Group's results)
the internal jugular vein may reach a diameter
exceeding 3-cm (see the figure 38)). Under
these circumstances, the intemal jugular vein
often becomes palpable along the line extending from the mastoid process to the ipsilatera l
sternoclavicular joint, and location of the
puncture site, and the punctur~ of the vein are
made easier.
4. Performing the "pre-venepuncture".
(This step is not necessary if the operator
has experience with the intemal jugular
venipuncture). The "pre-venipuncture", or
"test-puncture", is executed with a fine,
0.7 mm OD needle, S-0 cm long, provi ded with
short bevel (e.g. black TerumoR-needle). The
needle is coP~ected to a 2-ml disposable,
plastic, syringe containing 1-ml sterile, isotonic saline: During the "pre-venepuncture" the
patient performs Valsava's manoever as above
(altematively PEEP is being applied). The
"pre-venepuncture" is performed under continuou:
aspiration. 'lhe patient is "!.sked to breathe
normally (altematively the PEEP is released)
:.mmediately after dark, venous blood has be_en
Lobua . d_orl(.l(audall a- - -.
aspirated into the syringe. The me4ning of the
"pre-venepunc:ture" is to localise the intemal
~ar veig and its depth under the skin (usually ranging from l to 5-cm) depending on
patient's constitution. Longer distances are
encountered only in patients with pathologic
Slaua phreniOOC06talia __
obesity. Another meaning is to avoid an acci dental puncture of the earotid or vertebral
arteries with the introducers, or vein dilators
having diameters varying from 1.7 to more than
3.0-mm. Only exceptionally accidental punctures
of the arter i es with fine (0.7 mm OD) needle s
had severe consequences (hemiplegia). However ,
seve re compiications, arterlovenous fistulas
and hemiplegia,were reported after accidental
arterial punctures with the needle-introducers
having a bore larger than 2-mm . During the vene
puncture, the tip of the needle should be
Fig. 40. Digram showing the projection of the pleural dome directed towards the ipsilateral sterno(right side, lateral view) above the c lavicle (arrow). Ac - clavicular joint. If the operator is uncording to Merkel' Topographische Anatomie, Bd.II,l899.
experienced-, an assistant may put his

THE GOTHENBURG CVC-GROUP


22)

forefinger on patient's skin, on the spot projecting the isgilateral sternoclavicular


joint. The venipuncture is performed under an angle of 30-40 , its value depending on
the neck thickness (the thicker the neck, the larger the angle).
5. Choosing the insertian technigue. We prefer the seldinger technique. This technique
offers the possibility to use relatively smaller introducers (the outer diameter smaller,
or equal with the catheter outer diameter). Thereby, occurrence of severe complications
after accidental punctures of carotid/vertebral arteries, and nerves might be reduced (see
the preeectent paragraph).
6) Choosing the catheter: i) Stiff iTeflonR1 catP-eter may be accepted only for cannulation of right intemal jugular vein, only in emergency situations, and only for ~
rary use (the stiff, Teflon catheter must be exchanged with ~ softer one immediately the
condition of the patient pennits it). The stiff, TeflonR catheters must never be used for
central venous catheterization from the left intemal jugular vein (high risk for perforation of the superior caval vein, or even of the ~ight atrium, and heart tamponade).
ii) Soft catheters (silicone elastomer, and particularly polyurethane) must be preferred.
6. Performing the venepuncture. When a "pre-venepuncture" was performed, the operator
is informed about the vein location and depth from the skin surface. The venepuncture includes
the following steps: i) Connecting a 2-ml disposable syringe filed with 1-ml isotonic sa1ine
to the introducing needle (preferably a Teflon-sheath, e.g. Venflon 1.7 mm O.D.). ii) Performing the venepuncture in the same point as during the "pre-venepuncture"_. with patient 1 s neck
i~ the unchanged position.The tip of the needle-introducer .perforates only the skin.iii) Directing the needle to~ards the ipsilateral sternoclavicular joint and verifing the angle between
the shaf~ of the introducer-needle and patient's skin. iv). Asking the patient to perform
Valsalva's manoever(altematively 5-10 cm PEEP is applied on the intubated patients). v) Advancing the needle under continous aspiration. When the needle has penetrated the vein wall,
dark (i.e. venous) blood is aspirated into -the syringe (even if the patient is ventilated
with a gas mixtur~ containing 40% oxygen). Then, the needle is advanced 1-2 mm. Therebv the
tip of the Tef1onR (over-the-needle) cannula may enter the vein. vi) Pushing tne TeflonR-cannul a
into the vein lumen according to the usual technique, and asking the patient to breath normally.
vij) Verifying by aspiration if free in-and backflow through the cannula exists (in rare situatio~s the cannula may be kinked--particularly when Tef1on-cannulas longerthan 5-cm are used).
7. Introducing the guide-wire (when the seldinger technique is used). The guide-wire
should not be introduced more than l-cm below the ipsilateral sternoclavicular joint to avoid
the soft tip of the wire, the diameter of which is usually of approx. 0.9-mm, entering one
of the ostia of the small mediastina1 veins (usually the right mammary vein, or azygous vein),
and eausing malposition of the catheter tip. The guide-wire must not encounter any resistance
during i ts actvancement in to the veins. Keep the gulde-wire at hand on sterile cloths.
8. Estimating the distance from the insertion point to the superior _s:aval vein, or
right atrium. The distance from the insertian site to 2-cm above the 3rd, righ~, eostal
cartilage (lower part of the superior caval vein), or 2-cm below it (right ~trium) is
measured along the vein course with a disposable metric tape (Viggo's ~e1ay -catheters),
or JJSing the plastic styllets of the catheters (e.g. with Triplus Fretex -catheters), or
even the catheters sel ves. Routine1y inserted lengths: 15-cm on the right, and 18 0!'! H'!e le f!: _
9. Inserting the measured/estimated (wanted) length of catheter. During L~e insertion
of the_, re1atively soft polyurethane ca theters, their rotation and concomitant actvancement
facilitate penetration of the skin ru1d vein wall. After the tip _has passed the vein wall
(usually after 1-4 cm),no resistance oppesing actvancement of the catheter must ~e encountered.
lO. Withdrawing the guiding-wire from the catheter. During this manipulation~ the operator
gently ho1ds the catheter between the great and forefinger, and the hub of the catheter is
situated under the harizontal plane passing through the right atrium (the midaxillary line).
11, Checking catheter patency with a syringe containing isotonic saline. If free, in-and
backflow is obtained from the catheter, with no treJ?idations of the catheter orLand as11iration
of air-bubb1esl the catheter is patent, and correctly located in the central venous system.
12. Fastening the catheter to the skin. We strongly r~commend to fix ~e catheter to
patient's skin by 2 monafilament sutures(e.g . Dermalon-00 , or Novafil-00 ). The sutures
should be applied on silicone or rubber cuffs, and the knots must be performed with the
fingers (not with the needle-holder) to knot sufficiently hard--neither too hard, nor too
loose--to avoid catheter occlusion and its accidental withdrawal.
13. Checking once again catheter patency after fixation (see above - parag~aph 11th)
14. Radiological control of tip location. a) Catheter inserted via the left intemal
jugular vein: the tip location will be always ~hecked on a frontal thoracic radiograph,
or by C-arm fluoroscopy. This recommendation is based on our experience that the insertian of the catheter from the left interna! jugular vein is trouble-free in only 35% of
the cases. Thus, there is always a risk for catheter tip malposition (in the small mediastina! veins, opposite innominate, suBclavian, ~xillary, and even intemal jugular veins),
curling, or even knotting of the catheters. b) Catheter inserted from the right intemal
jugul~r vein: the radiologicaf control is not necessary in more than 99% of the cases provided that the following requirements are satisfied: i) the venepuncture was performed at
least 6-cm above the sternoclavicular joint; ii) the needle/introducer had a length of
maximum 5-cm; iii) the guide-wire and/or the catheter were inserted 15-cm into the vein;

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS

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).

VI. AJJV ANTAGES


l) Suitable during "on-going" surgery. - 2) Consistent anatomical location,
thereby relatively easy percutaneous puncture. - 3) Suitable in emergency conditions, e.g.
cardiac arrest, areas other than the operating room. 4) Suitable for insertian of pulmonary (Swan-Ganz) catheters, particularly from the right intemal jugular vein. 5) High rates
of intrathoracic catheter placements reaching up-to 91-100% with the right, and 80-94% with
the left internal jugular vein. 6) Radiological control is not necessary with the right internal jugular vein approach. 7) Absence of severe complications if correct insertian technigue
(see above) is used.

VII. DISADVANTAGES (PROBLEMS AND COMPLICATIONS)


l) ACCIDENTAL PUNCTURES OF THE NEIGHBOURING STRUCTURES:
a) earotid and vertebral arteries (0-12%) followed in exceptional cases by:
i) haematoma formation in the neck, possib.ly eausing respiratory obstruction; ii) arteriovenous fistulas; iii) occlusion of the ear otid arteries (thrombus, displacement of an atheromatous placque) and subseguent hemiplegia (in older subjects); iv) inadvertent, arterial .
catheterization (likely to occur in conditions of hypoxemia and low blood-pressure). This
complications may be avoided using a "finder-needle-technique" ("pre-venepuncture") rather
the "catheter-over-needle" technique for finding the intemal jugular vein.
b) Vein laceration followed by: i) haemothorax; ii) haemomediastinum; iii)
heart tamponade; iv) venobronchial fistulas eausing venous air- embolism. These camplicatians can be prevented using the "finder-needle" technique, small introducers (Seldinger
technique), and soft catheters, using preferentially catheterization from the right interna! jugular vein.
c) Nerve injuries : i) Cranial ne rves (IX, X, XI, and XII); ii) Spinal nerves
(roats and branches of the brachial and cervical plexus); iii) stellatum -with subsequent
Claude Bernard-Horner syndrome; iv) Phrenicus nerve wit subsequent diaphragma paralysis.
d) Injuries to othe r organs: i) Lung an pl eural dome (may be avoided performing the venepuncture at,or above the middle of the neck with 5-cm long introducers) followed by pneumothorax (0 - 2%); ii) Tracheal puncture and puncture of the cuff of an intratracheal tube followed by subcutaneous and medias tinal emphysema. iii) Thyroid gland;
iv) Thoracic duct with subsequent chylothorax .
2) MALPOSIONS
a) Right interna! jugular: exceptional, in the homonymous subclavian vein

THE GOTHENBURG eve-GROUP

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.

II. BASIC ANATOMY


The subclavian vein continues the axillary vein, and extends from the outer
border of tne first rib to the medial border of scalenus anterior, where ~t un~tes w~th
the intemal jugular vein to form the brachiocephalic (~nnom~nate) vein {Figs. 41-42).

Fig. 41. Diagram: right subclavian vein


course from the clavicle to the sterno ~
clavicular joint.

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.

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS


25)

The subclavian vein in adults is approx.3-5 cm


long, and 1-2 cm in diameter. However, the diameter may increase to 2.5-3.0 cm with the patient
doing Valsalva's manoever.
Surface projection. The subclavian vein can
be represented by a broad line convex upwards,
from a point just medial to the mid-clavicular
point to the medial edge of the clavicular
attachement of the sternocleidomastoid muscle .

Ant scalene m

'"""""_"V . .

Srernocledomostotd m .
C,sro-=too~culor-scolene

fl

Cl.l11iclr

m.

Fig. 43-a. Costoclavicular scalene trianle


(Schematic lateral view on the left side).
Note that the vein ~s separated from the
artery by approx. 1.5-cm.

Fig. 43-b. Costoclavicular scalene triangle


(Schematic lateral view on the right side).
Note that the subclavian vein is separated
from the subclavian artery by the scalene
anterior musCle. The clavicle is located in
front of the vein,and the first rib under it .
(According to Mcintosh - "Local Analgesia
Brachial Plexus - Livingstone Ltd. Edts.).

The distance from the skin to the vein is


2-5 cm in normal subjects, reaching 6-8 cm in
the obese ones, or women with large breasts.
Differences between the right and left subclavian veins. l) The right subclavian vein.
In supine position, with the arm at side, the
majority of the right subclavian veins passes
beneath the clavicle, close to the junction of
the inner and medial thirds of the bone. In
approx. 70% of cases, the vein passes beneath,
but_ did not extend above the clavicle. In approx.
30% of cases, the subclavian vein continues
above the clavicle. The subclavian/internal vein
junction forms an angle of approximately 90.
2) The left subclavian vein passes posterior
to the clavicle nea.r the junction of the inner
and seeond guarter of the bone in the majority
Fig.44. Costoclavicular scalene triangle.
of patients. This is a more media1 relationship
Right, retroclavicular structures with
needle in axillary and subclavian veins.
than that existing on the right side. Abduction
or elevation ("shrugging") of the arm modifies
The middle segment of the clavicle is
the relationshp between the clavicle and the
removed. (According to Moosman,l973)
vein: the vein assumes a more eaudal and medial
relatjonship to the clavicle, with less of the yein occupying a retroclavicular position. In some
cases, a vein which is in the path of the needle when the arm is at the side, is not in its path
when the arm is abducted, or the shoulder is elevated. Rotation of the head to the controlateral
side does not alter the vein-clavicle relationship. The subclavian/internal jugular junction
forms an ang~e of approximately 45 (Fig. 45).

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)

III. CATHETERIZATION TECHNIQUE


l) Patient's positio~. Trendelenburg (20-30), with a cushion under shoulder,
and the head and neck turned 30-45 towards the opposite side. The arm on the catheterization
side is at the side. An assistant grips patient's hand and pulls it downwards.
2) Vein approach: a) Cut- down above the clavicle (as for the intemal jugular
vein). b) Percutaneous approach: 4 poi nts (2 supra-and 2 infraclavicular) were described (Fig . 46)

H AAPAN IEMI - 197 4

1965 -

AUBAGNlA G -

_Aubagniac 's point is located between the


inner. and middle third of the clavicle and the
first rib. This point should be preferred for
insertion of single-lumen catheters. Advantages:
i) substantially higher rate {up-to 95%) ofsuccessful venipuncture at the first attempt; ii )
significantly lower risk for accidental injury
to the subclavian artery, brachial plexus cords ,
pleura , lung, ductus thoracicus, stellaturr., et c.
Disadvantages : i) higher risk (up-to 13%) of
catheter tip malposition in the ipsilateral jugular vein; i i) sometimes difficult thread i ng
of the catheter through the costoclavicular
ligament; iii) thus, the Aubagniac's point is
not suitable for insertian of large-bore catheters, usually necessitating Desilets' technique
(e.g . double- or multi-lumina catheters, dialys is
catheter, or Port- A-Catheters); iv) higher risk
for "pinching" of the catheters (particularly of
the soft, large -bore ones), and their occlusion,
between the clavicle and the first rib (Fig.48).

The sup t"acLavicu l at" .~o nd i n fraclavicul.ar "chssical" points


used f or the cathetet'iu.tion of the subc:bvian ve in*)

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

At tht tl.M. of c~ t heter l n s ert i on , the cl~v icular


flrst ri b ~ng le is v ide, and t he c.atheter c an pa ss i t aedid
t o t he ~ei n be:foC'e e nte r i n& t he s ubclav ian vei n (left ). In
the up n gh t position, the angle n~-rrovs and pinc es t he Ded i~~! r oositioned cat hete r ( righ t). Ac cord i na to Altke n e t .a l.

D emonstra tion of the an ~: l e ol the


nr.."dle durinc insertion. Cross sectioa of the sur-

round ini uructwes U sho""""


Di.t gr am illustrati ng the h l g her t'hk of .1.ccidental
i njuries t o pl eura a nd s ubc:lavian artery with '(off a ' s punct.
To avo id t he ris K, a very dafl ned a ngl e (un{ot'tunately s ub111itte d to h.rae i ndl vidua l vadations) is reconoended. Accocdina to Ja-as HP, Hyers TR . Ce ntra l press ure IDOnitoring : rslsln t erp C'e t ~ t ion , ~ buses, i ndlc~ t ions, a nd ~ nev technique . Ann
~-

l 977' lll '69)- 70l .

Fi g. 47

Wilson's point is located between the middl e


of the clavicle and the first rib, thus more
lateral than the Aubagniac'c point. Advantages :
i) lowe r ris k for "pi:lching" of the sof t, and
rPlative l y large catheters (particularly in the
uppri ght pos i t i on) than with the Aubagniac's
point; ii ) a dvantageous for insertian of largebore, mul tilumina and dial_ys catheters becaus e
of targer spac e between the clavicle and the 1-s
rib than at the Aubagniac's point; iii) lower
risk for malpositi on of the catheter tip in the
ipsilateral internal jugular vein. Disadvanatges

,. CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS


27)

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%) .

. Fig. 49. Diagram illustrating the relation of


the subclavian vein at the Wilson's point
(base of the triangle) and Aubagniac's point
(the apex of the triangle). According to Borja
& Hinsaw ( 1970).
3. Choosing the side. a) Left subclavian.
Advantages: lower risk for catheter malposition in the ipsilateral intemal jugular vein
because the left inneroinate vein continues the
subclavian vein in a rather obtuse (approx.140)
angle (see figure 4S-B). Disadvantages: i)
~ore dif~icult venipuncture (only 7S% successful puncture at the 1st attempt, vs. approx.
9S% on the right side); ii) higher risk of tip
malpositions in the opposite inneroinate vein
and the small, left mediastinat veins), and
iii) higher risk of perforation of the right
wall of the superior caval vein when stiff,
or large-bore (e.g. dialysis) catheters are
used (because the left inneroinate vein meets
the superior caval vein at a nearly straight
angle whilst on the right side the superior
caval vein continues_ the right inneroinate vein
in a straight direction). b) Right subclavian
vein. Advantages: i) Higher rate of successful
venipuncture at the 1st attempt (9S% vs 75%)
because of a - more eonstant anatomy; ii) no
risk for injury to the superior cava1 vein
with soft tip guide-wires or/and soft catheters; iii) lower risk of catheter tip malpositions in the small mediastinal veins. Disadvantages: i) higher risk (approx. 13%)-of
tip malpositions in the right intemal jugular vein (see fig. 4S-B).
4. Choosing the technigue. We strongly
recommend the seldinger technigue permitting a substantially less traumatic insertian and catheterization with soft polyurethane catheters.
S. Choosing the introducer. We recommend a s-cm long introducer, approx. 2-mm
diameter (Venflon-200). If longer introducers are needed, i t is bet ter to renoJIDf_e creff'
to catheterization via the subclavian vein.
The introducer (needle and TeflonR-sheath)
is bent over its entiTe length to an are of
approx. 30. This recommendation is based on
an anatomical finding: the subclavian vein
is usually ocated dorsal to the clavicle, not

Fig. so. Diagram: puncture of the right


subclavian vein with a needle bent at 30
over its entire lenghth (According to
Asimacopoulos et al., 1980).
under the clavicle , as it is commonly
thought. Therefore, in order to pass the
tip of a standard straight introducing._, . ..,.,.._
needle dorsal to the clavicle, the hub of
the needle must often be depressed into
the anterior part of the chest wall. In the
obese, women with large breasts, uncooperative, or poorly positioned patient, the
tip of the needle may pass inferior to the
vein, injuring the pleura, or subclavian
artery. When the curved needle is used,
without using any special positioning of
the patient, ~t is placed at 4S 0 to the
presurned course of the subclavian vein at the
inner ene-third of the clavicle (Aubagniac's
point). Passing just to the costoclavicular
ligament, the needle follows its 30 are,
entering the vein as it lies dorsal to the
clavicle. Thus, the problem of a straight,
standard needle-introducer passing inferior
to the vein is avoided, and the hand of the
operator and the hub of the needle are well
clear of the patient's shoulder and chest
wall (breasts, in women). Should the needle
not enter the vein, its curve will carry in
harmlessly inte the suprasternal fossa and
away from the pleura or subclavian artery. _
6. Choosing the catheter. We strongly
recommend soft, polyurethane catheters, developed to be inserted by the seldinger technique, 20-cm long (e.g. Viggo's SeldyCatheters-200 mm). STIFF ~ TEFLON-CATHETERS

THE GOTHENBURG eve-GROUP


28)

MUST NOT BE USED!!!! ... The stiff catheters


can not follow the curvatures of the subclavian vein, and may cause perforation of
the central veins, with subsequent haemohydromedistinum, particularly with the cathethers inserted from the left. The 20-25
cm-long catheters have the following
A)
advantages: i) they are suitable for
catheterization of the all adult patients;
ii) their fixation is easier than with
longer catheters.
7. Performing the venepuncture. Steps:
i) Local anaesthesia: the ehosen point
(Wilson, Aubagniac) is infiltrated with a
B)
solution of local anaesthetic, e.g.
0.5% Carbocaine. An anaesthetic solution
containing epinephrine (5 microgram/ml) is
used in patients with bleeding tendency
" '"
(leukemia with thrombocytopenia), but not
is those with high blood pressure (risk for
in
lung oedema). The infiLtration is performed
/.
"'
with a very fine, 3-cm long needle. Only
Gui d - '"~'
the skin and subcutaneous tissue will be
C)
infiltrated with 3-5 ml of anaesthetic
solution. ii) "Pre-venepuncture" to inves\ . Too-lonv lntroducer eausing lnjury to the
tigate vein location and depth in relation
subcl.l.vian artery;B IClnk.ing o f a too long sheath durin&
to the skin MUST NOT BE PERFORMED. The
lts advanc~nt i nto the s ubclavian vein, .akin& i a.pos s lreason is the risk for accidental puncture
ble thnad i ng of the auide - vire ; C. A too long s hath
advanc ed i nto the internal juguhr ve i n causin& Dalpos iof pleura and lung with the fine, longer
tion o f the cu i de - v l ce .
needle (e.g. TerumoR, 5-cm long, 0.7-mm
OD) and occurrence of later (after 3-4
days) pneumothor~. iii)eonnecting the
needle to a 2-ml disposable syringe filled
Fig. 51. Diagram: schematic representation
with 1-ml isotonic saline. iv) Directing
of the complications possibly occurring when
the needle: the tip of the needle is directoo long introducers are used, or when the
tea towards the base of the Dessillot's
introducer-cannula is too much advanced into
triangle formed by the clavicle (base of
the subclavian vein (The Gothenburg eve-Group's
the triangle)and the heads of the sternounpublished results)
cleidomastoid muscle (the sides). Thus, the
plunger of the syringe is in linewith the , ~ ~
8. Inserting the guide-wir ( Seldinger
axil ry fold (on the left side),and level ~
technigue). Steps: i) RotatnPg(the patient's
"ilt'e-t point where the eaudal third joins the
head and neck to the side of insertion and
middle third of the line extending from J
lifting maximally the shoulder on the insertion
the axillary fold to the acromion (on the
sideJ (Fig. 52-A) was recommended to avoid malright slde). The angle between the skin -position of the guide-wire (or catheter) in the
and needle is of approximately 45o. _,
ipsilateral intemal jugular veiP (Fig.S2 7~).
v)Venipuncture is performed with the
introducer curved at 30,connected to the
2-ml syringe, under continuous aspiration.
The needle-introducer must not be inserted
more than l-cm behind the posterior margin
of the clavicle (to avoid accidental punctures of the dorsal wall of the subclavian
vein and its laceration, subclavian artery,
pleural dome, lung, thoracic duct, stellatum,
p lexus brachialis cords) . Measurement of the
distance from the insertion point to l-cm
behind the clavicle with the introducer, performed before the attempt to venipuncture, is
strongly recommended to the beginners. When
dark,venous blood is aspirated into the syringe (2-4 cm from the skin), the introducer
is advanced further 2-3 mm (the tip of the
Patlent vith the nec k and head turned to the si.te
TeflonR-sheath may laying outside the vein
ot i nse ['ti on . The c atheter tip ls c orrec tly located l n the
[' i ght ~tdua (Curelaru t. e t al.. unpublished nsults) .
lumen, in spite of the fact that blood has
been asplLated into the syringe). Then the
TeflonR-sheath is advanced further approx.
Fig. 52-A. According to Fischer et al.,l97 7,
l-cm into the vein (if the cannul~ is adand the Gothenburg's eve-Group (unpublished
vnced the whole its length, or if it is
results).
too long, the sheath may kink--making insertian of the guide-wire/catheter impossible-Thereby, one changes (decreases) the angle foror harbour in the ipislateral intemal jugumed by the homonymous subclavian and intemal
lar vein eausing malposition of the guidejugular veins, and the guide-wire, or/and cathewire/catheter (Fig. 51-B,e.).
ter, have a greater chance to harbour in a corre

-~-/-~~--\- - ...
/

.....

\ \,,_,_to

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS


29)

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.

THE GOTHENBURG CVC-GROUP


30)

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.

(According to Waxman & Polglase,l981)

test is 100% worth of confidence if the


ausculation. is made with the patient in apnoe;
iii) rising of the venous pres suure bv approx.
10-cm H?O (~l kPa) when compression is applied

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

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS


31)

system, leaving the "heparin-lock", etc.


2) For tunnelled catheters (the tunnel
is shorter and easier to construct than
with the externa! and intemal jugular
catheter when the tunnel must be passed
over the prominence of the clavicle).
3) Very suitable for insertion of dialysis and multi-lumina catheters.

VI. ADV ANTAGES

l) The subclavian vein is always an open


vein because its walls are held apart by a
prolongation of coracocl~vipectoral fa~cia. ~us,
the subclavian approach 1s successful 1n pat1ents
with chock and hypovolemia, whilst--for instance-the intemal jugular is often unsucessful because
of collapsed vein.
.
.
.
2) An occlusive dress1ng can be eas1er ma1nV. CONTRAINDICATIONS
tained and changed than that of an intemal jugular line particularly in men. Thus, the risk of
catheter~related infections and sepsis is apparen1. In patients in whom high risk for
tly lower with the subclavian than with the interoccurrence of accidental pneumothorax
nal jugular CVC.
.
exists, e.g. : athma,bullous e~hysema,
3) The subclavian catheter eauses l~ss pa1n,
women with large breasts extend1ng to the
and thus is more comfortable for the pat1ent than
clavicle, pathologic obesity, etc.
is an intemal jugular venous catheter in the
2. Patients with severe chest trauma(?). neck area.
This contraindication is disputable. One ar4) Lower risk for accidental arterial puncgument is that subclavian venepuncture might
ture when compared to percutaneous approach to
generate further respiratory complications,
intemal jugular vein (l% vs up-to 10-15%).
e:g. in a patient having a ~emothorax, and
5) Shorter tunnel course than with the tunnelthe needle entered the pleural dome. Blood
led cvc from the externa! or intemal jugular
then aspirated from the pleural cavity may
veins.
be roistaken for venous blood. If the catheter
is inserted into the pleural cavity through
VII. DISADVANTAGES (PROBLEMS AND
a miplaced needle, intende~ intravenous ~luids
will enter the pleural cav1ty. In our op1SPECIFIC COMPLICATIONS
nion, this argumentation is right only in
patients in whom the paemot~orax was eaused
l) High risk of malpositio~ of cathe~er tip _
in the ipsilateral intemal 1ugular ve1n.The
by an injury to the subclav1~ ves~els. In
our experience, we preferent1ally 1nsert~
tip may harbour into the inte~l jugular vein
subclavian cantheter in patients with severe
during the insertion, or can ~1~rate from the
chest trauma via the subclavian vein on the
superior vena cava (a soft, s1hcone catheter)
affected side.
with vigorous activity, coughing, sneezing, etc,
3. Fracture of clavicle with potential
i.e. with an abrupt increase of . the cent~a~
or evident injury to the subclavian vessels,
venous pressure. The cate~er ~y.be repo~1t1oned
and haematoma at the base of the neck or/and
into the central veins us1ng cl1n1cal man1pulainfraclavicular region.
.
.
tions (Figs. 56-57), and the correct relocation
4. Presence of tracheostomy (h1gher r1sk
of the tip can be recognised by only clinical
of catheter-related infections and sepsis).
signs (Fig. 58).
In patients with this condition, ~e CVC should
2) Higher risk of pneumothorax occ~rence
be preferentially insert~d by the 1nte~l
(3-10% in the departments of anaesthes1a, and
jugular vein (Conso's po1nt). Alternat1vely,
up-to 30% in the departments of cardiology vs
the subclavian catheter must be tunnelled
>l% with the intemal jugular catheterizaticn
10-15 cm from the insertion site.
from--or above--the middle of the neck).
5. In patients with coagulopaties (?).
This contraindication is also disputable: one
3) Higher risk for injury to the thoracic -
believes that if the needle-introducer transduct (0.08% vs. only l observation- reported
verses the subclavian vessels and pleural dome,
to-date .,ith the intemal jugular approach).
the eonstant oozing of blood into pleural cavity Predisposing factors: left (particular~y)
can be stopped only by correcting the coa~l~
supraclavicular venepuncture; patholo~1c conpathy. However, this_ is a ve~ seldom p~SS1b1ditions eausing enlargement of--and h1gh
lity comparatively w1th the r1sk of acc1dent~l
pressure in--the thoracic_duct e.g. wi~
puncture of the earotid arterr (up-to l~%) w1th
insertion of left subclav1an catheters 1n
the approach to the internal .Jugular v~1n.
patients with lung cancer, lymphoma, throm6. A supraclavicular ven1puncture 1n the
bosis of the superior caval vein, aortic
left side should be avoided in cirrhotic paaneurysma, tuberculosis, lever c~r~ho~is,
tients because the thoracic duct is enlarged
thoracic injury, crush or blast 1nJur1es,
and thus likely to be punctured inadvertently.
rib or verterbral fractures, sudden compresIn some of these patients, the pressure on the
s.ion of the thoracic cage (as in cardiopulmoduct is higher than the venous pressure, and a
nary ressusscitation), after a heavy mea~,
significant lymphorrhagia may occur through the
etc. Diagnosis: i) Externa! seepage of m1lky,
puncture site.
.
nonoderus fluid (lymph) out along the cathe7. When the superiorvena caval system 1s
ter tract; Li) Ve.ry se.ldom, aspiration of idenunapproachable, e.g. me~iastinal tum~urs comtical fluid during the attempt to venipuncpressing the central v~1ns, thrombos1s of the
ture (personal observation); iii) chylothorax
great intrathoracal ve1ns, etc.

THE GOTHENBURG CVC-GROUP

.32)

1. Wichdraw unit onchalr athctcr lcn"h tO ccntimctcn.


cnsu~ intraYCnouS communiatioa.
.
) . The guide wire is s&owly passed throu:gh the cathctcr. The bad 11 turned
toward the ipsilatcral side, arrow.
<4. The cathctcr is advanccd ovc.r the wire.

2. Aspinte blood to

Fig. 56. Schematic representation: reposition of a misplaced subclavian


catheter (according to Gatti & Mullen, 1981)

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.

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS


33)

multi-lumina catheters. The catheters


should be withdrawn and inserted via other
(e.g. internal jugular) vein.

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 .

Fig. 58. Accordlng to Waxman & Polglase, 1981


when the same needle has transversed the thoracic
duct and pleural dome; iv) Formation of fibrinous
strings under the dressing (differentiating the
lymph from the infusion fluid, e.g. IntralipidR);
v) Thoracic radiograph demonstrating the chylo-
thorax; vi) Thoracocentes giving milky, nonoderus
fluid. Treatment: i) Keeping the dressing dry
(the lymphorrhagia may increase the risk of
sepsis - lymph enhances the growth of the bacteria even better than solutions of parenteral
nutrition); ii) Application of local pressure
(sand sack) for 30-60 minutes associated with
elevation of the head of the bed , after withdrawal of the catheter, may sto~ the lymphorrhagia; iii) pleural drainage when chylothorax
was formed; iv) rotal parenteral nutrition to
compensate for long-term losses of the lymph,
and occurrence of subsequent malnutrition; v)
positive-end-expi~atory-pressure ventilation
might seal a thoracic duct agair,st the pleura
(Kurtz & Hsu, 1980); vi) Throracotomy for surgical ligatian of the thoracic duct has been
performed after failu~e of the conservative
treatment to stop" the lymphorrhagia,14-28 days
after injury to the duct, and average daily chyle
loss of 1,500 ml (adult) or 100 ml/year of age
(children).
4) "Pinching" of the catheter, and its occlusion. Predisposing factors: i) elevated rib
surfaces (Fig. 59); ii) Soft, large-bore, and

HISTORY

Used extensively during the Korea


Vietnam wars. Reactualized by Swanson et al.,
1984, and Dailey, 1983-1985.

II. BASIC ANATOMY


The femoral vein arises deep in the
tigh, and becomes relatively superficial as
it erosses the inguinal (Poupart's) ligament.
(Fig.60) . Thereafter, the vein dives deep into

INGUINAL
LIGAMENT

Femoral vein anatomy.

Fig. 60. Anatomy of the femoral vein


(according to Dailey, 1985).

Ist rib im~nging on subclavian vein.


................. ..

the pelvis as the external iliac vein. Below


the inguinal ligament, it lies consistently
medial to the femoral artery and the femoral
nerve. Above the inguinal ligament, the vein
erosses beneath the femoral artery, and joins
the inferior caval vein to the right of aorta.
The anatomy of the femoral vein is relatively
eonstant and predictible. The femoral vein is
quite large, having a diameter of 12-16 mm .
Performance of Valsalva maneuver has been shown
to increase the width of the vein by one third ,
and nearly doubles its cross-sectional area.

III. INSERTION TECHNIQUES


l. Vein approach: i) Cut-down: practical l y
not used. 2) Percutaneous approach is almost
the only one used today.
2 . Choosing the vein. The right femoral

THE GOTHENBURG eve-GROUP


34)

leg slightly rotated laterally.


4. Landmarks. The femoral pulse is an extremly useful landmark for locating the femoral
vein in patients with demonstrable pulse. In
the pulseless patlents, cannulation of the femoral ve in is "blind", and the location of the
vein must be related to contiguous bony prommi~

s. Preparation~ careful scrubbing of the


inguinal region (Hibiscrub-sponge) and its
throughly washing with O.S% chlorhexidine in
70% alechol for at least l minute. Ihereafter,
the site is drapped with sterile, surgical
clothes fastened to the skin with self-adhesive
surgical tapes (thi3 preeautian ls necessary to
avoid centamination of the catheter with bacteria from genitalia and anus).
6. Venipuncture (steps). i) Local anaesthesia of the puncture site; ii) The patient
perform Valsalva maneuver whilst the operator
does the venipuncture (in the intubated
patients - PEEP of 10-cm water is applied);
iii) Puncture at the midpoint of the junction
of the medial and middle thirds of a straight
line drawn between the anterior superior iliac
spine and the pubic tubercle (Fig.61); iv) A
~-- - - --

_;_ ' ;~
~-:_ ~
\ '.
' /~y: ;,.,.,~.~
\Nffoooosuo .

""''"''"'

- -~- c-

- -'' . \

----------

Fig. 61. The landmarks (bony prominences)


used during the cannulation of the femoral
vein (according to Dailey, 198S).

needle~sheath (IeflonR) introducer,6-cm long,

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).

CENTRAL VENOUS CATIIETERIZATION - CLINICAL ASPECTS


35)

2. Absolute:i)burns, infection, ganglionary


mass, and femoral hernia in the groin; ii) peritonitis, increased intra-abdominal pressure, blockage or injury of the inferior vena cava.

VI. ADVANTAGES

I. INTRA/EXTRA _THORACAL VEINS


l) Azygos and accessorv hemiazygos
veins. The veins were approached after
thoracothomy. Indications: thrombosis
of both the superior and inferior caval
veins (Figs. 62-63).

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).

VII. DISADVANTAGES (PROBLEMS AND


COMPLICATIONS)
l. Not-suitable for measurement of central
venous pressure. The venous p~essure in the inierior vena cava normally is l to s-cm H2o higher
than the right atrial pressure, but with increased
intra- abdominal pressure the difference is proportionately greater.
2. Higher risk for post-operative bleeding at
the insertion site (see above)
3.Higher risk for thrombosis occurrence (20%,
if the duration of catheterization exceeds 72 hours).
This is explained by: i) higher venous pressure than
Fig. 62. Transthoracal central venous
in the superior caval vein, i.e. a certain degree
cannulation through the azygous vein
of stasis; ii) when the tip of a catheter reaches a
(according to Malt & Kempster, 1983)
point that is against the blood flow, the height of
intravenous fluid or the pressure of the infusion
pump and speed of infusion forces the infused fluids
some distance against the blood flow; if hypertonic
and/or irritant (low pH) are administered for a
longer time, venous thrombosis may result.
4. Higher risk (1-2%) of lung embolism.
s. Higher risk (aprrox. 6%) for catheter-related
sepsis (insertion site in the vicinity of anus and
genitalia).
6. Accidental puncture of the femoral artery
(6%).
7. Kinking of the catheter with flexion of the
thigh and reduction--or even temporary interruption
--of the infusion flow.
8. Malposition of the catheter tip in the tributaries of the femoral vein (approx. 8%).
9. Spasm of femoral artery. This is eaused by
inadvertent puncture of the femoral artery, and was
IUICUTAHEOUS
TUNNEL.
responsible for periods of temorary ischemia in the
catheterized lower extremity,and even foot gangrene
in 2 youngchildren (Nasbeth & Jones, 1963).
10. Retroperitoneal extravasation of the iniusates eaused by perforation of the vein, and extraFig. 63 . Anatornie relationship of the
vaseular catheterization, or by e rosion of the vein
central venous catheter inserted via
wall by a stiff catheter.
the azygous vein (according to Pokorny
et al., 198S).
11. Higher lethality (approx. 4% in older statistics vs. 0.1-0.S% with the subclavian and inter2) Right atrium was catheterized
nal jugular vein catheterization). The death was
in the intravenous drug addicts who had
usually eaused by lung embolism.
no venous access, and who for some reason
developed cardiac arrest and needed a
EXCEPTIONAL VEIN
right thoracotomy (Fig. 64).
3) Lateral thoracic vein is sometimes
APPROACHES
the only vein access through the intact
skin in the severely burned, or drug addicThese may be divided in intra/extra-thoracal,
ted patients. Catheterization technigue:
and intra/extra-abdominal.
An incision is made across the axilla

11lE GOTHENBURG CVC-GROUP

36)

on the chest wall. Ihe vein, located halfway


between the anterior and posterior axillary
lines under the fascia, is isolated. While
the ca theter is being advanced, the vein is
pulled laterally using a clamp to guide the
catheter tip centrally; otherwise, the catheter tip may go peripherally (Fig. 65).

3. Externa! iliac vein was approached


retroperitoneally in patients with thrombosis
of the superior caval vein and no approachable
femoral veins (Fig. 66-a,b).

Peritaneal ""tents

a)

Fig. 64. Inserting central venous catheters


through the right atrium (according to Parsa
& Tabora, 1985)

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. -

Fig. 66. a) Retroperitoneal approach to the


external iliac vein. b) Ihe route of the
catheter through the inferior epigastric vein,
the iliac vein, and the inferior vena cava to
the junction of the inferior vena cava and the
right atrium (according to Maher, 1983).

PARTICULAR

INSERTION

TECHNIQUES

I. INSERTING 2 CENTRAL VENOUS CATHETERS THROUGH 2 DIFFERENT VEINS


Indications. More than one central venous
lines are necessary for fluid replacement, blood
transfusion total parenteral nutrition, drug
(antibiotic~, cytostatics, hydrochloric acide
solutions), administration, and CVP-measurements.
Ihis technique supposes that more than one venous
route is approachable for insertian of the central
lines.

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS


37)

Insertion technigue is identical to that


described for each venous approach.

II. INSERTING 2 CENTRAL VENOUS


CATHETERS THROUGH THE SAME
VEIN

3. Interruption of infusion_, _of ppssibly


very impor.tant drugs (e. g. IntropinR) during
CVP-measurement.

Indications: as above, but no peripheral,


and only one central route is practicable
(Fig. 67).

a..)

b)

Fig. 68. Double-(a), and triple-lumen (b)


central venous catheters.
Fig. 67. Insertion of 2 CVC via the right subclavian vein. A) After the venipuncture, a guidewire is passed through the needle, and the needle
is withdrawan. B) A large-bore (8-French) introducer is inserted over the wire, and a seeond
guide-wire is passed through- the introducer. The
introducer is removed, leaving 2 guide-wires in
the vein. Finally, 2 single-lumen catheters are
threaded over the guide-wires (according to
Caroll et al., 1985).
Both the techniques described above are alternatives to double-or multi-lumina catheters.

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;

Indications of multi-lumen cathers.


l. General indications. Patients with: i)
only ene accesible central venous route; ii)
no accesssible peripheral veins; ;;i) ~~ need
of concomittantadministration of parenteral
nutrition, infusion therapy, blood or blood
components (e.g. platelet concentrates,
plasma, fibrinogen, etc), blood sampling,
antibiot~cs, infusion of strong drugs (e.g.
Intropin , HemineurinR, barbiturates, hydrochloric acide solutions, given for hours,
days, or even weeks), CVP-measurements, etc.
2. Particular indications: i) Patients
with malignant blood diseases, particularly
those who undewent bene marrow transplantation; ii) Neurologic and neurosurgical patients
in need for infusion, parenteral nutrition, and
continuously incravenous administration for
7-10 days of barbiturate solutions; iii) Patients with lever cirrhosis, or/and acute or
chronic pancreatitis and delirium needing infusion therapy, total parenteral nutrit~on.
and sedation with 1-2 liter Hernineurin per
day; iv) Patients with severe metabolic alealosis needing administration of hydrochloric
acide solutions for 2-4 days; v) Patients
needing concomitant regimens of parenteral
nutrition and chemotherapy (e.g. those with
digestive malignancies); vi) All other patients
needing long-term regimens of infusion, and


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).

6. Higher risk of catheter-related


sepsis: _3% with the single-lumen catheters vs 19% with the triple-lumen catheters in a controlled clinical trial by
Pemberton et al. (1986).
7. Higher tunnel infection rate
(approx. 65). However, controlied studies are not available.
8. Protably higher rate of catheter occlusion: the inner diameter of
each channel of a multi-lumen catheter
is smaller than that of a single lumen
catheter (controlled studies are not
available).
9. Substantiallv (8-10 times) more
expensive than the single-lumen catheters .

II. DIALYSIS CATHETERS


l) CATHETERS
Single-and double-lumen catheters are presentky available. The most
used are VAeCESS -4000 SUBeLAVIAN CANNULA
(Fig. 69) intended to be inserted by the

~
~
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

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS


39)

~
~~.,G~53.~~H~f{~~~::.~-~-~~~o..=~,,.~~~'!.~-~~~~-'==l
"-.,, .

~.

-~

Fig. 70. Diagram representing the double-lumen-subclavia cannula


(Vacces-4000) used for haemodialysis
The femoral approach should be used when
the attempts to cannulation via the other
routes were unsuccessful, or the route s
were impracticable. This recommendation
is based on the following arguments : a
femoral dialysis cathetPr immobili zes the
patient predisposing to thrombosis occurrence; risk for kinking of the catheter
with flexion of the thigh; higher risk
for catheter- related sepsis than with the
other approaches.
b) Warnings before insertion: i)
The dialysis catheters are potentially
dangerous and they can only be made safe
if strict rules are followed for their
insertian and care. ii) The patients
must be placed on cardiac monitor during
the insertian of the catheter. The reason
is that severe cardiac arrhythmias may
result if the guide-wire passed inadvertantly inte the right atrium or ventricle.
The guide-wire must be held securely
during its advancement into the central
venous system. iii) All clamps must be
placed only in the center of the polyurethane extension pieces. Note that
polyurethane can develop cuts or tears
if subjected to excessive pulling or
centact with rough edges. Repeated clamping near,or on the bard plastic portion
of the luer lock connectormay cause
tubing fatigue and possible dissconnection .
c) Performing the venipuncture. See
the respective venous approaches (subclavian, interna! jugular, femoral).
d) Inserting the guide-wire. The
flexible end of a guide-wire (0.89 mm x
70 cm) is inserted through the introducer
(needle, or plastic-sheath) inte the approached vein, and the introducer is removed .
e) Enlarging the introducing tract.
A small (approx. 5-mm) incision is made
at the insertian site, and the i ntroducing tract is widened by using a vein
dilator. A fine forceps (mosquito) may
be used to enlarge the orifice in the
skin at the insertian site. The vein dilater is introduced onlv 1-2 cm proximal
to the vein wall. During advancement of
the vein dilator, resistance is encountered at the orifice in the skin, and
at the orifice in the vein wall (second
resistance). Do not force the advance
ment of the vein dilator after the 2nd
resistance was overcome : this may
cause very severe complications,e.g.
laceration of the vein, or neighbouring
structures (e.g . earotid or subclavian
arteries, or even aorta, perforati on of
the superiorvena cava, etc.,).

f) Preparing the double-lumen catheter


for insertion. The catheter is irrigated with
heparinized saline (100 IU/ml). Thereafter,
the arterial extension is clamped using the
red clamp provided . The venous extension is left
open (not-clamped).
g) Inserting the catheter.The catheter is
passed over the stiff end of the guide-wire by
inserting the guide-wire tip into the tapered
end of the cannula. The blue venous clamp must
be in the open position to allow the catheter
to pass completely over the wire and inte the
vein. The cather may be rotated gently during
the insertian until the tip is correctly positioned . Catheters of 15-cm length should be
used when the right subclavian vein is catheterized and 20-cm with the left one . On the
right side,with subclavian approach, the whole
(15-cm) catheter length should be inserted.
Thereby, the catheter tip will be located in
the inferior part of the superior caval vein,
or at its junction with the right atrium. On
the left side, a 16-18 cm length is usually
sufficient. However, one must note that the
insertian from the left side, with subclavian
approach, may locate the tip of the catheter
against the right wall of the superior caval
vein, and free backflow of blood at aspiration
is not obtained. In such a case, the catheter
should be withdrawn until blood is freely aspirated from the catheter indicaling correct
location of its tip in the left innomLn..ate vein.
Attempt to force the advancement of the catheter
when resistance at the sup. caval vein is encountered must not be made: this may cause perforation of the superior vena cava right wall,
pleura, lung, and haemomediastinum, or kinking
of the catheter and harbouring of its tip in
the right innominate vein.
h) Removing the guide-wire
i) Flushing each lumen with 20-ml isotonic
saline (without heparin), and clamping the lines.
l) Leaving the "heparin-lock". Each lumen
of the catheter is filled with heparin (5,000 IU / ml
Venous
Catheter length
Arterial
lumen
lumen
(cm)
1.00 ml
0.90 ml
15
L 20 ml
20
1.10 ml
If the catheter is not immediately used,
no further heparin is necessary for 49-72 hours
- provided the catheter has not been flushed or
aspirated. If the catheter is not used ~ore than .
72 hours, the Y- extensions are capped w1th_plast1c
plugs provided with silicone bottom permit~ing
additional injections of "heparin-lock" (F1g.11) .
The "heparin-lock" solution must be aspirated out
of both the arterial and venous lumens immediately
prior to use the catheter, in order to prevent ~ys
temic heparinization of the patients, and bleed1ng.

THE GOTHENBURG eve-GROUP


40)

cannula, as indicated by the red clamp, is


connected to the arterial side of the dialysis machine. The venous lumen of the cannula
as indicated by the blue clamp, is connected'
to the venous side of the extracorporeal circuit (Fig. 73).

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

Fig. 73. Diagram: double-lumen subclavian


catheter connected to the dialysis apparatus.
Tunnelling of the double-lumen subclavian
catheters is strongly discouraged on the basis
of the following arguments: i) The catheters
are provided with fixed hubs on the Y-connections;
ii) Therefore, their tunnel1ing is unacceptably
traumatic possibly eausing s~vere bleeding in the
tunnel; iii) The patients needing haemodialysis
(usually for acute, or chronic rena1 insufficiency )
have--because of their condition--a spontaneous
tendenty to increased bleeding; iv) The tunnelling
may cause infection in the tunnel, and catheterrelated sepsis.These complications have a very
poor prognosis in the patients needing dialysis
procedures.
~

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

Fig. 72. Double-lumen dlalysis catheter


ready for use (according to Friedman et
al., 1979).

The dialysis catheters are indicated


the following purposes:
a) Haemodialysis for: i) Acute renal
ficiency; ii) End stage of renal failure
following conditions; failure, or absence

for
insufin the
of

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS

41)

vaseular acess; arterio-venous (-V) fistula


ineffective; A-V fistula infection; inadequate A-V fistula flow; non-mature A-V fistula, or bridge-graft; parafistular haematoma; A-V fistula aneurysm; inadequate peritoneal dialysis; elderly patients on longterm haemodialysis in whom presence of an A-V
fistula would be an intolerable addition to
cardiac out-put.
b) Ultrafiltration for fluid overload
with or without pulmonary oedema.
c) Apheresis treatments, e.g. plasmapheresis and leukopheresis.
5) CONTRAINDICATIONS
See the contraindications of the respective (subclavian, intemal jugular, and femoral) venous routes.
6) ADV ANTAGES
i) Rapidly implantable, non time-consurning procedure. So that, the dialysis may be
initiated within 15-20 minutes.
ii) No necessity of surgically trained
personnel (vascular surgeon): thus the haemodialysis never has to be delayed, or postponed because busy vaseular surgeons are notavailable.
iii) No necessity of hospitalization after
canulation.
iv) Less freguent complications when compared with surgical catheterizations (shunts).
v) More reliable than shunts prepared
with pressing emergency.
vi) In acute cases, usually sufficient
haemodialysis can be performed with a single
catheter pair until the patient's condition
is normalised.
vii) Protracted acute, or chronic patients
without shunt or A-V fistula can be kept alive
with haemodialysis, and with regular dialyses
the patient can be brought into a condition
which e~bles A-V fistula operation and wound
healing without damaging the condition and
number of blood vessels that could be considered for operation.
viii) Gaining time for complicated reconstructive vaseular surgery, or vaseular grafting.
ix) If needed, the dialysis catheter may
be used for other purooses, e.g. blood sampling, total parenteral nutrition, infusion of
antilymphocyte globulin, drug injections,
measurement of the central venous pressure,etc.
x) Decreasing the access-related length
of hospitalization.
xi) The overall cost per patient is much
reduced.
xii) Well-tolerated by patients, both in
the hospital, and at home.
xiii) Obviates the necessity of a singlelumen extracorporeal machine.

xiv) Cosmetic advantages: avoiding


sightly, vicious, and ugly scars.
7) DISADVANTAGES (PROBLEMs AND
COMPLICATIONS)

i) Potentially dangerous insertion,


particularly with the subclavian catheters
inserted from the left side.
ii) All the complications of the respective venous approach may occur.
iii) 1nsertion of the vein-dilator may
be impossible when the subclavian vein
puncture was performed at the Aubagniac's
point (the vein dilator can not be passed
through the costo-clavicular ligament).
Puncture of the subclavian vein at the
Wilson's point is therefore strongly recommended.
iv). Inadeguate arterial blood flow.
This may have 2 causes: a) Arterial side
holes are contacting the wall of the vein.
To correct this, the dressing around the
catheter entry site should be loosene~ (sometimes even the sutures) and the catheter
should be rotated to re-orient the sideholes. b) The side holes are plugged by
clots of fibrin deposits. In such a case,
flushing of the catheter with forceful
injections of heparinized saline, or attemps
to clear the line with a speciallv developed
catheter (Fig. 74) are usually ineffective.

r ,~

Fig. 74.0iagram: specially designed


declotting catheter used to sweep
the blood clots off the inner walls
of the outer (arterial) tube (according to Uldall etal.,l982)

THE GOTHENBURG CVC- GROUP

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

The withdrawar may expose to the


risk of bleeding and air-ernolism because
of: i) large-b0re catheter necessitating
creation of a large orifice at the insertian site; 2) formation of a subcutaneous
tunnel creating a communication between
the vein and atmosphere.
The following preeautians must be taken
during the withdrawal: l) Applying a gauze
compress on the entry site prior withdrawar of the catheter; 2) Press the skin
at the insertian site whilst rotating it
to distort the tunnel (the orifice in the
skin will be displaced in relation to that
in the subcutaneous tlssue); 3) Check for
continuing bleeding (oozing) at the insertian site; 4) If bleeding (oozing) is still
occurring, apply a ligature through the skin ,
thereby closing the orifice of the insertian
site, and sealing the tunnel; 5) Apply a
compressive bandage, or a sand sack on the
insertian site for 2- 4 hours.

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

The three components of the Port-A-Coth


system are illustrated including the slip ring that
slides over the silastic catheter securing it to the outflow track on the portal. A right-ongle Huber point
needle is inserted into the silicone-sealed weil and
connected to a portable infusion pump.

Fig. 75. Diagram showing the components


of the Port- A-Cath system (Pharmacia) and
puncture of the silicone disk with a Hube r
needle (according to Lokich et al.,l985 ).
the catheter (Port-A-Cath) is solded to
the portal.

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS

The Port-A-Catheters were introduced into


clinical practice in 1982, and since that
have enjoyed a large acceptance from both
the patients and doctors, and proved an
excellent function exceeding--in many cases--3 years of intermittent use.

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~.

Fig. 76-c. Port-A-Cath inserted into the


the central venous system, and the portal
implanted subcutaneously in the thoracic
wall.

Fig. 76-a. Cut-down of the common facial


vein in a child (according to McGovern et
al.l985).

Fig. 76-b. Tunnelling of the Port-A-Cath


subcutaneously, towards the chest incision
where the portal will be implanted c~ccor
ding to McGovern et al., 1985)

2) Percutaneous insertian of the Port-ACath via the interna l jugular, subclavian,


femoral, and axillary veins (in order of preference). The insertion is done either by a
genuine seldinger technigue (with thin catheters made of polyurethane, e.g. Viggo's PortA-Cath); or Desilets & Hoffman technique
(Pharmacia's Port-A-Cath) and "peel-away"
technique (Pharmacia and Infusaid's PortA-Cath) (Fig. 77). After insertian of the
catheter, it is tunnelled subcutaneously
from the insertian site to a pocket constructed in the thorax or abdomen wall, and
connected to the portal by the locking mechanism. Further, the portal is implanted and
fixed to the fascia with iresorbable sutures.
The portal is located in frDnt of u bony
structure (rib, iliac spine, etc.). Finally,
the incisions are closed.
PEROPERATIVE COMPLICATIONS
Warning: Implantation of Port-A-Catheters
may be a dangerous procedure. The doctors implanting Port-A-Catheters need experience in
both the central venous catheterization and
minimal training in vaseular surgery
. Peroperative complications: l) Clogging
of the system. This is ~revented by filling
the portal and the catheter with heparinized
isotonic saline during the manipulations of
insertion, and leaving a "heparin-lock" (2,500
IU heparin/5-ml isotonic saline) at the end of
implantation procedure. 2) Difficult cut-down
procedure in indurated tissues, previously submitted to radiotherapy, of affected by neoplastic infiltration. 3) Impossibility of catheterization (particularly via the cephalic vein).
4) Malposition of the catheter tip needing repositioning. 5) Haemorrhage. Intervention needs
surgical expertise and use of diathermy. 6)Injuries to the neighbouring st~ctures, particularl y
with percutaneous insertians (see the respective
vein approaches).

THE GOTHENBURG eve-GROUP

44)

Stages of PAC positioning.


Sketch of placement of the angiographic guidewire. advan ced as far
as the superiorvena cava. The guidewire is threaded through the
needle cannutating the right subctavian vein.
Through the peel-away introducer the silastic catheter is eased as far
as the superiorvena cava and the introducer is removed . The silastic
tunnellized catheter is connected to the steel and silicone capsule and

Fig. 77.

locked by a safety catch. as shown in the inset. Alter removing of the


introducer the infractavicutar inosion is sutured. The capsule is
advanced in the subcutaneous tissue and fixed to the pectoralfascia
with four sutures of nonabsortlable materlal. Incision for the subcut~
aneous pocket fotlows. The capsule. punctured through the skin with
a Huber needle is now ready for use .

Diagram representing insertion of Port-A-Cath using a "peel-away" introducer.


(According to Damascelli et al . l986).

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-

nuous use for mor~ than 5-7 days is discouraged


(may cause skin infection, and skin breakdown
at the implantation pocket). One should not
forget that Port-a-Cath is an implantable system
intended to be used for intermittent approach
to the central venous system. How the Port-ACath is used, it is shown in Fig. 78.
5) Preventing system clogging and occlusion
by flushing the system with 20-ml of isotonic
saline and filling it with "heparin-lock" (5-0
ml isotonic saline containing 100 IE heparin/m! )
after each use, and once a month when the PortA-Cathis not used. (For details see Pharmacia's
Intruction Manual regarding Port-A-Cath).

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS


45)

l) Local complications ('15%).


May be related to:
i) Predominantly to insertion/
implantation technigue, e.g.: mild
to moderate surgical discomfort;
erythema and swelling; bleeding;
haematoma; tunnel and implantation
pocket infection; skin necrosis
(wound breakdown).
ii) Predominantly related to PortA-Catheter: occlusion; migration of
the catheter (with subclavian percul. Preparation
2. Connection
taneous insertion); spontaneous withdrawal of the catheter (subclavian,
percutaneous insertion); catheter
disconnection; cather rupture and embolization; "Twidler's syndrome (unintentional, or intentional manipulation of the portal eausing modification of the relationship between
the injection chamber and catheter;
the syndrome is often observed in
children, naturally curious, so that
they might engage themselves in such
exploratory behaviour when found with
5. Start-Access
the presence of an implanted device);
resistance to injection, or infusion
flow; intermittent, or eonstant difficulties in drawing blood from the
portal.
iii) Predominantly related to the
portal (injection chamber): difficult
entry of the septum (silicone disk)
in obese patients; rupture of the
septum (manufacturing error); teleangiectasia in the skin overlaying
the portal (with the Vascular-Access
Port) eaused by formation of a granulation tissue around the portal
due to the dacron mesh included in
the flat rim embedding the base of
the injection reservoir; portal
6. Continuous infusion
7. End-Access
(foreign body) rejection.
iv) Predominantly related to the
use of Huber needles: dislodgement
Fig. 78. Illustrations showing how Pharmacia's Port-A-Cath is of the needles and extravastian of
the injectate/infusate.
used (according to Pharmacia's Instruction Manual, 1987)
6) Postoperative observation for local infection (erythema, exudate, suppuration), occurrence of vein dilatation
(indicating thrombosis), and free flow through the disk.
7) Dressing the insertian site and withdrawal of the
sutures: i) Dressing: possibly in the evening of the operation day (if the dressing is imbued with blood), thereafter
once a week for 2 weeks; further no more dressing is necessary. ii) Withdrawal of the sutures at 10-14 days after the
implantation.
POSTOPERATIVE COMPLICATIONS
Approximately 28% of the implanted Port-A-Catheters
present one or more complications. Of all the postoperative complications, 55% are eaused by a defective insertian technigue, 40% by errors in system approach and care,
and only 5% by patient's general condition, associated
disease, and behaviour,
The complications may be classified in the following
groups:

2) General complications (13%):


i) Sepsis (approx. 5%).
ii) Thrombosis of the central veins
(approx. 6%).
Approximately 13% of all implanted
Port-a-Gath-systems are withdrawn
because of complications.
INDICATIONS
The Port-A-Cath i.v. systems
are implanted for the following purposes:
l) Blood sampling
2) Drug injections (particularly
for intermittent administrations of
cytostatics in patients with advanced
malignancies) if the following cond itians are satisfied: i) children (o f :

THE GOTHENBUF.G CVC-GROUP


46)

affraid of repeated venipunctures); ii) younger


patients with an active life s~yle;iii) patients
facing a prolonged (longer than 3 months), intensive adjuvant chemotherapy program; iv) patients
neeeding chemotherapy regimens as intermittent
injections, or short-term (maximum 5-days) of continuous infusion; v) patients in whome the value
of chemotherapy has been established by ongoing,
or complete response; vi) outpatients, situation
when the capsule is not used, or used (pump).
3) Infusion therapy. Infusion rates of up-to
300 ml/hour are achievable with the presently
available infusion devices and Port-A-Cath i.v.
systems.
4) Short-term (5-7 days) parenteral nutrition. We strongly discourage the use of Port-ACath i.v. system for long-term parenteral nutrition at home on the basis of the following arguments: i) Higher risk for extravasation of the
infusate than with CVC; ii) Impossibility to
exchange the system in the case of occlusion.
CONTRAINDICATIONS
l) Absolute: i) Patients in whom the prospect of remission is poor; 2) Patients in whom
prolonged, continuous venous access is required;
3) Patients requiring only 1-2 courses of chemotherapy; 4) Patients in need for long-term regimens of total parenteral nutrition; 5) Patients
with local or/and systernie infections; 6) Patients with severe coagulation disturbances; 7)
Patients not-accepting implantation of Port-ACath, even if the patient would take actvantages
from it.
2) Relative: i) Patients with bene marrow
failure (higher risk for infection, catheterrelated sepsis, and bleeding).
ADVANTAGES
l) Cosmetically attractive (favorably received by female patients).
2) Decreased emotional stress: pain, anxiety,
and apprehension eaused by repeated venipunctures
are virtually eliminated. This is particularly
important in emotionally instable patients and in
children.
3) Permitting the patients complete mobility,
e.g. swimming, bathing, sport games, ear driving,
dancing, etc.
4) Untedious maintenance schedule: the PortA-Cath needs no care by the patient when it is
not being used (the system needs not undergo daily
dressing changes and heparin flushes). This makes
the Port-A-Cath suitable for implantation in the
patients incapable of caring for a transcutaneous
central venous line.
5) No risk for accidental withdrawal.
6) High rate of acceptance by both the patient
and the treating physician.
DISADVANTAGES
l) Significant more traumatic insertion.
2) Can not be used continuously: more limited
indications and functions.
3) More complicated function: i) Higher occlusion rate ( smaller diameters than the CVC); ii) Higher risk of infiltration of injectates/infusates
because of needle displacements; iii) Risk for skin
breakdown and rejection of the system; iv). More .
painful injection/infusion administration (through
skin punctures); v) Risk for "1widdler's syndrome"
- not-encountered with the central venous lines.

4) In the case of unsatisfactory


function, the docter may be biamed for
1

5) The Port-A-Cath can not be exchanThe system must be withdrawn in the


case of impaired function, and potentially
new implantation (of another Port-A-Cath)
should be considered.
6) The Port-A-Cath is 25-100 times more
expensive than a central venous catheter.
This, tagether with the additional expense ~
for anaesthesia (possible narcosis), prophylactic antibiotics and anticoagulants,
surgical and anesthesiological assistance,
pre-and postoperative hospitalization (not
all the Port-a-Catheters may be implanted
on an outpatient basis) make implantation
of a Port-A-Cath significantly more expensive than that of a central venous line.
Thus, to justify the increased expenses
for the patient, hospital, or/and communit'
the docters must be very careful in selec
ting their patients for implantation of
Port-A-Catheters.
~-

GENERAL TECHNICAL
ASPECTS
In the following, same general, technical aspects, regarding all types of
the catheters and venous approaches will
be discussed.

I. USE OF THE SELDINGER'S


GUIDE-WIRES
The Seldinger's guide-wires are
presently largely used in central venous
catheterization. The wires are fragile
instruments, and when incorrectly used
may give rise to very severe complications
Therefore, the following SAFETY MEASURES
REGARDING THE CLINICAL USE OF THE SELDINGE:
WIRES HAVE BEEN ELABORATED:
l) Test the guide-wire before using
it. The pre-use testing is performed by
attempting to stretch the spring. Its
fracture at the time of spring breakage
appears to be extremely unlikely even in
the hands of the allert and competent
worker.
2) Carefully inspect each guide-wire
before use. Such an inspection may detect
mechanical flaws of the wires, and defected wires will not be used.
3) Consicter the guide-wire a .delicate instrument and manipulate it accordingly . Safe use of the guide-wires follo w
from an understanding of their design. Exc
sive and repeated manipulations of a guid e
wire places undue stress on its weak areas
predisposing to wire damage. Vessel injury
may result from rough, irregular surfaces
of damaged area. Complete separation and
subsequent embolization is a potential
hazard. Remember that the force needed to
pull a guide-wire apart is much less than
expected. The approx. pull strength for a
0.64-mm 0 guide-wire is approx. 1.8 kg,

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS


47)

whereas that for a 0.89-mm 0 is approx. 2.7 kg.


4) Do not reuse guide-wires. With repeated
uses, mechanical flaws which are not easily detected by superficial inspection may exist, and
the risk of severe complications during manipulations of the wire is considerably increased.
Do not use TeflonR-coated guide-wires.
Teflon -coating on guide-wires can be slought
inta the vessel through abrasion with the catheter, or with th~ needle. There is no question
that the Teflo~ coat is disturbed by abrasion.
Loss of Teflon in the vessel is increased with
each reuse.
.
6)Do not use guide-wires with silicone
elastomer catheters,and with HydromerR or
heparin-coated,soft polyurethane catheters .. _
i) With soft silicone catheters, the pressure
exerted by operator's fingers during withdrawal of the guide-wire may detach the helical
spring from the guide-care. ii) With heparincoated catheters, the wiremaycause abrasion
of the coating. Furthermore, the heparincoating increases the frietian between the catheter and the guide, and may ~ecoil the wireguiding. iii) With Hydrorner -coated, soft polyurethane catheters, passage of the guide-wire
through the catheter may be impossible without
previous flushing of the catheter with sterile,
isotonic saline. Attempts to forceful threading
of the guide-wire, without previous flushing of
the catheter, may be followed by blockage of the
wire in the catheter. Further at temp t to guidewir~
withdrawal may decoil the wire.
7) Match adeguately catheter inner diameter
with the diameter of the guide-wire. The empirically recommended difference between the above
mentioned diameters--accordingly to our experience--is 0.15-0.4 mm. When the difference is
less than 0.15-mm, there is a high risk for decoiling of the guide-wire during its withdrawal
from the catheter.
8) ~nsert preferentially the guide-wire by
a Teflon sheath (cannula) or through a steelneedle with blunt bevel edges (see the figure
10). Insertian of the guide-wire through steelneedles without rounded heel (with sharp bevel
edges) may cause cutting-off of the wire, and
~bolization of the detached fragment.
9) Avoid too sharp, or too freguent bending
of the guide-wire at a given point. Probably this
physical factor is the most important in the
breakage of the guide-wire. The likelyhoad of repeated same-site flexion of the end of the immovable central care weighs against the indiscriminate use of the seldinger (or other fixed-core)
guides for other than the originally intended
purpose of percutaneous introduction.
10) Do not use guide-wires for exchange of
partially occluded catheters. The guide-wire may
be blocked in the catheter, and decoiling of the
spring may occur during forceful withdrawal of
the wire from the ca theter.
11) Do not force advancement of the guidewire when resistance is encountered during its
introduction. Forced advancement may cause
knotting or/and bending of tne guide-wire. Furthermore, its decoiling may occur during the
withdrawal. When resistance is opposed to advancement of the guide-wire, reinspect its tip, and

sa

and reposition the steel-needle or the


plastic cannula (this should be prefentially used) so that no resistance to passage of the wire occurs.
12) Create a sufficiently large inseislon at the insertian site.This recommenda ~
tian is valid for insertian of soft, largebore central (or other) venous catheters, or
vein dilators. This will permit smooth, onestep insertian of a vein dilator, or catheter
over the wire.
13) Do not ~ithd:::-aw thoe guide-wire
through a sharply beveled steel-needle. This
may cause cutting-off of the guide-wire
and embolization of the detached fragment.
14) Remove concomitantly the guide-wire
with the catheter when resistance is encountered during withdrawal of the wire. This will
avoid separation of the helical portion of the
wire from its stiff care.
15). Reinspect the wire andreplace it,
if necessary, when multiple manipulations are
required. This will avoid the use of a damaged
wire, and prevent very severe complications
(e.g. guide-wire breakage and ~bolization of
the detached fragment).
16) Reinspect always the wire for damage
upon removal from the catheter. i) This may
detect a possible complication (e.g. breakage
of the guide-wire) and permit quick consideration of the adequate therapeutical measures.
ii) Furthermore, "the guide-wires have memory"
deformation of the wire may indicate malposition of the catheter tip and make radiological
central necessary (e.g. with insertian of central venous catheters via the subclavian veins
17) Report defects of the guide-wires
to manufacturer, and consider that the remaining wires from a particular shipment may be
defective. Thereby one will prevent the use
of other guide-wires having the same defects,
and occurrence of an "epidemy" of complications. Nate the batch number.
18) Discard the guide-wire after removal
fuld never re-use it. This will prevent occurrence of both infectious and mechanical complications in the catheterized patients.

II. CATHETER TIP LOCATION


The following locations are recommmended:
l) Proximal axillary/distal subclavian
veins: "half-way" vein catheters (see fig. 26 )
2) Innominate veins: "lor.g-way"-catheters inserted via the basilic and cephalic
veins punctured at cubital fossa (see fig.l6 ).
3) Superior caval vein: i) "short-wav"
(axillary, subclavian, external jugular, and
inter jugular) catheters; ii) children.
4) Right atrium: a) CVC inserted
for total parenteral nutrition at home in
adult patients because of: i. lower risk
for thrombosis of the central veins; ii. passibility to withdraw the catheter approx.
l-cm each time (approx. once each other month ;
when exchange of an occluded Floswitch is

THE GOTHENBURG CVC-GROUP


48)

necessary; thereby, the catheter tip will


have a still adequate location, and the
active life of the catheter is prolonged.
b) CVC inserted for chemotherapy: thereb~
the risk of thrombosis of the central ve1ns
is reduced (higher blood flow). c) CVC
inserted from tl.e femoral veins.
OBS. a) Location of a CVC-tip in the
right atrium is strongly discouraged in
new borns,infants and children up-to 14
years on the basis of the following arguments: i) Higher risk (approx. 30%) of
severe heart arrhythmias than in adults
(2%) ii) Higher risk for perforation of
the ~ery thin wall of the right atrium,
even when soft (silicone) catheters are
used; iii) Higher risk fo7 formation of
intra-atrial "ball thromb1 11 because of
lower level of plasminogen in children,
particularly in the premature, and new
bom infants: the thrombi may involve
the wall of the right atrium, eausing its
pe~foration, even when soft (silicone,or
polyurethane) CVC are used.
b) The tip of the CVC must not
be located deeper than 4cm from the superior caval vein/right atrial junction, in
adults. This recommendation is grounded
on the following anatomical details; i)
the right border of the right atrium earresponds to a line drawn from the u~per
margin of the right 3rd eostal cart1lage,
approx. l-cm from the margin of the sternum,
downwards to the 6th eostal cartilage. This
line is gently convex to the right, and.it
is at its maximum distance from the med1an
plane (approx. 3-4 cm) in ~e 4th ~ntercos
tal space. ii) The right atr1oventr1cular .
(tricuspid) orifice is projec~ed ~n the sk1n
by a line, 4-cm long, commenc1ng 1n the .
median plane opposite the 4th eostal cart1lage and passing downwards and slightly to
the ;ight. The centre of this l~ne should be
opposite the middle of the 4th 1ntercos~l
space. iii) The distance from the super1or
vena cava/right atrial juncticn to the
nearest point on the line projecting the
tricuspid orifice is approx. 4-5 cm. So that,
if the catheter tip is inserted less than 4-cm
into the right atrium, there is only a low
risk that its tip enters the right ventricle
and potentially triggers severe heart arrhythmias.

III. FIXATlON OF CENTRAL VENOUS


CATHETERS
Two methods are presently used for
fixation of central venous catheters:
use of self-adhesive tapes, or suturing
the catheter to the skin.
l. ADHESIVE TAPES a~e preferred by
some a'.lthors on the following actvantages:
i) The adhesive tapes (adhesive strips) do
not limit maneuverability of the catheters
during dressing changes; 2) The strips permit the catheter to change position, avoiding
pressure sores at the site; . 3) ThQ strips do
not cause pain; 4) The str1ps are much _

cheapec than Lhe sutures; S)In the case


of accidental withdrawal, the catheter
can not be cut off by the strips, and
thereby the risk of bleeding and airerobolism is avoided. However the strips
have very serious disadvantages: i) very
insecure fixation, particularly in the
uncooperative patients (children, disoriented and combative adults); ii) sweating
and especially any concurrent beard (hair)
growth cause tapes to peal-off, whereupon
the weight of the giving set allows the
catheter to slip out; iii) Risk for displacement during manipulations for possibl e
refixation; iv) The strips do not avoid
"to-and-fro" movements of the catheters
favoring transport of skin bacteria into
the catheter tunnel, and occurrence of
catheter-related infections and sepsis
(5-7.5% with strips, vs. ~1% with sutures
- the Gothenburg CVC Gcoup's results).
Therefore, we strongly discourage the use
of steri-strips. or other tapes (e.g. MefixF
MeporeR, etc.) for fixation of central
vehous catheters.
2) SUTURES. Indications: a) Absolute :
i) Patients with limited venous access;
ii) Burned patients (in a burn area the
catheter can not be fixed by tapes); iii)
Children; iv) Agitated and uncooperative
patients. b) Relative (large) indications:
all central venous catheters.
Advantages: a) Suturing is the most
secure fixation, particularly when: i) two
monafilament (Dermalon-00, Novafix-00)
threads are used; ii) The sutures are applied on silicone sleeves; iii) The knots
are made with the fingers, avoidin~ either
too loose, or to hard knots, to ne1ther
permit catheter displacement, nor caus7
its occlusion; iv) The sutures are appl1ed
within l-cm fron the insertian site. b) The
suturing aveids in-and-out catheter displacements, colonization of the tunnel and
catheter, and prevents occurring of cathete1
related sepsis.
. .
.
Disadvantages: a) Risk of sk1n 1schem1<
erythema, inflanm~ation, and crustning;
b) risk of scar after catheter withdrawal ~
be a cosmetic argument against suturing
acceptance; c) discomfort with m~vements
of the extremity. However, the d1sadvantages have substantiall~ less weight .
when campared with the
vantages. part1cularly in the patients in whom ~e cent~a~
venous catheter represents the1r only l1fe
line" .

IV. TUNNELLING OF CENTRAL VENOUS


CATHETERS
INDICATIONS
1. Central venous catheters inserted
for long-term duration (e.g parenteral nutrition at home) .
2. All catheters to prevent or decreas
the rate of catheter-related sepsis. Th1s
indication is not supported by evidence.
Therefore, we strongly discourage the routine tunnelling of the central venous cathe
ters.

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS


CONTRAINDICATIONS

49)

l) Short-term (up-to a month) catheterization.


2) Cachectic patients (higher risk for in
fection in the tunnel, and catheter-related
sepsis)
3) Patients with bleeding tendency, e.g.
leukemia and thrombocytopenia (higher risk
for bleeding in the tunnel, and haematoma
formation).
4) Patients with low immunological defen~ (higher risk for infection in the tunnel,
and catheter-related sepsis).
5) Local conditions making the tunnelling
inappropriate and risky, e.g.: burn areas,
acne, irradiated skin, neoplastic infiltration, and other pathologic skin conditions
at the site of intended tunnel.
ADVANTAGES
l) More secure fixation of the catheter.
2) Easier catheter care by the patient' s
self, if the exit of the tunnel is adequately placed.
DISADVANTAGES
l) More traumatic and time-consurning
insertian Sometimes, general anaesthesia
is necessary to perform the tunnelling.
2) Extra-eguiprnent (tunnellers) is
necessary.
TECHNICAL DETAILS
A. Choosing the catheter
Two types of catheters are presently used
for tunnelling:
l) Hickman-Broviac's catheter (Fig. 79).
This catheter is very popular in USA.
The catheter is made of si~icone elastomer
and provided with a Dacron -cuff which is
placed subcutaneously, in the tunnel. The
cuff eauses formation of adherences which
--one belives--might impede migration of bacteria from the skin to the tip of the the
ca theter and blood stream. Thereby, the
occurrence of catheter-related sepsis would
be prevented. However, this supposition has
not been supported by evidence (to the contrary, it appears that the infection rate is
higher with Hickman-Broviac's catheter, or
at least not-different from that recorded
with other catheters.
Insertian technigue and vein approaches:
i) Cut-down of the cephalic vein at the delto- _
pectoral groove (standard technique - Fig. 80);
ii) Cut-down of the intemal jugular vein (alternative technique - Fig. 81) when the cephalic vein is impracticable; iii Percutaneous
approach to the subclavian vein using a ~'peel
away" introducer (Fig. 79).
Advantages: none. The belief that these
catheters might reduce the rate of catheterrelated sepsis has not been confirmed by evidence.

Disadvantages: i) Cumbersame and traumatic tunnelling. because the hub is fastened


to the catheter shaft (the procedure must

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

THE GOTHENBURG eve-GROUP

50)

3.

--

purse string
suture

Fig. 81. Alternate method for insertion of Hickman-Broviac catheter through

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS


51)

Fig. 82-a. Photo representing Viggo's Secalon-UniversalR catheter which


may be advantageously used for tunnelling.
keeping the existing tunnel functional.
Disadvantages: i) Higher risk of airand catheter embolism, if the Floswitch is
not correctly screwed (conected) to catheter
shaft; ii) Higher risk for catheter occlusion
by precipitates of parenteral nutrition at the
Floswitch level, obliging to its change (separate Flowswitch-es are available) each other
month.
b.

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.

Placing the tunnel exit


We recommend to tunnel the catheter minimum
10-15 cm in the adult patients. The tunnel is
located parasternally, avoiding injury to the
breasts in women. Tunnel exit should be located
at the 4th or 5th intereastal space, to be
visible and accessible to the patient for exchange
of dressing and connect~on of infusion system
(when Secalon-Universal catheters are used).
V. EXCHANGE OF CENTRAL VENOUS

the operator to measure the wanted length


CATHETERS
of the catheter following to be inserted
intravenously. The tunnelling is performed
A. INDICATIONS:
with aspecially developed probe, shaped
like a javelin, andhavinga diameter 0.2
1. Prophylactic exchange of the CVC once
0.3 mm wider than the catheter outer diaa week or each other week was advocated by same
meter. Alternatively, the catheter may be
authors to prevent occurrence of both the thromtunnelled with Abbott's instrument used
bosis/phlebitis and catheter related sepsis. No
for tunnelling of epidural catheters.
evidence supporting this recommendation is avaiAdvantages: i) Minimal insertion-and
lable to-date. The reports published to-date can
tunnelling trauma; ii) Ad~pted to all venot persuade the exper~enc~d clinicians inta accep nous approaches; iii) Minimal risk for
ting it. Thus, we strongly discourage the prophybleeding in the tunnel; iv) No risk of,
lactic exchange of the central venous catheters.
air-erobolism during insertian of the cathe2. Occlusion of the catheters when other
ter -- with "catheter-through-cannula"
~eth0ds {e.g~ tlushes w1th fiepar1n1zed sal1ne, or
technique; v) May be easily exchanged

TIIE GOTHENBURG CVC- GROUP


52)

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).

Steps: i) The catheter is clamped within


1-2 cm of the insertian site;ii) The sutures fixing the catheter at the insertian
site are removed; iii) The catheter is cut
off immediately proximal to the hub, and
the hub discharged; iv) A Teflon-cannula
is inserted over the occluded catheter; v)
The occluded catheter is withdrawn; vi) A
new catheter is inserted through the Teflonsheath; vii) The cannula is withdrawn and
the new catheter is fastened to the skin.
OBS: With this technique, it is recommended
to use splitting cannulas, like the "peelaway" sheath permitting dischaEge of the
sheath after its withdrawal from the vein
(when a standard, not-splitting cannula is
used, it must be kept in-place, over the
catheter) .
3) Occluded and tunnelled catheters. A
technique permitting exchange of the tunnelled
and occluded subclavian CVC was developed by
the Gothenburg Group, and reported in 1986
(Fig.83-1:7).

~!~~~~e~
floswit c h
----..
\

a.)
l . Dr~ing and anat:stht:tic infiltration.

FloswitCh

A--

b)

Fig. 82. Diagram illustrating exchange


of a CVC using the seldinger technique.
a) A sterile haemostat grasps the catheter, and a wire is introduced into the
catheter. Further, the catheter is withdrawn over the wire. b) A new catheter
is inserted over the guide-wire, and
the wire is withdrawn. Further, the
catheter is fixed (Blewett et al,1974) .

eter.

2. In cision , clamping and cutting of the occl d d .


u c cath

Ocduded C..cl\eter
Nor.-Ocduded
Wcheler 5.-gr~Mnt
~~..d~~~ - ~.

b) Exchange after 2 weeks. In most


cases, a patent soft-tissue tract is formed,
and a new catheter can be advanced into the
vein without the use of a guide wire.
2) Occluded, not-tunnelled catbeters.
In such a s1.tuation, a "cannula- over-catheter"
technique is used to exchange the catheter.
3. Passing a guide wire (A) tagether with the occludcd
cathetc r through the tunnel.

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS


53)

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.

II. MAINTENANCE OF STERILITY INSIDE


THE CENTRAL VENOUS LINES

5 .Insertion of a new ca t heter.


guide wire (B) .

~ tiffened

with another

6. Soft clamping of the new cathctcr and its passing


throut;h the tunnc:l guided by the (A) guide wire .

floSWit Ch

7. Catheter fixatiun and wound dosing.

Fig. 81:4-7. Exchange of the occluded and


tunnelled CVC (the Gothenburg CVC-Group's
results - 1986)

l) PRESENTLY UNVALID RECOMMENDATIONS:


i) use of in-line filters to prevent
the catheter-related sepsis;
ii) changing the CVC daily !!??), once
every other day, once a week, or at
least once a month;
iii) covering the catheter and its connection to infusion tubing with sterile dressing (gauze compresses) imbued with 1-2% tincture of jodine;
iv) heating the hub of the cvc;
v) electrical, thermic treatment (370C)
applied with a solder pencil to the
catheter hub;
vi) systemic antibiotic therapy, if it is
not indicated for other purposes.
2) PRESENTLY VALID RECOMMENDATIONS:
i) the solution mixture (in the case
of total parenteral nutrition) must
be made by sterile technique;
ii) all manipulations of the infusion
systems must ~e done with clean
hands ( washing with soap and tap
water); manipulations of the systems
with sterile gown, mask, gloves etc.,
are not justified by the long=term,
clinical experience;
iii) when manipulating the system, the
person (nurse) must watch the disconnected ends for sterility until
they are reattached;
iv) every time the spike of the intravenous svstem is removed from the
bottle, it must be prepared with an
antisepticum (l% tincture of jodine,
alternatively 0.5% chloihexiding in
60% alcohol);
v) when blood is given through the lines,
the lines must be flushed in immediatelv
after the completion of the procedure with 20 ml of isotonic saline; if clots
form and remain in the intravenous
tubing, the tubing must be replaced;
vi) change the infusion system at least
once every 48-72 hours;
vii) all parenteral nutrition solutions
--when prepared like mixtures--should
be completely infused within 24 hours ,
or discharged;
viii) using single-use (single dose) container

THE GOTHENBURG CVC-GROUP


54)

(vials) of additives (vitamins, minerals)


whenever possible for admixing parenteral
nutrition solutions;
ix) evaluate patients with CVC daily
for evidence of catheter related complications.

III. CARE OF CATHETER SKIN


SITE
l) PRESENTLY UNVALID RECOMMENDATIONS
i) Wearing sterile gown, mask, gloves to exchange the dressing;
ii) Dressing the site each day, or
each other day (routinely);
iii) Use of locally applied antibiotic
ointments (e.g FucidineR) or antimicrobials. (e.g. l% silver sulfadia~ine, er povidone jodine spray); the antibiotics favor
selective growth of resistant bacteria and
yeasts (e.g. Candida albicans), whilst
the povidone-jodine does not reduce the
rate of catheter colonisation and does not
significantly alter the types of the organisms isolated in controlled clinical
trials.
2) PRESENTLY VALID RECOMMENDATIONS
i) Daily inspection of the catheter
entry site for complications; the inspection is facilitat~d by a tr~sparent dressing (e.g. Opsite , TegadermK);
ii) Dressing the site with clean ' hands
(washed with soap and tap water);
iii) Changing the dressing on a regular
basis (once a week), and every time the
dressing is wet, or dirty, or blood accumulated at the insertian site;
iv) Dressing the site each day, or each
other day in high risk patients, e.g. bums,
open wounds adjacent to the insertian sites,
tracheostomy in the vicinity of a subclavian
catheter, transplant patients, immune deficient patients, patients wi~~ leukemia,etc.
v) Use 0.5% chlorhexidine in 60% aleohol as. antisepticum (long action, no painting of the skin); DO NOT USE ACETONEFOR
11
DEFATIIG11 (acetone increases pain and inflammation at the insertian site, and does
not decrease the rate of catheter-related
sepsis);
vi) Apply a tran~narent pol~ethane
film dressing (Opsite - TegadermK)' on the site;
this facilitates daily inspection of the
site, permits circulation of the air under
it, and it is cheaper than any other occlusive dressing.

IV. FLUSINHG OF THE LINES


l) Indications: i) after every blood sampling; ii) after blood transfusion; iii) partial occlusion (blood can not be sampled from
the catheter); iv) loose,total occlusion (neither the infusion may be given through the
line, nor blood can be sampled).
2) Contraindications : forceful flushes must
be avoided in patients having inserted siiicone elastomer CVC or Port-A-Catheters, and each
time when the occlusion appears irreversible.

3) Technigue. Use a 10-20 ml disposable syringe with isotonic saline. DO NOT


USE GLUCOSE SOLUTIONS TO FLUSH THE~:
glucose facilitates bacterial growth and
infection of the lines.
4) Complications. i) Risk of catheter
rupture and embolization of the ruptured
fragment by forced flushing of soft silicone elastomer catheters; ii) Risk of infiltration of the infusates when flushing-reslllted in the rupture of the catheters; iii) pos sible dislodgement of a tip 11 cap 11 ) thrombus .
However, one should stress that these
risks are more theoretical than real. !here
is at present a sufficiently large (huge)
evidence supporting the belief that flush i ng
of the catheters does not produce clinicallv
apparent negative effects.

V. ADDING HEPARIN TO THE


INFUSATES
Addition of 5,000-6,000 IU heparin per
day (adults) to the infused solutions was
earlier recommended on the belief that this
might reduce formation of tip ( 11 cap 11 ) thrombi,
reduce catheter occlusion rate, and decrease
the catheter-related sepsis. to-date, there
is no definite evidence that this practice
may be benefical.
Therefore, --- Sweden's Department of
Health ( 11 Socialstyrelse) strongly discourage
addition of heparin to the infusates given
via the central venous lines. This practice
only increases the cost of the care (heparin
is very expensive) with no beneficial effects.
An exception may be made for the patients
having a history of previous thrombosis or
coagulation tests indicating a high trend
towards hypercoagulation, and each time when
strongly irritant (thrombogenic) solutions,
e.g . cytostatics, hydrochloric acide solutions are given through CVC having their tips
located in the proximal axillary, subclavian,
and innominate veins,or via through catheters
inserted from the femoral veins.

. VI. LEAVING "HEPARIN-LOCK"


l) INDICATIONS~ i) The catheters
are not in use, but their future use is
not not-excluded (e.g. patients not needing
infusions, but recovery of their bowel function is questionable), ii) The catheters are
used intermittently (e.g. CVC used for total
parenteral nutrition at home, Port-A-Catheters
used for intermittent chemotherapy).
2) TECHNIQUE

a) Heparin solutions. The following


solutions have ben recommended on an empir~
cal basis: i) New bom and infants - l IU/ml ;
ii) Children up-to 12 years - 10 IU/ml; iii )
Children over 12 vears and adults: 100-500 I U
per ml. OBS. IN SMALL CHILDREN, SOME AUTHORS
USE SOLUTIONS MORE CONCENTRATED THAN THOSE
USED IN ADULTS, E.G. 1,000 IU/ml, BECAUSE OF
HIGHER RISK OF THROMBOSIS OF THE CENTRAL VEIN ~
IN THIS GROUP OF AGE.

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS

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

(NO MATTER OF VEIN APPROACH)


I. CATHETER OCCLUSION
l) RATE AND TIME OF OCCURRENCE

Approximately 25% of the CVC become occluded


within 40 days after the insertion.
2) MECHANISMS
a) Intraluminal occlusion by: i) clots
formed after blood transfusion or sampling without after-flushing of the lines; ii) precipitates
of total parenteral nut~iticn solutio~s (fats and
aminoacides. e.g. Vamin + Intralipid ,forming a
yello'Wish, hard deposit in the cathet~r lumen and
hub).
b) Extraluminal occlusion by thrombi formed at the catheter tip (fibrin-sleeve, "capthrombi").
3. PROPH.YLAXIS
a) Avoiding blood reflux into the Gatheters.
b) Flushing the lines with isotonic saline
after drug administrations, blood transfusion, or
blood sampling from the CVC.
c) Giving Vamin and Intralipid at separate
times (separated by intervals of other infusate administration)
d) Leaving cn"alcohol-lock" (2-3 ml 45% alcohol) for 30-45 minutes, every day, in patients
submitted to regimens of total ~arenteral nutri~ion
(thereby precipitation of Vamin and Intralipid
would be avoided). The method proved to be ~ffic~ent

in experiment,but needs further clinical


evaluation.
~)

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

THE GOTHENBURG eve-GROUP

56)

Gilligan's technique (1980). Laufer's technigue: 250,000 IU streptokinase dissolved


in 20-ml of 0.9% saline is slowly injected into the occlude~ catheter. Thereafter
S?-mg (i.e. 5,000 IU) h_e parin are i!ljected'
w1th a forceful hand into the catheter. Using
this methcd, the authors were able to double
the "catheter acitive life". OBS. THE OOSE
RECOMENDED APPEARS UNNEeESSARLY HIGH AND
SEVERE BLEEDING MAY oeCUR. WE DO NOT RECOM
MEND IT. Hurtubise's technigue: a solution
of 250 IU/ml streptokinase is prepared. Of
this solution, 0.3-ml is injected through the
"short-way", subclavian and intemal jugular, catheters, and 0.6-ml through the "longway", basilic and cephalic, catheters. A contact time of 5-10 minutes is allowed. Thereafter, aspiration of the residual' clots and
drugs is attempted every 5 minutes until the
patency of the catheter is restored. This
usually occurs with one injection of the fibrinelytic agent. If the catheter is not patent after 30 minutes, the procedure is
repeated 0nce. This method is efficient in
77% of cases after the first injection
(average needed time for desobstruction =
22 minutes) , and artother 23% are desobstructed
after 2 injections (average needed time = 45
minutes). Gilligan et als' method: a solution of 2,000 IU streptokinase per 1 ml isotonic saline is prepared. Five ml of this solution are slowly injected i.nto the cath.e+-e>r
After i.njection, the catheter is clamped. A
contact time of 6 hours is allowed. Thereafter
the clamp i. s ::-emoved, and the streptokinase
'
solution isflushed easily into the central
venous system.
OBS. THE STREPT0KINj\.SE eLEARS THE
LINES, RESTORTNG TIIEIR PA.TE'iCV, ONLY IN THOSE
INSTANeES WfiEN 'IliE CATHETER IS PARTLY BLOCKED
BY A TIP THROMBUS.
c) Instillation of a 2M hydrochloric
acid solution into the catheter. The instilled
volume is usually 1.5-ml (in adults) and should
equal the catheter volume. tndications: occlusion associated to catheter se~sis. Duration
of contact: 2 _ ~inutes. Advantages: indicated
particularly with occluded, tunnelled cathe~
t7rs; ef~icient against catheter-related sepS1s; avo1ds catheter exchange, or withdrawal
and re-insertion; simple and cheap; _e fficient
.in ~le~ing the catheter from proteinceous
debris (precipitates of parenteral nutrition
solution). Disadvantages: instillation of 1.5
ml 2M hydrochloric acide changes ( increases ? )
thevolume (approx. 8%) of the silicone elastomer catheters (the effects on other catheter
materials is not known).
d) E.xchange (or withdrawal and new
insertion) of the catheter when occlusion
proves to be insurmontable (see pp. Sl-52).

II. THROMBOSIS OF THE CENTRAL


VEINS
l) INCIDENeE AND OCeURRENeE TIME
Rates varying from 1.71% to 28.3%.were
reported. It may reach even 42% in patients
treatedwith chemotherapy (subclavian catheters)

for advanced mali~nancies. The mean rate


reportedwith eve-s inserted for total
parenteral nutrition was approx. 2%.
. Isolated thromb~sis of the axillarv
~was recorded 1n ~.71-5.55%. We registered a rate of 2.5% 1n our patients having
inserted "half-way" venous catheters. Isolated thrombosis of the subclavian vein
was noted in 1.71% to 28% (mean 2%). We
were unable to find similar figures for
the innominate veins and the superior vena
~-

The thrombosis may occur as early


as early as 6-8 hours after catheterization, and later than 2 months.
2) PREDISPOSING FAeTORS
The following factors were incriminated
as contributing to occurrence of the thrombosis: i. severity of the disease (more
frequent in patients with advanced malignancies); ii) Displacements of catheters
eausing injury to the intima of the central
veins; iii) Side of catheterization (more
frequent after catheterization of left subclavian and internaljugular veins); iv) Repeated catheterizations vla the same vein
v) Use of stiff catheters (e.g.TeflonR), ;articularly when inserted from the left side
vi) Type of infusate ( more often with administration of hyperosmolar and low pH. solutions of total parenteral nutrition, and
highly irritant infusions containing cytostatics); vii) Previous treatments, e.g.
radiotherapy; viii) eoagulation abnormaiities (e.g. decreased antithrombin-III levels);
ix) Reduced flow in the central veins eaused
by: heart insufficiency, prevenous (subclavian) phrenic nerv, sternoclavicular hyperostosis, presence of axillopec~oral muscle, or
an aberrant transverse cervical artery, etc.
x) Associated infection and sepsis; xi) Burn
patients.
---3) SYMPTOMs AND DIAGNOSIS
.
a) Isolated thrombosis of the axillarv
vein: spontaneous pain and tenderness at palpation over the axillary vein; palpation of
a hard venous cord in the axilla; oedema of
the forearm .
b) Isolated thrombosis of the subclavian vein: pain in the shoulder and the neck
on the side of catheterization; oedema of the
inflaclavicular fossa, and of the whole arm on
the side of catheterization; collateral venous
circulation in the shoulder on the catheterize
side.
c) Isolated thrombosis of the innominate vein. Usually, it is clinically silent,
suspected only by impossibility to advance
the catheter into the central venous system.
Attempts to catheterization via the subclavian
vein are followed by placement of the cathete
tip into the ipsilateral intemal jugular vein
or a superficial vein of the neck, or shoulder
With attempts to catheterization from the inte
nal jugular vein, the tip of the catheter is
directed into the ipsilateral subclavian/axill
veins. When extended to the intemal jugular v

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS


57)

oedema of the ipsilateral side of the neck.


exophtalmos on the affected side, and symp toms of cerebral oedema, eventually ending
with patient's death. When extended to the
ipsilateral subclavian vein, the symptoms
are identical to thrombosis of this last
vein.
Distribution of thrombi in the centtral veins(most usual locations) is indicated in Fig. 82.

Fig. 82. Diagram illustrating usual locations of


the thrombi in the central veins (according to
MUller & Blaeser, 1976).
d) Thrombosis of the superior caval vein
("Cava-syndrome"):
. . suffusion of the face, neck ,
upper extr~~t~es, dyspnea, cough, dysphagia,
and/or prom~nent venous collateralization).
DIAGNOSIS
The diagnosis is based on:
a) Clinical symptoms and signs (see above) .
b) Phlebography (venography). __This method is
the m6st accurate paraclinical investigation for
diagnosis of thrombosis of the central veins iE!g.
11. However, the method is expensive, invasive
(requires peripheral venous access), and uneorofortable for the patient . Further, contrast injections
have been reported to make upper extremity venous
thrombosis worse, and even to cause recrudescence
after a long interval, and therefore should not be
performed.
c) Radionuclide venography correlates well with
clinical and angiographic findings in occlusion of
the superior vena cava. Further, this technique
has the bonus of including a lung scan as a screening maneuver that is less invasive than the contrast venography. The method is presentely under
evaluation.
d) Visualiz.ation of thrombi by Doppler techni~
With this method, only major occlusive
thrombi may be detected to-date.
e) Magnetic resonance proroises to be the method
of the future for evidencing the thrombi in the
central venous system. The method has the a~vantage
of all three planes reliable detection of the intravascular thrombi. This is non-invasive, does not
use contrast media (an advantage in patients not
telerating radio-opaque dyes), and does not expose

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

Fig. 84. Substraction angiogram indicat i ng


thrombus partially occluding the right sub<
lavian vein (arrow). Contrast flows around
the clot and through the cellaterals i nto
the superior vena cava (according to
Ki nnison et al., 1986).
iodine necessary to perform a diagnostic
study is approx. 3 times less than with th
veography; ii) the contrast may be r educed
from 60-70% concentrations to 20% iodine
concentration (d i l ute contrast is less pail
ful to the patient); iii) digital substtraction angiography makes easier to esta
lish patency of the inneroinate veins. Di sa'

THE GOTHENBURG eve-GROUP


58)

fL

vantages: i) motion artefacts eaused by heart


activity or respiratory movements; ii) patients
cooperation is necessary to perform the study.
4) PROPHYLAXIS
i) Use of soft (silicone elastomer and
polyurethane) catheters; ii) Inserting the
catheters preferentially via the right sided
veins; iii) Locating the catheters in the
right atrium in patients needing long-term
regimens of total parenteral nutrition and
cytostatics; iv) Prophylactic anticoagulants
in patients with history of thrombosis and
laboratory investigations indicating an
accentuated trend towards hypercoagulation;
unfortunately, prophylactic administration of
heparin may be contraindicated in patients
with advanced malignancies submittet to cytos
tatic treatment, it is in those patients representing the highest risk for thrombosis of
the central veins (the heparin can not be
added to most cytostatics because of chemical
incompatibility).

streptokinase therapy include major


gastrintestinal haemorrhage, and haematuria .
- Urokinase was used by
Zimmerman et al. in 1981, in 18 cases,
starting from the hypothesis that the unproblematic dose actjustments and laboratory
controls of the treatment might reduce the
possible incidence of the bleeding encountered with streptokinase therapy. The initial
leading doses range from 150,000 to 250,000
IU, and are injected iv within 5 minutes .
The initial maintenance dosage of urokinase
ranges from 1,000 to 2,000 IU per kg body
weight and hour, for 12-36 hours (however,
lower dosages, e.g 400 IU per kg body weight
and hour, proved to be effective). Urokinase
is associated with heparin (15 IU/kg b.w.
and hour) given intravenously, simultaneausly
with the urokinase. For further therapy
(after 12-36 hours), the doses are adjusted
according to the alteration of coagulation
parameters, aiming at a fibrinogen concentration of 50-100 mg%. Heparin is given to
attain a prolongation of the clotting time
5) TREATMENT
2-3 times longer than the normal, and a PTT
i) Prompt withdrawal of the catheter
(partial thromboplastin time) 1.5-2 times
at the first signs of axillosubclavian vein
the normal value. A shortened euglobulin
thrombosis is recommended by most authors.
lysis time correlates with the lysis of the
However, in some high risk patients--when
thrombi, and appears to be the best test for
insertian of a new catheter by another route,
monitoring of the fibrinelytic therapy. Blood
e.g. subclavian or intemal jugular is assocoagulation analyses should be carried out
ciated with the risk of life-threatening componce or twice a day. Fibrinelytic therapy
lications-- the catheter may be maintained inwith urokinase should be carried out for at
place if systernie anticoagulant therapy is
least 2 days beyond the attainement of comimmediately started.
plete clinical resolution. After completion
of fibrinelytic therapy, anticoagulant theiL) Physiotherapy: arm elevation and the
rapy with heparin is carried out for 6-10
application of moist heat for symptomatic relief
days, followed by oral eaurnadin for an addiof swelling and pain.
tional 1-2 month-period. The results of
iii) Local application of HirudoidR-ointfibrinelytic treatment should be controlled
ment 3 times a day may enhance regression of
by phlebography. When the phlebographic finthe thrombi by activating fibrinolysis.
dings have improved, but a substantial occlusion of the central veins is demonstrated ,
iv) Systernie anticoagulation therapy.
a seeond period of fibrinelytic therapy
- standard heparin therapy should be
should be initiated. The duration of treatgiven intravenously for 5 to 7 days following
ment varies from 7 to 10 days. In 82% with
catheter removal: 5,000 IU as leading dose, and
recently developed thrombosis (8 days, or
thereafter 500 IU per kg body weight and day.
less), a nearly complete deobliteration of
The daily dose may be fractioned in 4-6 i.v. inthe central veins is obtained. The sidejections, or given continuously by an infusion
effects of urokinase therapy appear as clipump. If the catheter has not been withdrawn,
nically not-asignificant: febrile reactions
the daily heparin dose may be added to the infu- 11%; slight bleeding from venipunctures
sed solutions. In this way, it is probable that
- 3%; microscopic haematuria - 28%.
a higher concentration of heparin may reach the
central thrombi than when the heparin is given
vi) Antibiotic therapy. Routine antibio
by another vein,or subcutaneously. Thereby, lysis
tic therapy does not appear necessary, since
of the thrombi and resolution of the symptoms
the fever generally resolves after removing
are hastened.
the catheter. Massive antibiotic therapy
- eaurnadin therapy for "prophylaxis"
should be initiated and maintained in the
of recidives--after heparin administration-cases of associated catheter-related infectshould be given for an additional l to 2 monthtions and sepsis, and in suppurative thrombo
period.
ses.
v) Fibrinelytic therapy. This is indicated
vii) Surgical treatment may be indicated
in the thrombosis of the central veins extending
in the case of suppurative thrombophlebitis,
to the interna! jugular and subclavian veins, in
e.g. resections of some veins,(e.g. axillar i
the superior vena caval syndrome, and when the
prophylactic vein ligatures, fasciotomias or
anticoagulation therapy is insufficient, or thromthe affected limbs (to decrease oedema and
bosis is older than 7 days. Two fibrinelytic agents
prevent contractures and functional disabiare presently used:
lity of the extremity). However, these las t
- Streptokinase 120,000-125~00 IU per
proeectures are not always efficient, and
hour for 12 hoursis usually given. Addition of fresh, long-term plastic reconstructive surgery
frosen plasma is necessary to provide plasminogen
may be necessary to improve functionality of
substrate hastening clot-lysis. The hazards of
the affected limbs.

CENTRAL VENOUS CATHETERIZATION

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).

iii) Use of a hub non-soldered to the


shaft (e.g. Secalon-Universal catheters
provided with removable hub-flow interruptor- Floswitch);
iv) Use of infusion pumps lacking airdetector devices;
v) Accidental cutting-off of the
catheter (typical complication of the
catheters inserted via the internal jugular
veins in male patients using a razor blade
for shaving).
c) After withdrawal of the CVC
Usually, with large-bore CVC (e.g.
multi-lumen,dialysis, and pulmonary catheters) which have been in-place for more
than 2 weeks, a fibrous cract develops
around the catheter, and a communication
between the patient's central venous system
and atmosphere is established.Aircan be aspirated from the atmosphere--through the
fibrous tract--into the central venous
system, during inspiration
2) PATHOPHYSIOLOGY
a) The seriousness of an episode of
air-embolism is determined by: i) the
quantity of aspirated air (20 mlfseeond
cause symptoms, and 100 mlfseeond -death);
ii) Patient's position; iii) adaptability
of patient's cardiovascular system.
b) Air-bubbles 30 to 40 millimicron
in diameter behave like plastic solids
and lodge in the small pulmonary vessels,
right ventricle, and right atrium.
c) The resulting foamy collection of
blood and air obstructs the right ventricular outflow tract. Thereby, the pulmo. nary resistance increases, leading to significant elevations in right ventricular
and pulmonary systolic and diastolic pressures with a decreas e in le f t heart and
aorta pressures.
d) The air obstruction is enhanced
by formation of fibrin inta the pulmonarv
capillary vessels secondary to the churning effect of the air and blood.
The inter-relationshio of the phenoeecurmena characterising the .events
ring in air-embolism is presented in the
Fig. 85.

3) SYMPTOMS AND DIAGNOSIS


a) Neurologic symptoms: i) lightheadedness with confusion (at the beginning ) ;
ii) aphasia or/and neurologic deficit
(hemiplegia) - later. The central venous
system alterations may be due to hypoxia
and decreased cardiac output, or to accidental passage of air-emboli inta the
b) After insertian of the CVC:
arterial circulation with, or without, a
pre-existing cardiac defect.
i) Disconnection of the infusion system
from the catheter (Luer lock-connections are not
b) Respiratorv symptoms:substernal pain ,
used).
tachypnea, dyspnea, and finally - apnea,
ii) Fracture of the catheter, .. or separation of its hub from the shaft (~onstruction fault); associated or not with cyanosis.

THE GOTHENBURG eve-GROUP


60)

Venous air embolus

outflow tract obstruction


Acute right
ventricular dilatation

Markedly decreased
left ventricular output

Failure of pulmonary
circulation

Lack of blood for gas


exchange

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)

c) Cardiovascular symptoms: tachycardia,


cardiovascular collaps. On auscultation of the
chest, a wide variety of heart sounds are associated with air-embolism. Characteristic is the
so called "mil l wheel" ("bruit de moulin").
d) Digestive symptoms: nausea (very initial symptom).
4) eOMPLieATIONS
a) Paradoxical air-erobolism to the hrain
in patients with persistent high-to-left shunt
(e.g. persistance of foramen ovale). In these
patients, even 2-3 ml of air can cause cerebral
damage and eventually death.
b) eoronary air-erobolism (in the same conditians as above).
c) Acute respiratorv distress syndrcme
(ARDS) manifested by dyspnea, increased respiratory effort,severe intractable hypoxemia due
to intrapulmonary shunting of blood, diffuse
pulmonary infiltrates on chest radiograms, and
decreased lung compliance.
d) Lethality: i) Treated patients:30-40%;
ii) Untreated patients: ~ 90%.
5) PROPHYLAXIS
Virtually, all cases of air-erobolism can be
prevented. Therefore, prophylactic measures must
be undertaken during the insertion, after the insertion and during indwelling, and at withdrawal
of central veno~s catheters.
a) At insertion: i) Hypovolemic patients
should be rehydrated before central venous catheterization (if possible); ii) Inserting the eve
in Trendeleburg (20-30) position; iii) setting
PEEP of 5-10 cm H2o on the intubated pat~ents;
iv) Asking the patients to perform Valsalva's

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~

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS


61)
6) TREATMEN'I

i) Left lateral decubitus (Durant's


position). The efficacy of such a position
was believed to be related to the fact that
the outflow tract assumes a location inferior
to the body of the right ventricle with air
subsequently displaced to the more superior
position of the ventricle. Durant's position
combined with the use of steep Trendelenburg
position will increase such displacement.
ii) Aspiration of air from the catheter should be atempted, especially if it lies
within the right atrium or ventricle. Air can
be aspirated by a Swan-Ganz catheter during
its withdrawal from the pulmonary artery.
iii) Administration of 100% oxygen via
a face mask, or a tracheal tube.
iv) Less commonly used therapies:
- Emergency thoracotomy and needle
aspiration of the right ventricle;
- Hyperbaric oxygenation;
- Heparin infusion after resusscitation to prevent fibrin formation in the pulmonary cappilary, and occurrence of ARDS.

IV. CATHETER EMBOLISM


l) RATE OF OCCURRENCE
The rate of. occurrence is largely dependent on experience of the physician. In 1978,
Burri & Ahnefeld collected and evaluated 315
cases reported in the literature. A rate of
1% was reported with the silicone elastomer,
Hickman-Broviac CVC inserted percutaneously
via the subclavian vein.
2) RISK FACTORS
a) Type of material and conception of
CVC:
i. Inherent design and construction
faults, e.g faulty bonding of catheter shaft
to hub (Fig. 86).

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. 86. Diagram. Up - hub separated


from the shaft,causing catheter embolus;
Bottom - intact catheter (according to
Sprague & Sarwar, 1978).
ii) Catheter with removable hubs (e.g.
Viggo's Secalon Universal-65 to be used with
tunnelling of the shaft).
iii) Catheters made of materials having
poor mechanical properties (e.g. silicone elastomer). Approximately 1.0% catheter emoolization
was reported with Hickman-Brovi~c double-lumen

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).

THE GOTHENBURG CVC-GROUP


62)

e) Withdrawal of the catheter without


fastenly gripping it. This encountered to
the unexperienced operators after cutting
off of the sutures fixing the catheter to
the skin. During a forced inspiration, or
in patients submitted to mechanical ventilation, the catheter may be aspirated into
- the central veins if i t not hel d firmly.
The reason is formation of a tunnel around
the catheter after 2 weeks of indwelling.
So that, no friction exists between the
catheter and patient's tissues. The complication occurs during withdrawal or exchange of the catheter.
3) MECHANISMS
a) "Cutting-off" of the catheter:
- at its withdrawal from steelneedles provided with sharp bevel edges:
- by a razor-blade, during shaving,
in male patients having CVC inserted via
the external/internal jugular veins;
- during the insertion (with the
knife, or scissors),by an absent-minded
minded operator or assistant.
b) "Broken off" (rupture) of the
ca theter
- forceful injection of saline to
clear the line (with soft, silicone elastomer catheters, having poor mechanical
properties);
- explosion, blowing-off the
connection (on the battle-field).
- wearing of the catheter at a
eonstant point of compression ("pinching"),
e.g. with the large-bore Hickman-Broviac
catheters inserted percutaneously via the
subclavian veins, and cronically pinched
between the clavicle and first rib.
c) Separation
- Faulty bonding of the catheter
shaft to hub (see figure 86);
- Gutting-off mechanism;
- Withdrawal of the ca:heter by an
agitated, unconscious patient: the sutures
fixing the catheter to the skin may cut
the catheter, separating it.
d) Tearing-off of the catheter
- inadverted tearing during the insertian by a knife, needle, scissors, etc.;
- forceful flushing.
d) "Disappearance of the catheter"
- Disconnection of the hub and
aspiration of the catheter into the central
venous system with inspiration (causing a
negative pressure in the system);
- During exchange, or withdrawal of
the catheter (see paragraphe 2-e).
4) SITE OF EMBOLISM
i) Peripheral veins: 22% (with the CVC
inserted usually from the peripheral veins,
e.g. basilic, cephalic, and externa! jugular
veins.

ii) Central venous system (Figs. 88-89)


with the catheters inserted via the subclavian,
and interna l jugular veins, and mo re rare ly
with those introduced via the peripheral (basilic
and cephalic veins).

PC

Fig. 88. Diagram showing the usual sites


of the embolized catheter fragments (according to Burri & Ahnefeld, 1978)

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).

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS


63)

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)

catheters inserted via the subclavian veins


when radiological evidence of significant
catheter compression ("pitching") exists;
iii) Avoiding forceful flushing of the
soft, sLlicone elastomer catheters;
iv) Performing a chest X-ray at 2-to
3-month intervals in the patients having
a large-bore, silicone elastomer, BroviacHickman catheter inserted via the subclavian
vein, to identify signs of catheter pitching
(-''fish-mouth"--image) between the clavicle
and first rib;
v) Not-applying wrapping adhesive tape
around the catheter to stop the leak from a
damaged CVC; the catheter may rupture under
the tape;
vi) Not-applying ointments at the insertion site (the ointment may cause slipping
of the catheter out of the anchoring sutures ) ;
vii) Not-using the CVC for performing angiographic procedures: the high pressure
occurring within CVC during injection of the
contrast medium may cause rupture of the
catheter into the central veins, and embolization of the ruptured fragment.
d) During exchange and withdrawal
i) Concentrate your attention on all
steps of the procedure;
ii) Grip firmly the catheter before
the sutures fixing it to the skin are cut;
iii) Do not release the grip how long
the catheter is still intravenously inserted.
7) TREATMENT

When a catheter-embolism occurred,


the following measures must be immediately
undertaken (in sequential order):
a) Apply compression proximal to the
catheter entry site along the whole course
of the catheter until its entrance into the
thoracic cage;
b) Ask the patient not to move the
catheterized extremity: the catheter may
move further, to a more remote point,
into the central venous system with flexion
and extension of the extremity and muscle
contraction;
c) Try to palpate the catheter subcutaneously. There are 2 possibilities:
i) The catheter can be palpated.
Proceed as follows:
- infiltrate the skin with a
local anaesthetic solution;
- make a transverse incision
on the catheter course whilst keeping the
compression applied;
- identify the catheter by opening the fine connective tunnel surrounding
i t;
- take a fast grip on the catheter with a forceps (haemostat);
- release the compression, and
withdraw carefully the embolized fragment
whilst continuing to make a fast grip on it .
ii) The catheter can not be palpated.
If so, the central embolization of the fragme

THE GOTHENBURG CVC-GROUP

is most probable. Do the following:


- Try to identify the location of
the embolized fragment by thoracic radiographs (radio-opaque catheters),or by echocardiographic or angiographic procedures
(radiotranslucent catheters); ask the radiological department for expert advice and
help with retrieval procedures;
- Inform the departments of thoracic and cardiovascular surgery about the
complication, ans apply for expert advice
and help (possible thoracothomy and eardievaseular surgery).
d) Withdraw the embolized fragment. In
spite of the opinion emitted by Benedict (1970)
that "to try to remove broken-off pieces of
catheter 1s more traumatic and more dangerous
than to leave the harmless ca theters a lene",
attempts to withdraw the embolized catheter
fragments must be undertaken. One must not
forgetthat the Court can decide that the_company manufacturing the catheter, the hosp1tal
concerned, and the personnel responsible for
the insertion are liable for a catheter embolism and its complications . .
EXCEPTION to thls rule is the catheter
embolism occurring in patients with terminal
diseases, not enough fit to support the su:gery necessitated for removal of the embol1zed
catheter.
The following methods of withdrawal
of the embolized catheter fragment have been
developed:
i) Transvenous extraction of the
catheter using:
- Loop-carrying catheters (Fig.90);

Fig. 91. Forceps used for transvenous


extraction of embolized catheter fragments
(according to Burri & Ahnefeld, 1978)
have the following disadvantages: they are
absolutely or relatively rigid, associated with
a danger of venous wall perforation and s~vere
injuries to the vein intima or/and endocardiurn.
- Hooked catheters (Fig. 92). The
tip of the catheters can be straighte':le~ w~th
a deflecting guide-wire, so that the 1nJur1es
to the tricuspid valve or/and papillary muscle,
endocardiurn and vein walls may be prevented.

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).

- Fogarthy catheters. The use of


these catheters is especially indicated for
embolized fragments located above the right
atrium, or in peripheral veins.
ii) Direct (surgical) approach to ~e
embolized fragment intervening on a per1pheral
vessel or on the central venous system (thoFig. 90. Diagram of the "loop-carrying" catheters. racoto~y) with a lethality of approx. 4%.
(According to Burri & Ahnefeld, 1978)
The
method is very effective, and in 51.2% of
the embolized catheter fragments it was successful in withdrawing of the fragment. Further, ~t
is -:;imple and safe, and can be used anywhere 1n
emergency conditions, without any trouble.
- Endescopy forceps (Fig.91), e.g.
flexible bladder forceps, stomach biopsyforceps,
myocardium biopsyforceps,etc. These instruments

V. EROSION OF THE VEIN WALLS


l) PREDISPOSING FACTORS
i) Use of stiff, TeflonR, polvethylene and polyvinylchloride catheters;
ii) Turbulent venous blood flow
- at the junctions of:the intemal

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS


65)

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.

right ventricle, pulmonary artery (SwanGanz catheters).


OBS. Approx. 9% of the severely burned
patients may develop acute right-sided
endocarditis, and 1% of all eve-patients.

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

i) Withdrawal of the catheter followed by


new insertion via another route;
ii) Treatment of complications:
- pleural infusion (chest drainage);
- pericardial infusion (pericardicenthesis);
.
- haemomediastinum (transpleural/suprajugu!ar dra~nage- seldom necessary);
iii) Direct approach to the injured vein
or atrium _and surgery (seldom neces~ary)

3) TYPE OF LESIONS AND THEIR LOeATION


a) ~ endocardial (interstitial)
haemorrhages; vegetations (infected, or noninfected platelet-fibrin thrombi).
b) Locations: i) Superior vena cava
at its junction with the right atrium; ii) The
region of the coronary sinus, usually just
above and medial to it; iii) The tricuspid valve (one or more cusps,atrial surface and/or
chordae); iv) The pulmonic valve- one or
more cusps; v) The right ventricular outflow
- subpulmonic area.

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.

VI. LOCAL INFECTIONS

VII. ACUTE RIGHT-SIDED ENDOCARDITIS

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

a) Local. Attempts to sterilize


the in-place C.V-catheter by: i) Instillation
of 1.5 ml 2M hydrochloric acid (contact tLIDe
two minutes); ii) "Antibiotic-lock" ? (see
later in this compendium)
b) General antibiotics .

THE GOTHENBURG CVC-GROUP


66)

VII. CATHETER-RELATED SEPSIS

c) Other infection foci in the body


(haematogenous infection): less than 1.0%.

l) RAIES
3) BACIERIOLOGICAL FLORA

Largely dependent on the vein approach,


type of infusion, and patients' condition.
a) ~lf-way"-CVC: 0.32% - l episode for
2,429 catheter-days.
b) "Long-way" - brachial CVC: 0.4% - 1
episode for 2,000 catheter-days.
c) Interna! jugular CVC: 0.92-2.76%.
d) Subclavian CVC: 2.8-7%.
With interna! jugular and subclavian
CVC - l sepsis episode for 60 to 658 catheterdays was reported.
e) Femoral CVC: 5-20%.

The bacteriological profile of the catheter-related sepsis is presented in Fig. 95.

D
~

CATM(T(It

''~

ISOL,fr.f(J

k.OOO rso...t.T($ 'ltOW CAfM(T( -4S:SOCIAT[ O


K"TIC(IIft&

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

Fig. 93~ Diagram illustrating the routes for


centamination of the central venous catheters
b) Infusion fluids: approx. 25% of cases.
The infusion fluids may be contaminated:i) during manufacture (less than 0.1%), and ii) during manipulations and administration (Fig.94).
C'"'t..-ntnltfOtlln-U ..
fE11trtiUICI

Ou""' Menuhcture

- + - - - O u r+ng compoul'ldlt'IQ

====Attxtunv .c:Jmtniurahon wts


Ch~+"9

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

T opoc:! apphc at +Dt1S

ISktn an11Mpt ics.

=====-

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}

"-' <'-'"-~-- Contamonatton ..,oon tnwuon

--+-- Mn+pulating cannulas.'

MinHmUraton Mt junthons
Cannuta echan4Je

Fig. 94. Diagram showing possible ways for contaroination of infusion fluids (according to
Maki et al., 1973)

The following pathogens are usually


cultured from the catheter-tips and blood:
Staphylococcus epidermidis; Staphylococcus
aureus (particularly in the burned patients);
Candida albicans (in the patients submitted
to broad-spectrum antibiotic therapy, radiatio1
and steroid therapy); Klebsiella- in patients
receiving antibiotics; Corynebacterium (in
immunosippressed, bone marrow transplanted patients); other micro-organisms (Gram-negative
and Gram-positive rods, Bacteroides, Enterococ
4) RISK FACTORS
a) Patient's age: more frequent in new bor
and small infants, and adul ts over 40 years.
b) Severe illness: malnutrition; multitrauma; transplantation; immunosupression;
bums; cancer; chemotherapy; presence of remot
infectious foci (tracheostomy, pneumonia,
urinary infection, intra-abdominal abscess);
presence of sepsis during catheterization etc.
c) Venous route: more frequent with: i) th
Internal jugular CVC (contamination of the
lines with Staphylococcus epidermidis from
patient's nose and mouth, presence of beard
in men, and thus more difficult care of the
insertion site); ii) Subclavian CVC (presence
of hair in men, vicinity of nose, mouth, and
possible tracheostomy); iii) Femoral CVC (vicinity of anus and genitalia, presence of hair
and possible infected wounds or urostomy/colos
tomy bags, more difficult care of the insertio
site).
d) Repeated catheterizations: 22% contaminated catheter tips vs 15% with 1st catheterization.

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS


e) Concurrent thrombosis/phlebitis: the
thrombi act as an excellent trap for bacteria
carried by the blood stream, and as a site for
subsequent bacterial multiJ?lication, leading
to high yield on culture.
f) Vein approach: 41% contaminated cathe_ter tips with cut-down vs 5% with yenepuncture.
The cut-down may be associated with up to a
ninefold increase in the incidence of bacteremia when compared to the percutaneous venepuncture.
g) Number of attempts to percutaneous
venepuncture: 2 or more insertion attempts increased colonization of central venous catheter
tips by 10%.
h) Catheter material and type: stiff, large
bore (multi-lumen) catheters increase the rate
of catheter-related sepsis.
i) Catheter fixation: fast fi xation (sutures) avoids to-and-fro (in-and-out) catheter rnavements and transport of bacteria from the skin
to subcutaneous tunnel and blood stream.
j) Use of the central venous lines: including of three-way stopcocks, calibrated plastic
chambers, monitoring devices, and repeated use
of medication injection ports may increase the
risk for catheter colonization and related-sepsis.
k) Infused solutions: buffered isotonic
glucose and hypertonic glucose solutions support
the growth of Candida albicans; lipid emulsions
facilitate the growth of Gram-negative bacteria;
amino-acid . solutions support the growth of
Candida albicans; blood transfused through the
lines may favor catheter centamination and catheter-related sepsis with Klebsiella.
l) Compounding and storage of parenteral
nutrition solutions: i) Compounding: to minimize
extrinsic contaminationof the TPN-fluids, they
should be compoundedor admixed in a central or
intravenous additive pharmacy, using strict aseptic technique in a well maintained laminar flow
hood. ii) Storage: the TPN-solutions should be
administered promptly, or stored at 4 C until
use. The solutions should be administered within
24 hours of compounding.
m) Use of "heparin-lock" increases the risk
of infection.
n) Duration of catheterization: duration of
catheterization and daily risk of catheter-related sepsis are not correlated over a 4-month interval (if the care of the CVC is correct). Thus,
the recommendation to exchange the catheter every
other week to prevent catheter-related sepsis is
statistically unfound.
o) Absence of an intravenous therapy team:
42% catheter sepsis vs 13% of suspected or
documented catheter-related sepsis when a i.v.
therapy team exists.
5) SUSPICION ON CATHETER-RELATED SEPSIS
a) Patient having a CVC i nserted;
b) Clinical symptoms and signs of sepsis
(fever, chillings);
c) No other clinically evident remote
infectious foci.

67)

6) DOCUMENTED CATHETER-RELATED SEPSIS


a) Before withdrawal of the CVC:
i) Conditions and signs of suspected
catheter-related sepsis;
ii) Positive (quantitative) cultures
of the blood withdrawn from the CVC and a
peripheral vein indicating growth of the same
bacteria in both the blood samples with a
number of colonies 10 times higher in the
blood from the CVC than in that from the peri pheral vein, or more than 10,000 colonies pe r
milliliter in the CVC-blood.
iii) No other remote infectious foci
were found by paraclinical investigations.
b) After withdrawal of the CVC
i) The same conditions, signs and
symptoms as in 5-a,b,c and 6-a.
ii) Positive cultures for the same
microorganism in both the blood and CVC-tip;
iii) Disappearance of sepsis symptoms
and signs after withdrawal of the catheter
(however, a later effect of the therapy
--e.g. in the patients treated with antibiotics--can not be excluded with certainty).
7) PROPHYLAXIS OF THE CVC-RELATED
SEPSIS
a) Presently not documented (valid)
recommendations:
i) Routine tunnelling of the CVC.
The belief that routine tunnelling of the
catheters (particul~rly when the CVC is provided with a Dacron -cuff eausing formation
of adherences betwen the tunnel and catheter )
could not be confirmed in controlled clinical
studies. However, the tunnelling might be
indicated each time when the insertion site
of the catheter is located in the vicinity
of an infection focus (e.g. tracheostomy,
colostomy, etc.).
ii) Using in-line Millipore filters .
Arguments against use of the in-line filters:
- The in-line filters are ineffective
againts bacterial spores and toxins;
- The in-line filters reduce the infusions
flow rates under the clinical necessities; t e
obtain adequate infusion flow rates, the use
of pumps is mandat9ry;
- The in-line filters may bind some drugs
reducing their potency, when administrated ir
clinically acceptable dosages;
- High cost: the cost/effectiveness of thE
in-line filters is not yet documented;
- In-use contamination: any manipulat i on
at, or below, the in-line filter may contaminate the system.
However, the filter might have some ~
special indications:
- CVC inserted inta neonates;
- burn patients;
- leukemia patients;
- tranplant pa~ients;
- immunesuppressed patients.
iv) Adding heparin to the infusates
One believed that addition of 5,000-6,000 I U

THE GOTHENBURG eve-GROUP


heparin/day to the iniusates might prevent
thrombus formation at the tips and around
the catheters ("fibrin-sleeves") thereby
inhibiting seeding of the thrombi by the
bacteria circulating in the blood. The
results obtained to-date regarding the efficiency of the method are contradictory, and
the Department of Health of Sweden (Socyalstyrelse) strongly discourages addition of
heparin to the infused solutions. Furthermore, the expense connected with such a prophylactic measure is not justified by the
protection it offers.
v) Avoiding flushing of the eve-lines.
One believed that flushing might transport
bacteria from the line to the blood stream. A
large,clinical experience demonstrates that this
recommendation is untenable. Flushing is many
times indispensable to keep patency of the lines
and avoid their withdrawal.
vi) Avoiding withdrawal of blood from
a eve used for total parenteral nutrition.
The higher risk of occurrence of eve-related
sepsis when this practice is used is not demonstrated. Furthermore, in many clinical
conditions, when the patients has no other
approachable vein, the eve is the only one
existing route for blood sampling. Even
when a supplementary route is available, blood
sampling from the eve-line aveids patient's
discomfort and suffering.
vii) Avoiding the use of a single-lumen
eve-line for multiple purposes, e.g. blood sampling, infusion of TPN-solutions, measurement of
evP, blood transfusion, administration of medications, etc.). This recommendation is also
untenable on the basis of good common clinical
sense, at least in the patients in whom the above
mentioned uses of theeveare necessary, and the
patients have no other p~acticable venous routes.
viii) Changing the tubing {infusion system)
used for administration of total parenteral nutrition solutions every 12-24 hours. This recommendation is not supported by bacteriological
studies performed in England and Canada. !hese
studies demonstrated that exchange of the system
every 24 hours provides little additional protection campared with the exchange of the system
at every 48 hours (Buxton et al., 1979), and
evenatevery 72 hours (Bond & Maki, 1979). One
must stress that exchange of the infusion systems
every 48-72 hours may give important savings to
the hospitals and communities. One should not
forget that the resources available for infection control are limited, even for most riches
countries of the world. However, the infusion
system should be exchanged each time blood or
fet emulsions were given through the eve-lines,
as well as when inadvertent centamination of
its junction components has occurred.
ix) Wiping administration set lines with
tincture of iodine or iodophor at least daily
and immediate before any manipulation of the
svstem and maintainence of the iodine or iodophore in-place with sterile gauze sponge at all
tubing junctions. This practice is cumbersome,
and its clinical significance is not demonstrated.
x) App lying antibiot i c s local"ly, at the.

68)

insertian site, during the dressing of


the site. This practice is not anymore
used. The local antibiotics may select
growth of resistant bacteria.
xi) Caring the catheter insertian
site with sterile mask, gown, and glowes.
The additional, little protection is not
justified by the east. Caring of the insertian site with clean, washed hands (soap
and tap water} is sufficient, as it demonstrated by the everyday clinical practice.
xii) Thermal treatment of the eve-hub.
This recommendation was based on the belief
that the hub is an important source of
infection predisposing to the eve-related
sepsis. Two methods were recommended and
used:
- Flaming {burning) of a metal
catheter hub (Holm, 1972). Disadvantages
and dangers: the method is not practicable
with the present catheters provided with
hubs made of plastic materials; even with
metal hub, flaming of the hub may cause
damage to the catheter exposing to soiling
of the infusates, air-and catheter-embolism; flaming the hub with an alcohol flame,
daily,is extremely risky in the patients sub rnitted to concomitant oxygenotherapy, and
may cause severe bums and even explosions
(Malmvall et al., 1980); burning of the hub
is not effective against bacteria and yeasts
vehiculated from and with the infusates,
against the infection vehiculated around
the catheter (in its subcutaneous tunnel),anc
from the catheters (bacteria entraped in
the precipitates of parenteral nutrition
solutions),and those seeding possible thrombi formed at the eve~tip.
- Electric,thermal treatment
{370) with a solder pencil(Schildt et al.,
1979) has the same inconvenient as the precedent method. In addition, this method
neccessitates an extra-equipment which is
relatively expensive.
xii) Routine catheter exchange each
(Malmvall et al., 1980), or each other
(Bozetti et al., 1982) week. The recommendation is based on a statistical significance defying the common,good,large clinical experience accumulated to-date with
the not-exchanged catheters. We strongly
discourage the routine exchange of the evelines, as it is not supported by evidence.
xiii) Systernie antibiotic therapy. This
method did not decrese the rate of colonization of the eve-tips or bacteremia rate,
but might increase the incidence of everelated sepsis with resistant Gram-negative
bacteria, or fungi (eleri et al. ,1980; All e
a981).
b) Presently valid recommendations
i) Maintenance of the infusion sys tem at all times as a "closed system".
ii) Daily inspection of the insertian site for possibe infection.
iii) Dressing of the insertian site

69)

CENTRAL VDmUS CATHETERIZATION - CLINICAL ASPECTS


on a regular basis (usually once a week,
and every time the dressing is wet, or
dirty).
8. TREATHENT OF THE CVC-RELATED SEPSIS
a) CVC-related sepsis is suspected :
Look at the insertian site or/
and tunnel:
*) Insertian site and/or the
tunnel are infected:
i- withdraw the catheter;
ii- culture the insertian site,
blood from the catheter, and
catheter tip;
iii- insert a new CVC via another
vein approach, if necessary;
iv- start general (i.v) antibiotic treatment;
v- open and drain the tunnel,
if it is infected (suppuration).
**.) Insertian site and/or the
tunnel are not infected:
i- inform the members of the i.v.
therapy team (if such a team exists in the
hospital): expert clinical judgement and laboratory support is required to determine the
probable site of infection and decide whether
the catheter should be removed or not; .
ii- perform 3 blood cultures from
a peripheral vein (not invalved with the
catheter),and from the catheter; before sampling the blood, clean the hub of the catheter
(or the 3-way stopcock) with 10% iodine solution,or 0.5% chlorhexidine in 60-70% alechol; use sterile gloves in sampling the blood;
iii- ask the laboratory to culture
the blood samples for growth of both aerobe
and anaerobe bacteria, and yeasts (fungi);
iv- ask the laboratory to perform guantitative, or at least semiquantitative cultures;
v- wait minimum 72-96 hours before
disearding the results as negative;
vi- culture other possible sites
of infection: surgical or tramatic wound,
sputum, secretion from a tracheostomy, pleural effusion, urine, etc.;
vii- ask expert persohnel (surgeon,
orthopedist, vaseular surgeon, radiologist)
to examine the patient for possible other infectious foci: pneumonia; urinary infection;
intra-abdominal post-operative complication
(abscess) or ac~te disease (e.g. chelecystitis, appendicitis, diverticulitis, etc);
suppurative thrombophlebitis; osteomyelitis
of the clavicle (when attempt to suclavian
venipuncture was made, or the CVC has been
insertedvia the subclavian vein), etc.;
viii- in order to answer the above
questions special investigations may be necessary: 'thoracic and abdominal radiographs,
total body tomography, ultrasound investigations, etc.
ix- withdraw the catheter only if
this is not essential for patient's treatment;
x- IF THE CVC IS ESSENTIAL FOR PATIENT'S TREATMENT~ DO NOT WITHDRAW IT!!!! .. ~

l&I ~l! 'M ~'Rm~I MAJORITY OF


THE SEPSIS IS NOT CAUSED BY THE
CVC!!!!! .. ~AND THE CATHETER MAY BE KEPT INPLACE AND SERVE THE PATIENT!!.~~
xi- try to sterilize the catheter by
instillation of 1.5 ml of 2M
hydrochloric acid allowing a
centact time of 2 minutes; thereafter aspirate the solution,
and flush the line with sterile
isotonic saline;
leaving an "antibiotic lock" for
30-60 minutes (2-3 tim~s/day), e.g.
clindamycine (Dalacina ) 2-ml (150
mg/ml) + tobramycine (NebcinaR)
2-ml (40-80 mg/ml); this local
treatment may often sterilize an infected
catheter avoiding its withdrawal and the possble complications occurring with a new insertian;
xii- start general (systemic) antibiotic
treatment (use preferentially the intravenous
route, giving the antibiotics via the CVC-line);
xiii- if the infusate is suspected to be
contaminated, culture the fluid and save the
container;
xiv- treat other infection foci (local
antibiotics, surgery) if such foci are identified;
xv- wait for the results of bacteriologic investigations.
~~
CASES~

b) The CVC-related sepsis is confirmed


In such a case, no other infectious foci
could be evidenced and the quantitative cultures indicated 10 times more colonies of the
same microroganism in the blood sample from the
CVC-line than in the peripheral blood.
In such a situation, the following 2
attitudes are possible:
i) Exchange of the catheter. I t is
indicated every time when new insertian appears
particularly hazardous. Disadvantage: possible
centamination of the new catheter by a colonized ,
infected subcutaneous tunnel, of by colonized/
infected fibrin-sleeves and/or tip thrombi.
ii) New insertian is recommend every time
when it is technically possible and not associated with the risk of life-threatening complications.
The systernie antibiotic therapy must be
continued. In spite of the fact that all the
investigations performed confirmed what it was
logical to be considered a "catheter-sepsis",
it is not excluded that this "catheter sepsis"
has been only the clinical ~~d bacteriological
manifestation of an otherway clinically silent
infectious focus (e.g.a suppurative thrombophlebitis in a burn patients, or an intra-abdominal
abscess escaping even the most sophisticated
investigations like datatomography or ultrasonography).
Remissian of the symptoms related to
catheter sepsis after withdrawal of the CVKline is not an absolute evidence that the
catheter was responsible for the septical
episode. The remission may well be. subscribed
to a later effect of the antibiotic therapy.


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)

of obstacles often encountered at the


axilla during advancement of the catheter.
2) AXILLARY VEIN
No reports regarding the use of this
vein approach were published to-date.
3) EXTERNAL JUGULAR VEIN AND COMMON
FACIAL VEIN
Indications: the first choice in neonates and infants.
Approach: i) Cut-down (Fig. 96) or
ii) Percutaneous puncture (the external

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.

II. GENERAL CONTRAINIDICATIONS


There are no absolute contraindications
to central venous catheterization depending on
child's age, body weight, and proportion.

III. EQUIPMENT AND TECHNIQUE


Soft (silicone elastomer or--preferably-polyurethane) catheters and the seldinger insertian technique are strongly recommended.

IV. VEIN APPROACH


1. Cut-down of the externa! jugular veins,
or of the common facial vein (Fig. 96).
2) Percutaneous approach to the femoral,
externall intemal jugular, and subclavian veins
was extensively used in the last years.

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.

VI. PARTICULAR VEIN APPROACHES


l. BASILIC AND CEPHALIC VEINS AT FOSSA
CUBITI
This approach is very seldom used because

Fig. 96. Diagram illustrating ~ut-down


of the common facial vein (according to
McGovern et al.,l985).
jugular vein is well developed and easily
approachable in children, particularly when
crying).
Eguipment: i) Introducer: 4.0-cm long
(Teflon-sheath over steel-needle); 17-G
(1.3-mm outer diameter). ii) Guide-wires:
not Teflon-coated, J-shaped, 0.53-mm diameter, 30-cm long (for the 15-cm long catheters), and 40-cm long (for 20-cm long catheters). iii) Catheters made of polyurethane,
15-cm (small children) or 20-cm (older children) long, 0.75/1.3-mm inner/outer diameters.
Catheters with smaller inner diameter would
increase the catheter occlusion rate (particularly when blood, blood products, and tota l
parenteral nutrition solutions are given
through the lines), and would give false
readings of the central venous pressures.
Tip slipped catheters would facilitate
skin and vein wall penetration.
Technigue of insertion: similar to that
used in adult.
Sucess rate of catheterization lower
than in adults: approximately 50% (Nicolson
et al., 1985).
Particular complications: i) Higher
rate of thrombosis of the externa~j~gular
vein than in adults (10% vs approx. 0.5%).

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS


4) INTERNAL JUGULAR VEIN
a) Eguipment: see extemal jugular vein.
b) Approach: percutaneous - seldinger technique.
c) Insertian technigue (particular details):
i) Anaesthesia. General anaesthesia should
be preferred in small and uncooperative children.
This would avoid accidental perforation of the
vein because of child's unrest, and would increase
the rate of successful insertian up-to that recorded in adults, i.e. more than 9S%.
ii. Patient's position. The venipuncture
will be performed according to recommendation of
Oda et al. (1981) with hyperextension of the neck
accomplished by placing a small pillow (see below)
under the shoulders (Fig. 97).

Fig. 97. Diagram showing position of a child


during percutaneous puncture of the intemal
jugular vein (according to Krausz et al.1979)
iii. Venipuncture. The intemal jugular
vein may be distended asking the child to perform Valsalva's maneuver (older children who
can cooperate), setting PEEP of S-cm H O, or
exerting pressure on the right hypochohdrium
(lever) eausing a hepatojugular reflux.
- A high cervical approach should
be preferred. This will substantially increase
the rate of successful insertion, avoiding
injury to the pleural dome. Altematively,
a posterior~ midcervical approach may be used
(Fig. 98).
- The venipuncture is performed
under continuous aspiration, using a 2-ml plastic syringe, as in the adults. Immediately after
puncturing the skin, O.S milliliter of saline
solution is injected in order to rernove a possible skin plug from the needle lumen (tpe needle
has a very small diameter). The intemal jugular vein is usually entered within 1-2 cm of the
skin surface. After a successful venipuncture,

71)

the sheath (cannula) of the introducer


is advanced not more than O.S-cm in new
born, and 1.0-cm in older children.
iv. Inserting the guide-wire and the
catheter. Theinserted lengths of the
guide-wires and catheters from the insertian sites should be equal with the distances from these sites to the superior
edge of the 2nd rib, parastemal, right
side.
d) Particular complications _(~xcept those
encountered in adults): i) higher rate
of paroxysmal supraventricular or ventricular tachycardia when the guide-wire, or
the catheter has reached the right atrium ,
or the right ventricle. ii) A higher rate
of silent thrombosis of the left innominate
vein (approx. 10%) with the catheters inserted from the left side.
e) Particular contraindications in children:
i) infected bums in the neck; ii) presence of ventriculoatrial shunts. Other cont
raindications are similar to those in adults

Fig. 98 Diagram showing the posterior,


midcervical approach to the intemal ju~
lar vein (IJV). Other symbols: CCA- comme
earotid artery; CHSM - clavicular head of
stemomastoid muscle; CL - clavicle; ECA extemal earotid artery; PL - pleura;
SA - subclavian artery; SCJ - stemoclavicular joint; SHSM - stemal head of sterne
mastoid muscle; SV - subclavian vein.
(According to Chahtrat et al., 1983).
S) SUBCLAVIAN VEIN
a) Basic anatomy. Few data have been
reported on the anatomy of the subclavian
vein in children. Kahl (1973) supposes that
the diameter of this vein in new bom is
of about S.O-mm. In older children, Moosman
(1973) supposes that the distance between
the subc1avian vein and subclavian arterv
would be of S to 8-mm, vs 1S-mm in adults.
b) Eguipment: i) Needle-introducer provided with Teflon-sheath, 4.0-cm long, 1.4
-mm outer diameter (17-G); ii) Guide-wires :

THE GOTHENBURG CVC- GROUP


20 and 30-cm long are adequate for insertion
of 10 and 15 cm cvc; diameter 0.53-mm; straight,
soft tip, non-coated. iii) Catheters: polyurethane, 10 and 15-cm long, 0.75/1.30 mm inner/
outer diameters, preferably with slipped tip.
iii) Special introducers, e.g. a 5-French PeelAway-Sheat Introducer (Cook International) and
a vein dilator of adequate length and diameter
are necessary for insertion of soft, silicone
elastomer catheters (e.g. Hickman-Broviac's
pediatric catheter).
c) Venipuncture. i) Child's position:
like in adults. ii) Distension of the vein
by exerting compression on the liver projection (right hypochondrium), eausing venous
reflux in the superior vena cava system. iii)
Venepuncture with the needle curved at an arch
of apprx. 30. _The vein is encountered within
1-2 cm from the skin. After a successfu veni puncture, the introducing sheath (Teflon -cannula) should be further advanced 0.5-cm in the
neonates and not more than 1 . 0-cm in older
children.
d) Inserting the guiding-wire. A lenght
of guiding-wire equal with the distance from
the puncture site to the superior edge of the
2-nd rib is inserted intravenously. REMEMBER
THAI INSERTION OF THE GUIDE-WIRE INTO THE RIGHT
ATRIUM OR VENTRICLE MAY TRIGGER SEVERE SUPRAVENTRICULAR/VENTRICULAR TACHYCARDIA,PARTICULARLY
IN NEONATES AND SMALL CHILDREN.
e) Inserting the catheter. The distance
from the insertian site to the superior edge
of the 2-nd rib is measured, and a catheterlength equal with the distance is inserted into
the venous system. Nessler (1977) recommends
standard lengths of 4. 5-cm in the new boms ,and
and of 7.0-cm in small children.
f) Rates of successful insertions: 75% to
96%.
g) Particular complications: - Higher rate

72)

thoracic radiographs,the tip of the catheter


should be seen in the inferior caval vein
within the thorax. INTRA-ATRIAL LOCATION OF
THE CATHETER TIP MUST BE AVOIDED.
f) Rates of successful insertions ranging
from 68 to 86% have been reported.
g) Particular complications (in children):
i) Accidental puncture of the femoral artery 14%; ii) Thrombosis of the inferior extremity
manifested by swelling of the leg - 11%; iii)
Spasm of the femoral artery (accidental puncture of the artery) followed by periods of
ternporarv ischemia, and even foot gangrene
(Nasbeth & Jones, 1963); iv) Arteriovenous
fistula; v) Erosion of the femoral/iliac vein
and extraperitoneal infiltration of the infusate.
h) Particular contraindications (in
children): i) Malformations of the lower
extremity; ii) Congenitally dislocated hip;
iii) Contractures of the extremity; iv) All
factors distorting vaseular anatomy; v) Abdominal pathology (e . g. tumours, haematoma, enlarged organs, e.g. hepatomegaly, congenitally
complete interruption of the inferior caval
vein, etc .. ).

VII. GENERAL TECHNICAL DETAILS

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 )

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS

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

Insertian of a central venous catheter is a procedure which must be performed with


ereat accuracy, after a very careful consideration.In indicating the procedure, and choosing the catheter type, technique, and vein approach
''TAKE

ALWAYS

BENEFIT

IN

CONsiDERATION

RATIO,..AND
THE

DO

NOT

TH:E

RISK-

FORGET - - -

ECONOMICS ' '

C>C>C>0000C>C>C>
SELECTED

REFERENCES

I. MONOGRAPHS
L Burr i C, Ahnefeld WF. The caval ca theter. Springer-Verlag, Berlin-Heidelberg.-New

York, 1978, 84 pp.


2. Peter JL.A manual of central venous catheterization and parenteral nutrition.
Wright PSG, Bristol-London-Boston, 1983, 273 pp.

II. PAPERS
l. Aubagniac R. L'injection intraveineuse sous-claviculaire. La Presse Medicale
1952, 60, 1456.
2. Ayim NE. Percutaneous catheterization of the axillary vein and proximal basilic
vein. Anaesthesia 1977,32: 753-9.
3. Blitt DC, Carlson LG, Wright AW, Otto WCh. J-wire versus straight wire for central
venous system cannulation via the externa! jugular vein. Anesth & Analg 1982,
61:536-7.
4. Bor ja RA, Hinshaw RJ. A safe way to perform infraclavicular ;ubclavian vein catheterization. Surg Gynecol Obstet 1970, April:673-6.
5. Bothe A,Piccione W, Alnbrosine JJ, Benotti NP, Lokich JJ. Implantable central venous
access system. Am J Surg 1984, 14 7, 565-9.
6. Boulanger M, Delva E, Maille GJ, Paiement B. Une nouvelle voie d'abord de la veine
jugulaire interne. Canad Anaesth Soc J 1976,23, 609-15.
7. Bregnan H, Hoover M. The double-lumen subclavian cannula. A unique concept in vaseular
access. Dialysis & Transplantation 1982,11, 1065-70.
8. Brinkman J, Costley OD. Intemal jugular venipuncture. J.A.M.A.1973,223,182-3.
9. Burgess EG, Marine JR, Peuler JM. Effect of head position on the tip location of
venous catheters insertedvia basilic vein. Anesthesiology 1977,46, 212-3.
10. Chalfin JL. A single venipuncture technique for placement of multiple central venous
catheters. J Trauma 1983,23,408-10.
11. Chatrath PR, Stock LGJ, Jones HDO. Forum. Intemal jugular catheterization in small
children. The use of a posterior approach. Anaesthesia 1983,3~, 380-5.
12. Cote JC, Jobes RD, Schwartz JA, Ellison N. Two approaches to cannulation of a child's
internal jugular vein. Anesthesiology 1979,!50:371-3.
13. Curelaru I, Linder LE, Gustavsson B. Displacement of catheters inserted through
interna! jugular vein with neck flexion and extension. Intens Care Med 1980,6:179-83.
14. Curelaru I, Wojciechowski J, Zachrisson FB, Hultman E, Gustavsson B, Linder LE.
"Half-way"-venous catheters.II. Anatomoradiological basis. Acta Anaesth Scand (suppl)
(in press).

THE GOTHENBURG CVC-GROUP


15. Deborah SD, Matlak EM, Black ER, Overall CJ, Dolcourt LJ, Johnson GD. Insertion of
small central venous catheters in neonates and young infants. J Pediatric Sur, 1982,
17. 944-9.
16. Defalque JR. The subclavian route. A critical review of world literature up to 1970.
Anaesthesist 1972,21, 325-35.
17. Desilets ID, Hoffman R. A new method of percutaneous catheterization. Radiology, 1965,
as, 14.
18. Dijk van B, Bakker MP. Appraisal of the dislocation of central venous catheter tips
using subclavian and arm veins. Anaesthesist 1972,2>, 148-40.
19. Edfeldt H, Forsberg L, Johansson AL, Nordstrm L. Central venkateter med J-ledare via
vena jugularis externa. Lkartidningen 1980, 7 7:1208-10.

20. Eerola R, Kaukinen L, Kaukinen s. Analysis of 13800 subclavian vein catheterizations .


Acta Anaesth Scand 1985,2~, 193-7.
21. Ellis WB. Use of logic-based flow pattern in the investigation and management of surgical
disorders. Br J Surg 1975,>2:800- 3.
22. English WCJ, Frew MR, Pigott FJ, Zaki M. Percutaneous catheterization of the intemal
jugular vein. Anaesthesia 1969,2~:521-31.
23. Filston CH, Grant PJ. A safer system for percutaneous subclavian venous catheterization
in newbom infants. J Pediatric Surg 1979,1~:564-70 .
24. Gatti EJ,Mullen LJ. The malpositioned subclavian catheter. Surg Gynecol Obstet 1981,
153:91-2.
25. Gay EAJ. Guide-wire technique for central vein cannulation. Br Med J 1976,3
21-2.

J~1y,

26. Getzen LC, Pollak EW. Short-term femoral vein catheterization. Am J Surg 1979,138,
875-8.
27. Gillette FG, Susini J. Deep brachial vein catheterization for total parenteral nutrition .
An alternate approach: review of 154 cases. J.P.E.N. 19894,8:49-50.
28. Glynn XFM, Langer B, Jeejeebhoy NK. Therapy for thrombotic occlusion of long-term

intravenous alimentation catheters. J.P.E.N.

1980,~:387-90.

29. Greenall JM, Blewitt WR, McMahon JM. Cardiac tampenade and central venous catheters.
Br Med J 1975,2:595-7.
30. Gustavsson B, Linder LE, Hultman E, Curelaru I. "Half-way"-venous catheters. I. Theo-

retical premisesand aims. Acta Anaesth Sand - Suppl. (in press).


31. Hurtubise RM, Bottino CJ, Lawson M, McCredie BK. Restering patency of occluded central
venous catheters. Arch Surg 1980,115:212-3.
32. Jakobwski D, Moon M, Arbeter A, August Ch, Pereira G, Roth K, Cooper A, Ziegler MM.
Simultaneous bilateral central venous catheters: a safe technique. J.P.E.N. 1982,E>,
311-3.
33. Kalso E, Rosenberg HP, Vuorialho M, Pietil K. How much do arm movements displace
cubital central venou~ catheters. Acta Anaesth Scand 1982,2>, 354-6.
34. Keonase PP, Attrill H, Northover J, Jones MJB, Cribb A,m Frost B. Effect of catheter

35.
36.
37.
38.

39.

40.

41.

tunnelling and a nutrition nurse on catheter sepsis during parenteral nutrition.


Lancet 1983,December 17:1388-90.
Kern AK, Fischer EJ. The geometry of the central venous catheters wire stylette as an
indicator of correct catheter position. Surg Gynecol Obstet 1983,15>, 361-2.
Kozeny AG, Vertuno LL, Bansal KV, Hane EJ. Rapid access for emergency dialysis.
Am J Kidney Dis 1984,~:63-5.
Land ER. anatornie relationship of the right subclavian vein. A radiologic study pertinent
to percutaneous subclavian vein catheterization. Arch Surg 1971,1()2:178-80.
Land ER,The relationship of the left subclavian vein to the clavicle. Practical considerations pertinent to the percutaneous catheterization of the subclavian vein. J. Thoracic
Cardiovasc Surg 1972,>3:564-8.
Linder LE, Stenqvist O, Curelaru I, Gustavsson B, Hultman E, Wojciechowski J.Central
venous catheterization by basilic and cephalic veins (optimal catheter bendning stiffness,
insertion technique and venous approach). Acta Anaesth Scand, Suppl. (in press).
Linder LE, Wojciechowski J, Zachrisson FB, Curelaru I, Gustavsson B, Bylock A, Stenqvist O.
"Half-way"-venous catheters. V. Clinical experience and thrombogenicity. Acta Anaesth
Scand, Suppl. (in press) .
Lumley J, Rusell JW. Insertion of central venous catheters through arm veins. ~
Intens Care 1975,3:101-4.

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS

75)

42. Maher WJ. A technique for the positioning of permanent central venous catheter
in patients with thrombosis of the superior vena cava. Surg Gynecol Obstet 1983,
156, 659-60.
43. Malmvall EB, Alestig K, Dottori O, seeberg S. Septicaemia in patients with central
ve in ca theters. Acta Chi r Scand 1980, 14 6:155-9.
44. Malt AR, Kempster M. Direct azygos vein and superior vena cava cannulation for parenteral nutrition . J . P.E.N. 1983,. 7:580-1.
45. McMichan CJ, Michel L. Guide-wire sheath technique for pulmonary artery catheterization
and central vein cannulation. Intens Care Med 1979,5:37- 9.
46. Miller BD, Broom J. Early non-radiological recognition of misplacement of central venous
catheter. Br Med J 1983,287:95-6.
47. Moosman AD. The anatomy of infraclavicular subclavian vein catheterization and its implications. Surg Gynecol Obstet 1973,136:71- 4.
48. Meyenfeldt von FMM, Stapert J, DeJong MCP, Soeters BP, Wesdorp CIR, Greef MJ. TPN catheter
sepsis: lack ~f effect of subcutaneous tunnelling of PVC catheters on sepsis rate.J.P.E . N.
1980,4:514-7 .
49. Nessler R. Die supraclaviculre Anonymapunktion. Anaesthesist 1976,25:303-7.
50. Older OP, Levitt M. A technique for subcutaneous tunneling of subclavian catheter.
Anaesth Intens Care 1981,~:60-3.
51. Pharmacia AB . Vgledning fr Port- A-Cath. Pharmacia AB,75182 Uppsala, 1985.
52. Pokorny JW, McGrill WCh, Harberg JF. Use of azygos vein for central catheter insertion.
Surgery 1985,~7 :362.
53. Raja MR, Kramer SM, Fernandes M, Rosenbaum LJ, Barber K. Subclavian vein and femoral
catheterization for hemodialysis - one year comparison. Trans Am Soc Artif Intemal Organs
1982,28:58-60.
54. Ricksten SE, Medegrd A, Curelaru I, Gustavsson B, Linder LE. "Half-way"-venous catheters.
IV. Physiological basis: estimation of central venous pressure from a "half-way"-catheter
tip. Acta Anaesth Sand (in prss).
55. Robinson JP. Access to the central circulation in the presence of combined superior and
inferior vena caval obstruction. Brit J Radio! 1984,57:169-70.
56. Schechter CD, Acinapura JR. Subciavia vein catheterization. Part I. N Y State J Med 1979,
~~~~~:346-52.

57. Schechter CD, Acinapura JR . Subclavian vein catheterization. Part II. N Y State J Med 1979,
Ap~:i.1: 732-40.
58. Stark DD, Brasch CR, Gooding AC. Radiographic assessment of venous catheter position
in children: value of the lateral view. Pediatr Radiol 1984,14:76-80.
59. Swanson SR, Uhling NP, Gross LP, McCabe JCh. Emergency intravenous access through the
femoral vein. Am Emerg Med 1984,13 : 244-7.
60. Waxrnan PB, Polglase LA. Intemal jugular vein malposition of subclavian catheters .
Med J Aust 1981,1:296-8.
61. Webre RD, Arens FJ. Use of cephalic and basilic veins tor introduction of central venous
catheters. Anesthesiology 1973,38:389-92.
62. Weechsler JR, Byrne JK, Steiner MR . The misplaced thoracic venous catheters: detailed
anatomical considerations. Critical Reviewsin Diagnostic Imaging 1984,21:289-305.
63. Wojciechowski J, Curelaru I, Gustavsson B, Linder LE. "Ha1f-way"-venous catheters.
III. Tip displacement with upper extremity movements. Acta Anaesth Scand- Suppl. (in press ).
64 . Woods GD, Lumley J, Russeli JW, Jack DR. The position of central venous catheters
inserted through arm veins: a preliminary report. Anesth Intens Care 1974,2:43-7.

oooOOOOooo

OBS . , OTHER REFERENCES TO THE AUTHORS (IOAN CURELARU)

.. .:.:

76)
THE GOTHENBURG CVC-GROUP
CONTENTS

CHAPTERS

PAGE(S)

DEFINITION ............................................... 1-1


HISTORY (MILESTONES) ..................................... 1-1
BASIC ANATOMY OF THE CENTRAL VEINS ....................... 1-3
INDICATIONS FOR CENTRAL VENOUS CATHETERIZATION ........... 3-3
CONTRAINDICATIONS TO CENTRAL VENOUS CATHETERIZATION ...... 3-3
CENTRAL VENOUS CATHETERS (MATERIALS) ..................... 3-4
INSERTION TECHNIQUES ..................................... 4-7
Percutaneous insertion ............................................. 4-6
Cut-down ......................................................... 7-7

VEIN APPROACHES .......................................... 7- 7


BASILIC AND CEPALIC VEIN CATHETERIZATION ("LONG-WAY") .... 7-12
BASILIC AND CEPHALIC CATHETERIZATION ("HALF-WAY") ....... 12-15
AXILLARY VEIN CATHETERIZATION ........................... 15-17
EXTERNALJUGULAR VEIN CATHETERIZATION ................... 17-19
INTERNALJUGULAR VEIN CATHETERIZATION ................... 19-24
SUBCLAVIAN VEIN CATHETERIZATION ......................... 24-33
FEMORAL VEIN CATHETERIZATION ............................ 33-35
EXCEPTIONAL VEIN APPROACHES ............................. 35-36
PARTICULAR INSERTION TECHNIQUES ......................... 36-37
PARTICULAR CATHETERS .................................... 37-46
Multi-lumen catheters ....................................... 37-38
Dialys is catheters ..................................... 38-42
Port-A-Catheters ............................................ 42-46

GENERAL TECHNICAL ASPECTS ............................... 46-53


I.
II.
III.
IV.
V.

Use of the Seldinger's guide-wires ......... . .................. 46-47


Ca theter tip location ..................................... 4 7-48
Fixation of central venous catheters ....................... 48-48
Tunnelling of central venous catheters ..................... 48-51
Exchange of central venous catheters ........................ 51-53

POSTOPERATIVE CARE OF THE CENTRAL VENOUS CATHETERS ...... 53-55


I.
II.
III.
IV.
V.
VI.

Use of the CVC-line ............................................ 53-53


Maintenance of sterility inside the CVC-lines ................. 53-54
Care of catheter skin site ..................................... 54-54
Flushing the CVC-lines ......................................... 54-54
Adding heparin to the infusates ................................ 54-54
Leaving the "heparin-lock" ................................... 54-55

GENERAL COMPLICATIONS OF CENTRAL VENOUS CATHETERIZATION ... SS-70


I. Catheter occlusion .............................................. 55-56
II. Thrombosis of the central veins ................................. 56-59
III. Air-embolism ................................................... 59-61

..

77)

CENTRAL VENOUS CATHETERIZATION - CLINICAL ASPECTS

IV.
V.
VI.
VII.
VIII.

Catheter-embolism ........................ 61-64


Erosion of the ve in wall s ...................... 64-65
Local infections .......................... 65-65
Acute right-sided endocarditis ....................... 65-66
Catheter-related sepsis ............... 66-70

PARTICULARITIES OF CENTRAL VENOUS CATHETERIZATION


IN CHILDREN .............. 70-73
SELE CTED REFERENCES ........... 7 3-7 5
CONTENTS ...................... 7 6- 7 7
oooOOOOooo

GOTHENBURG,

the

1st

OF

SEPTEMBER,

1987