Oct 15, 1987 - C Shoemaker and Edward Abraham. 502 pages, illus- trated. Marcel Dekker, New York. $83.50. This highly practical book gives details about ...
Annals of the Royal College of Surgeons of England (1988) vol. 70
Subclavian vein
catheterisation for parenteral
nu tritio n
J
P FLETCHER FRACS FRCS
Senior Lecturer in Surgery
M LITTLE MI) MS FRACS Professor ofSurgery Department ofSurgey, University of Sydney and Westmead Hospital, Sydney, New South Wales, Australia
J
Key words: SUBCI.AAVIAN VEIN CA'I'IIETEIRISAI'ION; l'ARE.NTEIRAI. NUTRITION;
Summary Two hundred and lwenty-six central venous calheters were placed in 195 conseculive patients requiring central venous catheterisalion for total parenteral nutrition (TPN). Of these 226 calhelers, 198 were placedperculaneously into the subclavian vein by the infraclavicular route. In 99 conseculive subclavian calheter insertions, a 12G needle wilh inlroducing sheath was used lo puncture lhe vein (Group 1). The Seldinger melhod of calhelerisation was used in anolher 99 consecutive subclavian catheter inserlions (Group 2), the vein being punctured wilh a 19G needle. Pneumothorax occurred on three occasions (3.0%) in Group I but did nol occur in Group 2. However, there were two episodes of pleural extravasalion in Group 2 (2.0%) which may have been due lo guide wire perforation of a central vein; this complication did not occur in Group 1. Although the Seldinger technique of inserlion should reduce the incidence of pneumolhorax, care should be taken in passage of the guide wire.
Introduction Subclavian vein cathctcrisation is thc prefcrred mcans of acccss to the vcnous circulation for administration of total parcntcral nutrition (TPN), but is not without risk of scrious complications (1-4). Placcmcnt of a subclavian cathetcr such as a VygonNutricath® (Ecoucn, Francc) cnables subcutancous tunnclling which may lessen the incidence of catheter scpsis (5-6). Howevcr, attcmpted puncture of the subclavian vcin with a 12G necdlc and shcath increascs the risk of pncumothorax and inadvcrtent subclavian artery puncture.
An alternativc mcthod of subclavian vein puncturc with a 19G ncedlc and placemcnt of the cathctcr by the Seldinger tcchniquc (7-8) was cvaluated in this study. Materials and methods Onc hundred and nincty-fivc consecutivc paticnts rcquiring central venous cathetcrisation for TPN wcrc
Correspondence to:J P Fletcher, Department of Surgery, Westmead Hospital, Westmead, Sydney, New South Wales, 2145,
Australia
SII)INGER
lECHNIQUE
studied prospectively. Thcrc werc 122 males and 73 females. Agcs ranged from 13 to 85 ycars with a mcan of 52.3 ycars. Thcrc werc 226 central venous cathcters placed in the 195 paticnts. Of thcsc, 14 catheters werc placcd via the jugular vcin, 8 via the fcmoral vein and 6 paticnts had a Hickman cathetcr inserted via a cephalic orjugular vein; thcsc 28 cathetcrs using sites other than the subclavian vcin wcrc excludcd from the study. One hundrcd and nincty cight cathetcrs werc placed percutancously into the subclavian vein by the infraclavicular routc. In Group 1, comprising 99 consecutivc subclavian cathcters, a 1 2G necdlc with shcath was used to puncturc the vein (9-10). A standard approach was used with the paticnt in the supinc position, arms adducted and a 150 hcad down tilt. The antcrolateral arca of neck and chcst was prcpared with povidone-iodine solution and stcrilc drapcs applied. A point of cntry below the midpoint of the claviclc was chosen and 1% lignocainc infiltrated infraclavicularly and for 5-6 cm in the direction of the ipsilatcral nipplc. The cathetcr shcath and necdlc were asscmblcd and attachcd to a 5 ml syringc. A small incision was madc at the chosen point of entry and the ncedlc and shcath passed in a planc horizontal to the chest wall in the direction of the suprasternal notch. A ncgative pressurc was kept on the syringc whilc the necdlc was slowly advanced until vcnous blood was frecly aspirated. The shcath was advanced as the necdlc was withdrawn followed by insertion of the silicone cathctcr through the sheath which was then rcmoved. The introducing ncedlc with sheath was then uscd to puncture the skin 5-6 cm infcrior to the initial puncturc site and advanccd towards the catheter to crcatc a subcutaneous tunncl, carc being taken not to damage the cathctcr. The necdlc was withdrawn and the cathetcr guided through the shcath which was in turn withdrawn to allow connection of the hub and intravenous tubing. Corrcct cathetcr placement was confirmed by lowering the infusion bag and obscrving rctrogradc flow of blood into the intravenous tubing. The catheter hub was sccured with a silk or Nylon suturc and a sterile transparent plastic dressing applied. A chest X-ray was obtained prior to infusion of parcntcral nutrition solution.
Subclavian vein calhelerisation for parenteral nutrilion
TABILE,I 11 Results and complications of catheter insertion
TABILE I Comparison of Groups I and 2 Group I Group 2 Number Mean age (years) Male:female ratio Indication for TPN: Postoperative abdominal surgery Multiple trauma Pancreatitis Gastrointestinal obstruction Inflammatory bowel disease Preoperative Fistula Miscellaneous
151
99 53.5 2.0
99 51.1 1.6
34 13 10 9 7 5 6 15
34 18 11 10 9 7 3 7
In Group 2, also comprising 99 consecutive subclavian catheters, the techniquc of inscrtion was the samc cxccpt that the Seldinger method (7-8) was used to inscrt the cathetcr. The vein was punctured first with a 19G necdlc. A guidc wirc was threaded down the necdlc and the ncedlc removed. An introducer shcath, of similar sizc to the sheath ovcr the necdlc used in Group I patients, was passcd into the subclavian vein ovcr the guidc wire; after removal of the guidc wirc the catheter was passed through the introducing shcath which was then rcmoved. The only diffcrencc betwcen the two groups was that the subclavian vein in Group 1 was punctured with a 12G ncedlc compared to a 19G needle in Group 2 and a guidewire was used in Group 2. The siliconc catheter had an internal diametcr of 1.2 mm and an cxtcrnal diametcr of 2.0 mm. Cathctcrs werc placed by rcsident staff under the supcrvision of senior staff of the Intensivc Carc Unit and the Nutrition Support Scrvicc. Cathetcrs werc removed at the completion of TPN or if catheter scpsis was suspected because of fever without other demonstrable cause. Catheter infection was considered proved if therc were positivc catheter and peripheral blood culturcs. There were no statistically significant differences betwecn Groups 1 and 2 (X2-square and t-test analysis) with respcct to the indication for TPN, or agc and sex ratio (Tablc I). Results Therc werc no statistically significant differences (%square analysis and t-test) bctwecn Groups 1 and 2 with rcspect to mortality, duration of TPN or lifc of cathetcr (Tablc II). Therc werc thrce instanccs of pncumothorax rclated to cathcter insertion in Group 1 (3.0%) and nonc in Group 2 (Table II). Two of the threc pncumothoraces werc trcated by insertion of an intcrcostal tube and in the other the lung was allowed to rc-expand spontancously. All threc patients had an uncomplicated recovery and an otherwisc uneventful course whilst recciving TPN. Inadvertent puncturc of the subclavian artery was noted in threc instances in Group 1 (3.0%) and in two instances in Group 2 (2.0%). Therc werc no untoward sequelac in thcsc cases. Therc was no instancc of plcural cxtravasation in Group 1, but this complication occurred in two Group 2
Group I Deaths Duration of TPN (days ± SEM) Catheter life (days ± SEM) Pneumothorax Subclavian artery puncture Pleural extravasation Catheter infection
Group 2
4
6
18.1±1.3 18.5±1.8 3 3 0
19.7±1.7 17.8±1.6
5
0 2 2 7
paticnts (2.0%). Both paticnts had an apparently uncventful linc insertion with positive 'flashback' of venous blood into the intravenous tubing on lowering the infusion bag and a normal postinsertion chcst X-ray. Within sevcral hours of commencing TPN there was marked rcspiratory distress, a further chcst X-ray showed pleural effusion and parenteral nutrition solution was recovcred on inscrtion of an intercostal cathetcr. Both patients required vcntilatory support in the intensive carc unit but eventually recovcred satisfactorily. Therc werc 12 instances of proven cathetcr infcction (positivc peripheral blood and catheter tip culturc), fivc from Group 1 (5.0%) and seven from Group 2 (7.0%).
Discussion Potentially scrious complications arc associated with percutancous subclavian vein cathetcrisation. Thcsc include pncumothorax, haemothorax, arterial puncturc, pleural cffusion, cathetcr malposition and air cmbolism. Christensen et al. in 1967 (2) reported a serious complication rate of 4.5% for subclavian catheters inscrted for both monitoring and intravenous fceding while Benard and Stahl reported a 6.0% incidence in 1971 (3). Ryan el al. in 1974 (4) reported a 4.0% incidcncc of serious complications associated with inscrtion of cathctcrs for intravenous fceding but these cathetcrs were not nccessarily placed by mcmbers of a parcnteral nutrition service. Blackett el al. in 1978 (1) reported a 2.3% incidence of scrious complications associated with insertion of catheters for intravenous fecding; thesc catheters werc placed by a limited number of personncl from thcir Departmcnt of Surgery and this cmphasises the rcduction in complications which can bc achieved when cxpcrtisc is developed by such a group. Sitzmann el al. (8) havc also reported a major complication ratc of 2.3% for cathetcr inscrtion, and this group advocates the usc of the Scldinger tcchnique for placemcnt of a central venous cathetcr. The complication rate in our scrics is comparable to othcrs reported. Wc felt that the incidence of pneumothorax could bc reduced by using the Scldinger tcchniquc, which allows puncture of the subclavian vein with a 19G rather than a 12G necdlc. However, there were two instances of pleural cxtravasation with the Scldinger techniquc despitc an apparcntly uneventful linc inscrtion. The only cxplanation appeared to bc that of the guide wirc perforating a central vein and entering the plcural cavity, which resulted in cxtravasation of parcntcral nutrition solution when infusion of this was started. This complication required managemcnt in the intcnsivc carc unit with ventilatory support and was therefore more sevcrc than the three pneumothoraces in
152
J P Fleicher and J M Lillle
Group 1, which werc readily managed by cither inscrtion of an intercostal tube or obscrvation. The guidc wire should be inspected prior to insertion to ensure that it has a soft, blunt flcxiblc tip. It should not bc forced if it docs not pass casily. In conclusion, no method of subelavian vein catheterisation is frce of complications. Although the Seldingcr techniquc of inscrtion should rcduce the incidencc of pncumothorax, carc should be taken in passage of the guidc wire.
References 1 Blackett RL, Bakran A, Bradley JA, Halsall A, Hill GL, McMahon MJ. A prospective study of subclavian vein catheters used exclusively for the purpose of intravenous feeding. BrJ Surg 1978;65:393-5. 2 Christensen KH, Nerstrom B, Baden H. Complications of percutaneous catheterisation of the subclavian vein in 129 cases. Acta Chir Scand 1967;133:615-20. 3 Benard RW, Stahl WM. Subclavian vein catheterizations: a prospective study. I. Non-infectious complications. Ann Surg 1971;173:184-90.
4 Ryan JA, Abel RM, Abbot WM, Hopkins CC, Chesney TM, Colley R, Phillips K, Fischer J. Catheter complications in total parenteral nutrition. N Engl .1 Med 1974;290:757-61. 5 Ross AHM, Anderson JR, Walls ADF. Central venous catheterisation. Ann R Coll Surg Engl 1980;62:454-8. 6 Keohane PP, Jones BJM, Attrill H, Cribb A, Northover J, Frost P, Silk DBA. Effect of catheter tunnelling and a nutrition nurse on catheter sepsis during parenteral nutrition: a controlled trial. Lancet 1983;2: 1388-90. 7 Seldinger SI. Catheter replacement of needle in percutaneous arteriography; new technique. Acta Radiol 1953;39:368-76. 8 SitzmannJV, Townsend TR, Siler MC, BartlettJG. Septic and technical complications of central venous catheterization: a prospective study of 200 consecutive cases. Ann Surg 1985;202:766-70. 9 Powell-Tuck J. Skin tunnel for central venous catheter: non-operative technique. Br Med J 1978;1:625. 10 Linton DM, Bean E, Cronje CJ, Elliot MS, Wright J, Marquard FC. Central venous catheterization for parenteral nutrition: experience at Groote Schuur Hospital. S Afr Med J 1983;64:351-4.
Received 15 October 1987
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