A new simple technique for the insertion of cuffed central venous catheters: an initial experience

BACKGROUND: Although tunneled polyurethane catheters with polyester cuffs are useful when prolonged central venous access is necessary but their insertion still remains challenging at times. We report the first study of a new cuffed polyurethane catheter (Seldicuff) that can be easily inserted using the Seldinger technique without the need of a vein dilator and that incorporates a tunneling needle onto the catheter. A Seldicuff catheter was placed in 15 patients (mean age: 53 +/- 11 years) who required prolonged parenteral nutrition. All catheters were inserted into the right subclavian vein. The procedure lasted 6.4 +/- 0.8 minutes and no complication directly related to catheter placement was noted. Catheters remained in position for a mean duration of 103 days (range, 58 to 220 days). During this period, no infectious or mechanical complications were observed. CONCLUSION: These results demonstrate that placement of this novel cuffed catheter is as simple as inserting a conventional central venous catheter.     

Percutaneous placement of an intercostal central venous catheter for chronic hyperalimentation guided by transhepatic venography

BACKGROUND AND METHODS: Increased utilization of central venous catheters for hyperalimentation has caused a rise in the incidence of central venous complications including occlusions and stenoses. When this occurs, the continued use of these catheters becomes more difficult. We describe a technique for catheter placement in a patient requiring access for total parenteral nutrition who had extensive central venous occlusion involving both internal jugular veins, both subclavian veins, and the infrorenal inferior vena cava (IVC). RESULTS: A percutaneous transhepatic venous catheter had been placed in a patient with inferior vena caval, subclavian, and internal jugular venous occlusions. The Hickman catheter functioned well until the patient developed fungal sepsis and a large fibrin sheath around the catheter tip creating the need for a new access site. Placement of an intercostal venous catheter was performed using transhepatic venography to map patent collateral veins and microcatheters to access an intercostal route for Hickman placement. CONCLUSIONS: Patients who require long-term central venous access often develop stenotic and occlusive complications in the central venous circulation. Individualized, unique and innovative routes to the central venous circulation must often be utilized to maintain venous access in these patients. Transhepatic venous mapping and microcatheter techniques aid in the finding of alternative sites in these patients with difficult access problems.     

New syringe to prevent mechanical complications of central venous catheter placement.

Prompted by the continued frequency of mechanical complications associated with central venous catheter placement, a more effective and stable and safer catheter placement device has been proposed. Fifteen critically ill surgical patients who required central venous access for total parenteral nutrition (TPN) and fluid management had a central venous catheter placed using the new syringe technique. Despite an equipment-use learning curve, there was no equipment failure. In 14 patients, catheter placement was successful. In one dehydrated patient, repeated attempts at percutaneous infraclavicular subclavian access were not successful, but internal jugular vein access was gained. There were no mechanical or infectious complications in the 15 patients. The new syringe provides a stable platform, reducing the fumbling usual when disconnecting the needle from the syringe and thereby avoiding the potential complications of dislodgment or hub contamination of the introducer needle and air embolism.     

置入式中心静脉输液港常见并发症的原因分析与防治

目的:探讨置入式中心静脉输液港相关并发症的原因和防治对策。方法:将103例病人在X线透视下经右锁骨下静脉穿刺行中心静脉输液港置入术,回顾性分析相关并发症的原因,并探讨防治对策。结果:101例病人成功完成手术,成功率达98.06%,2例手术失败。发生相关并发症为19例(18.45%)。结论:完善围手术期处理,加强临床护理培训,可有效地降低中心静脉输液港置入术相关并发症的发生率。     

Duplex Doppler ultrasound identifies veins suitable for insertion of central feeding catheters.

Central venous access for feeding catheters may prove difficult in patients who have had numerous previous central line insertions or complications. Duplex Doppler ultrasound was used to identify the anatomy and patency of major central veins in 11 patients in whom attempts at obtaining central venous access by an experienced operator had failed at least once and in 40 control subjects. Doppler ultrasound demonstrated the subclavian veins (diameter 12.5 +/- 3.5 mm, mean +/- SE) and internal jugular veins (11 +/- 3.5 mm) in all the control subjects. In the patients, 18 of 44 veins were patent, 11 were small or had low blood flow, and 15 were thrombosed. In 7 patients who required central feeding catheter insertion, a suitable vein was identified and the catheter suitably placed, even in 3 subjects where no central vein was considered normal. Duplex Doppler ultrasonography is a useful technique for identifying veins suitable for the insertion of central venous lines when access has previously proved difficult.     

Complications and cost associated with parenteral nutrition delivered to hospitalized patients through either subclavian or peripherally-inserted central catheters

BACKGROUND AND AIMS: Total parenteral nutrition (TPN) is typically delivered through catheters inserted into the superior vena cava (SVC) via a subclavian or internal jugular vein approach. A peripherally-inserted central venous catheter (PICC), utilizing a cephalic or basilic venous approach, may provide a safe alternative to the standard catheter approach and, because non-physician providers can insert the PICC, may introduce a potential cost-savings to health care institutions. We sought to determine if PICC lines are safer and more cost-effective than the standard central venous catheter approach for hospitalized patients who require TPN. METHODS: One hundred and two hospitalized patients (age range, 18-88 years) who required TPN were prospectively randomized to receive therapy via a centrally-inserted subclavian catheter (n=51) or a peripherally-inserted PICC line (n=51). The primary end-point was the development of a complication requiring catheter removal. Other end-points included catheter infection and thrombophlebitis. Cost associated with insertion and maintenance of each catheter was also studied. RESULTS: Complication-free delivery rate (without the need to remove or replace the catheter) was 67% for subclavian catheters and 46% for PICC lines (P<0.05). The overall infection rate was 4.9 per 1000 catheter days and was similar for each catheter type (P=0.68). PICC lines were associated with higher rates of clinically-evident thrombophlebitis (P<0.01), difficult insertion attempts (P<0.05), and malposition on insertion (P<0.05). No catheter complications resulted in significant long-term morbity or mortality. No significant difference was noted between the two catheter types in terms of aborted insertion attempts (P=0.18), dislodgement (P=0.12), or line occlusion (P=0.25). After standardizing costs for each hospital, the direct institutional costs for insertion and maintenance of PICC lines (US$22.32+/-2.74 per day) was greater than that for subclavian lines (US$16.20+/-2.96 per day;P<0.05). CONCLUSION: PICC catheters have higher thrombophlebitis rates and are more difficult to insert into certain patients when compared to the standard subclavian approach for central venous access in hospitalized patients who require TPN. Because of this, PICCs may be less cost-effective than currently believed because of the difficulty in inserting and maintaining the catheter.     

Long term parenteral therapy by percutaneous tunneled silicone central venous catheter--a follow-up of 300 catheters

We have developed a technique for the management of central venous catheters which incorporates percutaneous insertion and daily care for routine use in different wards. A follow-up of the first 300 catheters is presented. When intravenous therapy was planned for more than two weeks, a silicone rubber catheter was introduced percutaneously with a skin tunnel and the position of the tip in the lower superior vena cava checked by venous pressure measurement. The metal hub of the catheter was disinfected daily by heating with a modified soldering iron which has been proved to be effective by in vitro testing with different microorganisms. The external jugular vein was used in 164 cases (55 per cent) the internal jugular vein in 115 (38 per cent) and the remaining catheters were inserted by the subclavian or antecubital route. Correct positioning was obtained in 96 per cent and serious early or late complications were rare there being only one case of septicaemia in a total treatment period of 270 months. One patient developed a lung infarct, but no case of pneumothorax has been seen. The mean duration of the catheters was 27 days (range 1-239) and the common reasons for termination were cessation of need in 84 per cent, mechanical obstruction in 6 per cent and inadvertent removal in 6 per cent. The described method has proved to be safe and to function well on ordinary wards.     

心电图在监测中心静脉导管位置中的应用

近一年来为12例患者施行右锁骨下静脉穿刺中心静脉插管。心电图监测显示，当导管尖端到达上腔静脉内时P波变为高尖，术后经X光透视并摄取胸片证实导管尖端位于上腔静脉内。提示心电图技术可用于监测中心静脉导管尖端位置。     

Medical residents' self-reported adherence to guidelines during placement of central venous catheters .

In teaching hospitals, the majority of central venous catheters are placed by medical residents. No studies have examined residents' adherence to safe practices during these procedures. We conducted a survey to gather self-reported data on the techniques that internal medicine residents use when placing a central venous catheter to minimize their own risk of infection and their patients' risk of bleeding-related complications.     

对比两种中心静脉导管的临床应用

目的 对比两种中心静脉导管的置管方法特点及并发症。方法 按时间先后用美国BD公司生产的一次性“经外周静脉置入中心静脉导管”（Peripherally Inserted Central Catheter,简称PICC）或美国Arrow公司生产的双腔或单腔中心静脉导管。观察30天,共80例病人（n=40:40),甲组应用双腔中心锁骨下静脉穿刺至上腔静脉置管,乙组应用PICC导管行经外周静脉置入中心静脉导管。结果 置管成功率：PICC导管置管成功39例占97．5％;锁骨下静脉穿刺成功40例（100％）。导管骨下静脉穿刺导管有1例气胸并发症占2．5％。导管异位,PICC导管有2例占5％;锁骨下天然脉穿刺导管有1例占2．5％。静脉炎发生率,PICC导管有2例占5％;锁骨下静脉穿刺导管无一例静脉炎发生。结论 PICC导管穿刺无风险,部分治疗可取代锁骨下静脉穿刺导管;是抢救危重病人有用的通道。     

超声引导下经外周静脉置入中心静脉导管置管术在老年患者中的应用

目的 分析超声引导下经外周静脉置入中心静脉导管（PICC）置管术在老年患者中应用的置管成功率和并发症的发生率。方法37例有PICC置管适应证的老年患者,其中18例（48．6％）肘部没有可见或可触及的浅静脉,选择上臂深静脉,采用超声引导下改良的Seldinger穿刺法进行PICC置管,分析置管成功率和并发症发生率。结果37例老年患者,超声引导下PICC置管成功率为100％。PICC管留置时间为（32．0±19．8）d,2例（5．8％）患者分别在置管后第21和39天因为静脉血栓形成而拔管,18例（48．6％）患者的PICC仍在使用。结论应用超声引导技术,使部分肘部无可见或可触及浅静脉的老年患者也能安全置入PICC。     

Placing of Hickman catheters under ultrasonic guidance]

We describe a new technique using ultrasound guided puncture of the subclavian vein and fluoroscopic control of the guide wire and the catheter position. Using this technique we performed 70 catheter introductions in 54 patients at the radiological department of the University Hospital of Rotterdam. Long term administration of chemotherapy was the most frequent indication for introduction of the Hickman catheter. The puncture related complication rate was compared with the complications of the 'blind' percutaneous puncture method, as mentioned in literature. All the ultrasound guided punctures of the subclavian vein were successful and no puncture related complications, such as pneumothorax, haemothorax or arterial puncture, occurred. Since ultrasound guided puncture of the subclavian vein in combination with fluoroscopic control of the guide wire and catheter reduces the risk of complications of introduction of Hickman catheters, we consider this technique superior to other methods.     

Simultaneous bilateral central catheters: a safe technique

Optimal central catheter care includes restriction usage for blood sampling and blood product administration on enhance continued sterility, but our experience with 25 children receiving bone marrow transplants after cytoreduction challenges this concept. Prior to transplantation, bilateral percutaneous subclavian vein silastic catheters were inserted without incident, one utilized for continuous nutritional support in caloric quantity to assure body weight maintenance, and the contralateral catheter utilized for daily venous sampling plus administration of medications including blood products. Patients subsequently entered a protective environment and bi-weekly surveillance cultures were monitored. Nutritional therapy was given for 876 days through 53 catheters. One patient developed culture-proven sepsis, an organism first cultured from the skin. The patient complication rate of 4% and the per diem rate of 0.11% in this immunocompromised population compares favorably to the 10.5 and 0.32% incidence we previously reported for 200 children with unilateral catheters. These data demonstrate that bilateral central catheters can be safely utilized in children for nutrition and sampling.     

完全植入式中心静脉输液泵的应用探讨

目的 探讨完全植入式中心静脉输液泵的应用.方法 对217例完全植入式中心静脉输液泵的应用及并发症进行回顾性分析.结果经锁骨下静脉置管胸壁皮下输液泵植入199例,经颈内静脉置管胸壁皮下输液泵植入17例,植入成功率为99.6%(216/217).中心静脉输液泵植入后长期正常使用207例(95.8%),因并发症导致输液泵取出9例(4.2%).相关并发症:锁骨下动脉误穿3例(1.4%),并形成局部血肿1例;导管置入右心室导致室性心动过速1例(0.4%),泵体周围软组织感染5例(2.3%),经抗炎治疗无效并取出2例;导管脱位2例(0.9%);导管堵塞行输液泵取出6例(2.8%),其中导管扭曲3例,导管内血栓形成3例.总体并发症发生率为7.8%.结论 完全植入式中心静脉输液泵可以提供更加长期、安全的静脉通路,植入手术简单,但有一定的并发症发生率,需要注意监测.对于需要长期静脉输液的患者,特别是接受化疗的肿瘤患者具有较高的临床应用价值.     

An alternative placement of implantable central venous access systems

A modified technique of inserting an implantable venous access system in the inferior epigastric vein is described. This route can be used in cases where the jugular or subclavian veins are unsuitable. After exposure of the inferior epigastric vein in the lower part of the rectus sheath, the catheter is placed in the vein with its tip at the junction to the iliac vein, with the aid of fluoroscopy and x-ray contrast. Protrusion of the tip into the lumen of the iliac vein is avoided. The technique was successful in four of the five patients where an attempt was made to insert the catheter. In the fifth case the vein was too narrow to allow catheterization. In the four cases where the catheter was successfully inserted there were no complications. This technique may allow use of the inferior vena cava for venous access without the high risk of intravenous thrombosis which is inherent with current methods.     

Central catheter-related infections: comparison of pulmonary artery catheters and triple lumen catheters for the delivery of hyperalimentation in a critical care setting

We prospectively studied the risk of catheter-related sepsis (CRS) in 75 critically ill patients who received total parenteral nutrition (TPN) through 158 pulmonary artery catheters (PACs) and 214 triple-lumen catheters (TLCs). We relied on semiquantitative cultures of the catheter tips, peripheral blood cultures in febrile patients and clinical response to catheter removal to diagnose catheter-related sepsis. The infection rate was 2.5% (4/158) of PACs and 6.5% (14/214) of TLCs (p = 0.124). Colonization rates were 29.1% for PACs and 32% for TLCs. PACs were left in place a significantly shorter length of time than TLCs, 3.1 vs 5.1 days (p less than 0.005). Guidewire exchanges and subclavian vein insertions were associated with a decreased rate of CRS when compared to new insertions and internal jugular vein insertions, respectively. We conclude that pulmonary artery catheters can be used safely for the delivery of hyperalimentation in critically ill patients with no increased risk for catheter-related sepsis compared to triple-lumen catheters. The use of the PAC in this manner allows for the use of a single central venous catheter for the delivery of hyperalimentation and hemodynamic monitoring.     

Ultrasound guidance versus anatomical landmarks for subclavian vein catheterization: a prospective study

Background: Several clinical practice guidelines strongly support the use of ultrasound guidance (USG) for internal jugular vein catheterization. The level of evidence concerning the use of USG for subclavian vein (SCV) cannulation remains low. Aim: To compare the effectiveness and safety of USG and anatomical landmarks approaches for cannulation of SCV. Methods: This was a prospective randomized study. Patients aged over 18 years old who requiring elective central venous catheterization were included. Non-inclusion criteria were thrombosis of the vein or major coagulopathy. All catheterizations were performed by two anaesthesiology residents. Patients were randomized into two groups: ultrasound guidance group (US group) and anatomical landmarks (LM group). The main outcome was the success rate. The secondary outcomes were the first attempt success rate and the incidence of complications. Results: Seventy patients were included (35 in each group). The success rate was higher in US group compared to LM group without statistical significance (100% vs 85.7%; p=0.054). The first attempt success rate was significantly higher in the US group (82.9% vs. 40%; p<10^-3). The incidence of mechanical complications was significantly lower in the US group compared to LM group (5.7% vs. 37.1%; p=0,001). Conclusion: according to our study, US guidance for SCV catheterization seems to be an interesting alternative to anatomical landmarks approaches     

食管癌围手术期应用3种不同途径中心静脉置管分析

目的通过对颈外静脉、股静脉、经外周静脉置入中心静脉导管（PICC）置管进行比较,探讨食管癌患者围手术期中心静脉置管的最佳途径。方法对3种不同途径中心静脉置管共264例进行分析,分别比较穿刺总成功率、一次穿刺成功率、穿刺过程并发症发生率、导管留置时间及置管期间并发症发生率。结果颈外静脉、股静脉、PICC置管组一次穿刺成功率分别为85.33%、86.95%和92.59%,总的成功率分别为96.15%、95.83%和90.00%,3组差异无统计学意义（P〉0.05）;穿刺过程中并发症发生率分别为5.77%、10.42%和6.67%,差异无统计学意义（P〉0.05）;置管期间并发症发生率分别为：7.69%、70.83%和28.33%;,颈外静脉组明显低于另外2组,差异有统计学意义（P〈0.05）。结论 3种穿刺途径均穿刺成功率高,穿刺过程中并发症发生情况均无显著性差异,但置管期间并发症发生率颈外静脉组明显低于另外2组,食管癌患者围手术期的治疗静脉通道应首选颈外静脉置管。     

An anti-stray stylet for subclavian catheterization by the infraclavicular approach

OBJECTIVE: Misplacement of subclavian vein catheters has been reported. We assessed the rate of misplacement of a subclavian vein catheter with and without a novel stylet. METHODS: A prospective, randomized, controlled clinical trial was conducted between September 2001 and June 2003 in a university hospital. Two hundred sixteen adult patients were enrolled to receive subclavian vein catheterization under non-emergency conditions. Patients were randomly assigned to undergo right subclavian vein catheterization with the stylet (n = 109, stylet group) or without the stylet (n = 107, control group). The rate of subclavian vein catheter misplacement was determined and risk factors for failure and complications were analyzed. RESULTS: There was no incidence of catheter misplacement in the stylet group, but this occurred in 12 patients in the control group in whom the catheter was misplaced into the ipsilateral internal jugular vein (0% versus 11.2%, P = 0.0003). In multivariate analyses, use of the stylet (odds ratio = 0.062, 95% confidence interval = 0.008 to 0.495, P = 0.009) and a close to average body mass index (odds ratio = 0.73, 95% confidence interval = 0.54 to 0.98, P = 0.038) were associated with low risks of complications and failure, respectively. CONCLUSIONS: This stylet is useful for decreasing the incidence of misplacement of subclavian vein catheters. Body mass index is predictive of failed vein puncture.