Table Of ContentC. Burri F. W. Ahnefeld
The Caval Catheter
With the Collaboration of
K. H. Altemeyer, B. Gorgass, 0. Haferkamp
D. Heitmann, G. Krischak, P. Lintner
A. Ott, H. H. PassIer, E. Plank, D. Spilker, W. Stotz
With 54 Figures
Springer-Verlag
Berlin Heidelberg New York 1978
Professor Dr. Caius Burri
Abteilung flir Vnfallchirurgie des Zentrums
fur Operative Medizin der Vniversitiit
SteinhovelstraBe 9
7900 Vim (Donau)
Professor Dr. Friedrich Wilhelm Ahnefeld
Department fur Aniisthesiologie des Zentrums
flir Interdiszipliniire Medizinische Einheiten
der Vniversitiit
SteinhovelstraBe 9
7900 Vim (Donau)
Translated from the German edition "C. Burri,
F. W. Ahnefeld, Cava Katheter"
ISBN-13: 978-3-540-08566-9 e-ISBN-13: 978-3-642-66834-0
001: 10.1007/978-3-642-66834-0
Library of Congress Cataloging in Publication Data. Burri, Caius. The caval catheter.
1. Intravenous catheterization. 2. Vena, cava. I. Ahnefeld, Friedrich Wilhelm. II. Title.
RC683.5.l5B86.617' .414.77-27484.
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Preface
The application of the caval catheter in emergency medicine and
intensive care has today become routine. Generally, even in
severe shock this route of access to the cardiovascular system is
available in order to apply life saving volume substitution. It also
permits longterm infusions in modern intensive care, particularly
continuous administration of high-osmolarity solutions in par
enteral nutrition. In both fields it represents one of the most
important diagnostic parameters of circulatory disorders, enabl
ing the registration of central venous pressure. Its undeniable
advantages are counterbalanced by the dangers inherent in all
invasive methods. Since sufficient experience and precise sta
tistics are now at our disposal, the time has come for a provisional
survey. While a few years ago it was considered mandatory to
propagate the central venous access in order to advance new
therapeutic and diagnostic methods, it is now necessary to recon
sider and reformulate indications for its use. In this task it is
essential to weigh the expected advantages against the possible
complications in each and every case of catheter application. Cri
tical scrutiny must include evaluation of techniques, approaches,
and finally catheter materials; this paper presents the results of
such a survey. The physician is hereby given the opportunity of
being completely informed of evaluating the validity of his
standard procedures.
VIm, April 1977 C. BURRI F. W. AHNEFELD
Table of Contents
I. Introduction......... 1
II. Indications for Caval Catheter 3
A. Caval Catheter in Emergency Situations 3
B. Caval Catheter in Long-Term Therapy 7
C. Caval Catheter in Children 9
III. Puncture - Exposure of Vein 16
IV. Approaches to Caval Vein 21
A. Basilic Vein . . . . . . . 21
B. ExternalJugular Vein . . 22
C. Approach by Internal Jugular Vein 25
D. Subclavian/Anonymous Vein 27
E. Femoral Vein . . . 30
V. General Directions 31
A. Preparation of Puncture Site 31
B. Puncture ........ 31
C. Introduction of Catheter 31
VI. Catheter Material-Models 32
VII. Complications of Caval Catheterization 39
A. Complications from Serial Compilations in Relation
to the Site of Approach . . . . . . . . . . . . . 39
B. Complications of Caval Catheterization Outside
Serial Complications .............. 45
VIII. Frequent Autopsy Findings in Patients With Caval
Catheters .................. 61
IX Recommendations for Caval Catheterization 65
References . . 68
Subject Index 83
List of Co-Authors
Altemeyer, K. H., Department flir Anasthesiologie des Zentrums
ftir Interdisziplinare Medizinische Einheiten der Universitat Ulm
Gorgass, B., Rettungszentrum Bundeswehrkrankenhaus Ulm
Department ftir Anasthesiologie der Universitat UIm
Haferkamp, 0., Abteilung flir Pathologie der Universitat VIm
Heitmann, D., Abteilung ftir Anasthesie und operative Intensiv
therapie des Kreiskrankenhauses Heidenheim
Krischak, G., Abteilung flir Unfallchirurgie des Zentrums ftir
Operative Medizin der Universitat Ulm
Lintner, P., Abteilung flir Unfallchirurgie des Zentrums ftir Ope
rative Medizin der Universitat Ulm
Ott, A., Anasthesie-Abteilung der Stadt. Krankenanstalten
Ntimberg
Passier, H. H., Abteilung flir Chirurgie des St. Vincenz-Kranken
haus Hanau/a. M.
Plank, E., Abteilung flir Unfallchirurgie des Zentrums ftir Ope
rative Medizin der Universitat UIm
Spilker, D., Department ftir Anasthesiologie des Zentrums flir
Interdisziplinare Medizinische Einheiten der Universitat UIm
Stotz, W., Department ftir Anasthesiologie des Zentrums ftir
Interdisziplinare Medizinische Einheiten der Universitat UIm
Bundeswehrkrankenhaus Ulm
I. Introduction
When FORSSMANN (169) reported his at This recent spread has essentially three
tempts to sound his own right heart with reasons:
a rubber catheter in 1929 he met with in Firstly the physiologic and patho
comprehension and rejection among his physiologic basis was worked out, in the
colleagues. Such trials in man seemed too German language zone mainly by ALL
dangerous and unjustifiable. FORSSMANN'S GOWER'S group (4, 5, 80, 81, 82, 83, 84,
superior at the time forbade him to con 86, 87) who made possible the interpreta
tinue his investigations but some decades tion of measured CVP values and thus the
later his daring was rewarded with therapeutic consequences arising from
a Nobel prize. In the last 20 years it.
catheterization of the heart and central Secondly, parenteral feeding has in recent
vascular system has developed impressive years gained increasing importance and
ly. Catheterization of the caval veins, the widespread use (2, 59, 74, 75, 96, 102,
right heart, and pulmonary artery is no 128, 132, 135, 161, 191, 205, 216, 226,
longer the preserve of top cardiologic 311,365,385,388,390,395,399). Final
centres but is used widely. The caval ly, venesection is no longer necessary for
catheter today is part of accepted routine the introduction of a caval catheter with
in surveillance and treatment, and not on the sets now on the market. The catheters
ly for patients in intensive care units. can be introduced by experts without any
This development goes back to the publi great demands on technique, personnel,
cations of MEYERS (340) and ZIMMERMANN and time (41, 58, 79, 89, 119, 160, 235,
(496) in 1945 who recommended the ve 267, 268, 418).
nous catheter for parenteral feeding of Owing to this development the limits of
children. For some time after that use was indications for the introduction of a caval
restricted to a few hospitals. In 1958 catheter have not only become wider but
GRITSCH and BALLINGER (201) reported also increasingly indistinct. We have now
the successful use of a certain catheter reached a point where it is no longer
model in 1000 of their own patients and necessary to propagate the caval catheter
a consumption of over 500,000 PVC but to emphasize critical limits of indica
catheters in the United States and other tion in view of the possible of serious and
countries. In Europe OPDERBECKE (364) occasionally fatal complications.
published his first experiences with basilic When using a caval catheter it is necessary
catheters in 150 patients in 1961, drawing in each individual case to weigh up the de
attention to the central position of the sired advantage against possible complica
catheter tip which is now considered tions.
necessary. From this time on there was On the basis of a study of ours published
a rapid spread of the use of caval cathe in 1971 (88) in which nine European
ters, which in the past decade has as clinics and the same number of bac
sumed enormous proportions. teriologic and pathologic institutes took
2 Introduction
part, and of knowledge gained since from the caval catheter, to express a critical
the literature and our own experience, it opinion on alternatives and possible ap
will be attempted here - with special proaches to the superior caval vein, and to
consideration of catheter-induced compli work out statements on catheter material
cations - to delineate the indications of models and the care of caval catheters.
II. Indications for Caval Catheter
A. Caval Catheter in veins in trapped or buried accident victims
Emergency Situations (AHNEFELD, 3; GORGASS, 194). Since in
tensive medical treatment with its special
In many places the caval catheter is still facilities, central venous pressure (CVP)
used only for in-patients. In regions with measurement, parenteral feeding, etc., is
a well-developed emerency medical ser likely to follow, there is only a relative in
vice which as an extended branch of the dication for caval catheterization in
hospital starts its activities at the site of emergencies when puncture of a suitable
emergency, appropriate treatment is in peripheral vein is possible. The limitation
troduced here (Table 1). Under preclini of this relative indication is due mainly to
cal care conditions special, generally ag the fact that puncture of peripheral veins,
gravating circumstances must be consid fixation of self-retaining cannula, and set
ered. ting in motion of infusion or drug ad
Traumatic emergencies and acute life ministration take relatively little time,
threatening situations in all fields of especially when other emergency mea
medicine, forms of acute circulatory sures like artificial respiration and/or car
failure, intoxication, anaphylactic or diac massage are required immediately,
anaphylactoid incidents, as a rule require since even the expert must expect a cer
immediate intravenous administration of tain percentage of unsuccessful. punctures
potent drugs and suitable infusion solu of central veins. These principles must be
tions. An additional indication for punc observed also in corresponding situations
ture of central veins, unfamiliar to the at sites of emergencies outside hospital.
hospital surgeon, is the inadequacy of arm At the site of accident or emergency the
possible approaches for the caval catheter
are the subclavian or brachiocephalic/
Table 1. Indications for caval catheterization in anonymous vein, the internal jugUlar, ex
emergencies ternal jugUlar, and basilic vein. Since
puncture of the femoral vein is hardly
1. Need for rapid intravenous drug administration,
performed any more even in routine
infusion and pacemaker implantation
treatment because of the high rate of later
In - circulatory arrest
- anaphylactic reactions complications and therefore should not be
- anaphylactoid reactions practised under rest conditions either, this
- toxic reactions
theoretic possibility can be ignored with
- loss of volume
regard to emergency treatment (BURRI,
2. Peripheral vein puncture impossible 88).
in - vascular collapse In emergency situations the time factor is
- thrombosis
of the greatest importance. The approach
- obesity
to the superior caval vein requiring the
- inaccessibility
least time with the highest possible suc-
4 Indications for Caval Catheter
cess rate should therefore be given prefer comparable statements in the literature
ence. and our experience the order 1) internal
The approach to the caval vein system jugular vein, 2) subclavian vein, 3) exter
from the cubital veins always takes longer nal jugular vein will be adhered to even at
than from the veins of the neck and the this stage.
subclavian vein, even if the catheter can As mentioned before, in assessing the dif
be moved on without resistance. The fact ferent approaches the second decisive
that the pushing forward of the catheter criterion for emergency treatment is the
after successful puncture of the basilic and time required for successful puncture,
especially the cephalic vein produces dif pushing forward of the catheter and pro
ficulties in a considerable percentage of visional fixation.
cases and can then be continued only after According to experience at the Rescue
injection of infusion solution or abduction Centre Ulm, the following times apply to
and external rotation of the arm, limits the three remaining approach paths:
the suitability of these puncture sites in Subclavian vein: under 1 min
emergencies even more. Internal jugular vein: over 1 min
The pros and cons of the other ap External jugular vein: considerably more
proaches will now be weighed with regard than 1 min
to certainty of aim and time require Under the conditions described the three
ments. possible approaches may be summarized
The certainty of aim of a method depends as follows:
partly on the given anatomic conditions of
the approach path with its individual var
a) Puncture of Subclavian Vein
iations but essentially also on the sur
geon's technique and experience (Fig. 1). Despite the at first sight relatively low
Clearly defined statements on certainty of certainty of aim, as described in our study
aim are made in Chapter IV (Approaches (88), this path proves the most suitable in
to Superior Caval Vein). On the basis of acute emergencies in the opinion of the
emergency surgeons of the Ulm Rescue
Centre.
Criteria for route
of access to caval
Reasons:
vein in emergency
1. According to statements in the litera
Anatomic conditions
ture, the certainty of aim in several
and
experience of punctures on the same or, if necessary,
operator alternate sides is 93 %.
2. The actual time required for successful
puncture up to the start of drug ad
ministration or infusion is under or
about 1 min.
Successful puncture
b) Puncture of Internal Jugular Vein
and
pushing forward The method of internal jugular vein punc
and
ture is tempting because of its high cer
provisional
fixation tainty of aim. Allowing for a change of
sides a success rate of 95% is achieved.
Fig. 1. Criteria for approach to caval vein in
emergencies Although the low rate of serious compli-
