In Vitro Comparison of Central Venous Catheters for Aspiration of Venous Air Embolism: Effect of Catheter Type, Catheter Tip Position, and Cardiac Inclination Pamela G. Hanna, MD,* Nikolaus Gravenstein, MD,? Annette G. Pashayan, MD+ Departments

of’ Anesthesiology

of Medicine,

Gainesville,

Study

Objective:

and Neurosurgery,

University

of’ Florida

College

FL.

To test the relative ejjiciency of balloon-tipped and plain catll-

eters for aspiration of venous air embolism. Design: The following four single-lumen central venous catheters were studied in J. Clin. Anesth. 3:290-294,

a .rilastic model of the right atrium, tricuspid valve, and uena cavae: (lj

1991

gauge single-orifice catheter; (2) the 14-gauge Bunegin-Albin (3) the 7-Fr pulmonary

*Resident in Anesthesiology

the I6-

multiorifice catheter;

angioCgraphy catheter with balloon distal to orifices; (4)

the 7-Fr pulmonary anCgioLgraphy catheter with balloon proximal to orifices. A 10% tAssociate Professor, Neurosurgery *Assistant Professor, Neurosurgery

Anesthesiology

and

glycerol-water

solution was circulated at 3.7 to 4.0 Llmin. Catheter. tips were

positioned at 1 cm increments from Anesthesiology

and

- 3 to f 3 cm around the superior vena UIW-

ri + I

I + I

3 i- I

2t :!+

Values are means 2 SD. 14-ga B-A MO, Bunegin-Albin multi-orifice; 1%ga SO, single-orifice; PA Angio (pulmonary angiography) PA Angio proximal, balloon proximal to orifices; down = balloon deflated; up = balloon inflated. *Negative

Table

sign indicates catheter

2.

Mean

Percentage

tip position above the SVC-RA

of Air Aspirated Air Aspirated

by Venous

by Catheters

(superior

Catheters Positioned

vena cava-right

with Heart Relative

distal, balloon distal to orltices:

atrial) junction.

Model

Inclined

to Superior

65”

Vena Cava-Right

Atria1 Junction*

@) Catheter

-3

14-ga B-A MO 16-ga SO 7-Fr PA Angio Distal down Distal up 7-Fr PA Angio Proximal down Proximal up

cm

321 86 k 2

-2

722 83 t 4

7-c3 1+1 64 k 2 15 + I

cm

521 221 68 k 2 1.1, k

1

-1cm

Ocm

35 -f 3 64 k 4

cm

+2 cm

+3 cm

33 2 2 42 -c 4

22 k 4 3t I

8+-2 2t I

4-t 2?2

22 k 1 38 k 4

22 I 50 + 3

:ir I 26 -t 2

2t I 3 -t I

l&l 22

53 2 3 13 2 I

27 !I 1

lkl

‘> + 1

3 k I

;I,

0 2 1 22 1

622

+1

1

I

Values are means 2 SD. 14.ga B-A MO, Bunegin-Albin multi-orifice; Ifi-ga SO, single-orifice; PA Angio (pulmonary angiography) PA Angio proximal, balloon proximal to orifices; down = balloon deflated; up = balloon inflated. *Negative

292

sign indicates catheter

J. Clin. Anesth.,

tip position above the SVC-RA

vol. 3, July/August

1991

(superior

vena c-ava-right atrial) junction.

distal, balloon distal to orifices;

Central venous catheters: Hanna et al. Table 3. Best Position of Each Catheter 80” and 65” Inclinations of the Heart.

and Percentage

of Air Aspirated at

80” Catheter 14-ga B-A MO 16-ga SO 7-Fr PA Angio Distal down Distal up 7-Fr PA Angio Proximal down Proximal up

65”

Position (cm)

Air Aspirated (%I

Position (4

-1 -3

62 * 5* 56 f 7

-3

-1 0 -3 -0

Air Aspirated 6)

0

28 k 2 30 k 2

-1

54 +- 2 26 k 1

-2 -3

38 k 2 86 2 2* 22 * 1 50 * 3

0

68 k 2 15 k 1

Values for air aspirated are means + SD. *Best catheter at each angle. 14-ga B-A MO, Bunegin-Albin multi-orifice; 16-ga SO, single-orifice; PA Angio (pulmonary angiography) distal, balloon distal to orifices; PA Angio proximal, balloon proximal to orifices; down = balloon deflated; up = balloon inflated. Negative sign indicates catheter tip position above the SVC-RA (superior vena cava-right atrial) junction.

I *rPA II,.

B-A MO C.th.t*r

*1sg.s0

c.tw.r

And.3

Distal _ Bdlom Balloon

I FrPA ADli.3 Proximi Balloon B.lloon

It

1en.

go*

7 FrPA Aagio Distal

I FrPA Angia Prc.xim.l

It

svc

B

svc -3cm -!hm

WC-IIA

Junction

-1cm ()

_

u

aD

(1

+1cm

RA

+2cm +3cm

RA

+3em

Figure 2. Optimal positions of each catheter tip for air recovery at 80” cardiac inclination (see also Table I) [* = best catheter at best position (p < 0.05); WC = superior vena cava; RA = right atrium; 14-ga B-A MO = 14-gauge Bunegin-Albin multiorifice; 16-ga SO = 16-gauge single orifice; 7 FrPA Angio Distal = pulmonary angiography with balloon distal to orifices; 7 FrPA Angio Proximal = pulmonary angiography with balloon proximal to orifices; J = balloon deflated; t = balloon inflated; negative sign = catheter tip position above the WC-RA junction].

Figure 3. Optimal position of each catheter tip for air recovery at 65” cardiac inclination (see also Table 2) [* = best catheter at best position (p < 0.05); SVC = superior vena cava; RA = right atrium; 14-ga B-A MO = 14-gauge Bunegin-Albin multiorifice; 16-ga SO = 16-gauge single orifice; 7 FrPA Angio Distal = pulmonary angiography with balloon distal to orifices; 7 FrPA Angio Proximal = pulmonary angiography with balloon proximal to orifices; 1 = balloon deflated; t = balloon inflated; negative sign = catheter tip position above the WC-RA junction].

ficiency of air aspiration. Of the balloon-tipped catheters, the best functioning was the 7-Fr angiography catheter with the balloon proximal to the orifices and the catheter tip positioned 2 cm above the SVC-RA

junction; 68% of the air was aspirated when the balloon was deflated. When the balloon was inflated, only 26% of the air was aspirated at its optimal catheter tip position. J. Chn. Anesth., vol. 3, July/August

1991

293

Acknowledgments

Discussion ‘The use of a multiorifice balloon-tipped catheter, designed for pulmonary angiography, was proposed in 1980 to monitor and treat venous air embolism.!’ ‘I’o date, no laboratory, animal, or human study has attempted to systematically compare a balloon-tipped, flow-directed catheter of this type with other previously studied catheters. Using an established model,” we studied the efficacy of two such puhnonary angiography catheters and found that the balloon-tipped catheter offered no advantage and, in fact, when compared with the single-orifice or multiorifice catheters currently in use, presented a disadvantage. Observation of the in vitro model showed that the balloon did not cause localization of the catheter aspiration orifices to the air-fluid vortex in the SVC. In fact, balloon inflation hindered air from contact with the orifices. These catheters have closed distal ends precluding air aspiration from that site. The size, number, and position of the orifices was neither designed nor optimized for the application studied. ‘I-he study model also clearly demonstrated that positioning any catheter tip inside the atrium had no benefit. Optimal positions for the single-orifice and multiorifice catheters determined in this study are almost identical to those described by Bunegin et CLI.~~ The study data suggest that, in instances where the inclination of the patient’s heart is only 65”, a conventional, single-lumen, central venous catheter positioned in the usual central venous pressure location (i.e., 3 cm above the SVC-RA ,junction) is more effective than either the larger, specialized, multiorifice central venous catheter or the balloon angiography catheters studied. The single-lumen central venous catheter has other advantages in addition to efficient air aspiration, such as ease of insertion (no introducer required) and reliable tip positioning based on electrocardiogram (WC;) criteria. For patients inclined to 80”, the amount of air recovery (62%) was less than for those with only a 65” inclination (86%). Better air recovery with the multiorifke rather than the singlelumen catheter was demonstrated, but whether the difference in air recovery (62% 11s56%) is clinically important is not clear.

294

J. Clin. Anesth.,

vol. 3, July/August

1991

M!e would like to thank ice S. Albin, made and

MD,

the silastic Lynn

Dirk

whose model

tar

their

Mr. Leon

Bunegin

instruction possible, editorial

and and

and

Maul--

cooperation

Michelle

Martin

assistance.

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1353-8.

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10. Diaz PM: Balloon catheter should increase recovery of embolized air [Correspondence]. Anesthesiology 1982;57: 66.

11. Bunegin capture

I,, Albin MS: Balloon catheter increases ail [Correspondence]. Anesthe.rioZqg?. 1982;57:66-

7.

12. Bunegin L, Albin MS, Helsel PE, et al: Positioning the right atria1 catheter: a model for reappraisal. Anesthr.\iOlOgy198

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