Routine Subclavian Vein Catheterization
in Abdominal
Surgical Practice L. Dieter Voegele, MD, Charleston, South Carolina
Aubaniac [l ] first introduced subclavian vein catheterization to resuscitate combat casualties. Wilson [Z] and Dudrick and Wilmore [3,4] standardized the procedure and found it a convenient and desirable route for administration of fluids of high osmolar concentration, special measurements, or rapid resuscitation. It saved peripheral veins from the sclerotic effects of these solutions. However, this method of fluid administration has usually been reserved for severely ill patients in whom the risk of the procedure could not be interpreted as representing a greater risk than the conditions requiring treatment [5]. Peripheral vein catheterization, either percutaneously or by cutdown, certainly has its attendant risks. Phlebitis is seen quite often, especially when antibiotics are administered through plastic catheters. The danger of suppurative thrombophlebitis is a real one. The immobilization of the arm with cumbersome boards and copious amounts of tape are at least a source of irritation to the patient and often confine the patient needlessly. Complications from subclavian vein catheterization have been few under a great variety of circumstances when the procedure has been performed by trained personnel [6-81. Between May 1974 and March 1975, ninety-four consecutive patients with abdominal surgical procedures had subclavian vein catheters inserted routinely before operation. Approximately 10 per cent of these patients represented emergency interventions, such as upper gastrointestinal bleeding, peritonitis, or gunshot wounds. However, the great majority were elective abdominal procedures. (Table I.) The purpose of this study was to evaluate subclavian vein catheterization in routine operative patients and to determine if it was a safe technic with minimal morbidity. Fromthe Department of Surgery, Medical University of South Carolina, 80 Barre Street, Charleston, South Carolina. Reprint requests should be addressed to L. Dieter Voegele, MD, Department of Surgery, Medical University of South Carolina, 80 Barre Street, Charleston, South Carolina 29401.
170
Material and Methods From May 1974 to March 1975 ninety-four subclavian vein catheterizations were performed in patients under going abdominal surgery. All catheter insertions were carried out or closely supervised by senior surgical residents at the Medical University of South Carolina Hospital. Catheters were inserted in the operating room under sterile conditions. Immediately after induction and intubation, the patient is placed in a slight Trendelenburg position to maximally fill and dilate the subclavian veins. The right infraclavicular approach was preferred (but the left side or supraclavicular approach can just as easily be used). The right arrh of the patient is put in adduction along his side. The neck is not turned. The person who scrubs the patient stands on the left side of the patient and washes the proposed subclavian puncture site. This should result in a wide sterile field which is then draped off by a small-aperture drape sheet. The scrubber then addresses himself to his other scrubbing tasks and the operator proceeds with the insertion of the subclavian line. While the catheter is being passed through the introducing needle, the anesthetist should hold the patient’s breath to prevent any negative pressure drawing air into the vein. After the line is secured at the puncture site, Betadine ointment is applied and a gauze dressing is held in place with elastoplast. The patient’s standard operative site can now be draped in the usual fashion. Portable chest x-ray equipment in the recovery area was employed for each patient to ascertain correct placement of the catheter. The catheters were not used for blood sampling. Catheters were removed and tips cultured, and concomitant blood cultures were made if the patient had a temperature elevation that could not be explained and was therefore likely to be from the line.
Results Placement of the subclavian catheter was effected with very little morbidity. (Table II.) On one occasion, an arterial puncture was carried out. The needle was withdrawn, gentle compression was applied, and then the vein was cannulated
The American Journal of Surgery
Subclavian Vein Catheterization
TABLE I
Ultimate Use of SukIavien Procedure
Emergency procedure Elective procedure Parenteral nutrition Central venous pressure monitoring Administration of whole blood or red blood cells Routine intravenous
Line
TABLE II Number 9 85 12 20 2
60
without difficulty. On another occasion, a hematoma developed from an unsuccessful puncture. Compression was applied and no further attempts were carried out. The most significant problem encountered was an inability to find access to the subclavian vein. This could be on the basis of hypovolemia, positional or anatomic variations. This occurred in four instances. A maximum of three attempts were made. On one occasion, the supraclavicular approach was then substituted and this was successful. Eight patients had their catheters removed because of fever. Five patients had clinical evidence of sepsis. Streptococcus faecalis grew in blood cultures and catheter tip cultures from one patient with ascites and a disrupted pyloroplasty. Another patient with pseudomonas pneumonia on a respirator demonstrated growth of the organism on the catheter tip and in the blood cultures. However, one of the septic patients showed only Staphylococcus epidermidis on the catheter tip, and multiple blood cultures were negative. Two other patients who were definitely septic, one with a pancreatic abscess and the other with a pelvic abscess, had negative cultures of blood and catheter. Three patients had otherwise unexplained fevers. No organisms were recovered. No source of contamination was found and the temporal course of the febrile episode hardly corresponded to removal of the catheter. On one occasion the catheter passed upward into the jugular vein. This was spotted on the chest x-ray film taken in the recovery room and the catheter was withdrawn. There were no instances of pneumothroax, catheter embolism, or air embolism. Comments At one time or another, nearly every imaginable complication has been noted in the literature [9]. Nevertheless, in reviewing the experience with ninety-four patients who underwent routine preit is operative subclavian vein catheterization, clear that the ease of performance, the ready ac-
Vohmm 131, FoWary 1076
Complications Associated with Subolavian Lines Complication
Hematoma . Arterial puncture Jugular placement Unable to place Sepsis Fever only
Number
1 1 1 4
5 3
cessibility of a large flow venous channel and the comfort to the patient who does not have his arms or hands tied up with tapes and boards make this technic worthwhile. The relatively minor complications we have encountered represent no danger to the patient in addition to his underlying problems and do not detract from the desirable aspects of the technic. Because of the careful initial management, the units were easily converted to the lifeline hyperalimentation system. More commonly, however, the lines were used to administer postoperative fluids, antibiotics, or to measure central venous pressure On two occasions, blood was administered through the catheter. This method of intravenous access is functional and safe and provides added versatility for speed of administration and types of fluids administered, and above all it frees the patient from bandages, irksome tapes, and other immobilizing devices on the extremities. It avoids the risks of thrombophlebitis in peripheral veins. As others have noted [10,11], basic precautions and vigilant care of the subclavian unit must be taken. It would not be wise to treat lightly either the insertion or the follow-up care [6]. It should not be performed by the occasional operator. The catheters themselves cannot easily be indicted for infectious complications. However, as others have mentioned [7,10,12], in the face of established infections these foreign material cannulas can become foci of nidation. Neither heparin flushes nor amphotericin flushes were carried out in this group of patients [13]. Certain precautions need to be reemphasized: it is not a procedure for the operator who rarely employs it [11], and asepsis and a closed system between bottle and patient must be respected for the duration of the catheter use. The surgeon should perform a small, finite number of “sticks” if he or she experiences difficulty with finding the vein. The procedure should only be performed on one side or the other unless chest x-ray film is available. Chest x-ray film must be taken in each instance to confirm the position of the catheter tip.
179
Summary Ninety-four routine subclavian vein catheterizations in patients with abdominal surgical procedures were performed by the resident surgical staff at the Medical University of South Carolina Hospital over a ten month period. This was done primarily to have ready access to large veins during surgery and to free the patients’ extremities from uncomfortable immobilization and the risk of superficial thrombophlebitis in the postoperative period. The procedure is safe, and complications can be kept to a minimum if experienced personnel place and then care for the catheter. References 1. Aubaniac R: Une, novells voie d’injection ou de proncture veineuse: la Voie sous-claviculaire. Sem Hop Paris 28: 2445,1952. 2. Wilson JN, Crow JB, Defvlay CV, Prevedel A, Owens J: Central venous pressure in optimal blood volume maintenance. Arch Surg 85: 582, 1952. 3. Dudrick SJ, Wilmore DW: Long-term parenteral feeding.
180
Hasp Practice 3: 85, 1968. 4. Wilmore DW, Dudrick SJ: Safe long-term venous catheterization. Arch Surg 98: 256, 1969. 5. Dudrick SJ. Steiger E, Long JM: Role of parenteral hyperalimentation in the management of multiple catastrophic complications. Surg Clin North Am 50: 1031, 1970. 6. Merk ED, Rush B: Emergency subclavain vein catheterization and intravenous hyperalimentation. Am J Surg 129: 266, 1975. 7. Copeland EM Ill, MacFadyen BV Jr, M&own C, Dudrick SJ: The use of hyperalimentation in patients with potential sepsis. Surg Gynecol Obstet 138: 377, 1974. 8. Dennis C, Grosz CR: A quarter century of intracaval feeding. Surg Gynecol Obstet 135: 883, 1972. 9. Bernard RW, Stahl WM: Subclavian vein catheterizations: a prospective study, I Ann Surg 173: 184, 1971. 10. Curry CR, Quie PG: Fungal septicemia in patients receiving parenteral hyperalimentation. N fngl J Med 255: 1221, 1971. 11. Dudrick SJ, Rhoads JE: New horizons for intravenous feeding. JAMA 215: 939, 1971. 12. Freeman JB, Lemire A, MacLean LD: Intravenous alimentation and septicemia. Surg Gynecol Obstet 135: 708, 1972. 13. Brennan MF, Goldman MH, O’Connell RC. et al: Prolonged parenteral alimentation: Candida growth and the prevention of Candidemia by amphotericin instillation. Ann Surg 178: 265, 1972.
The Amerkan Jwnal of Sur9ery
in Abdominal
Surgical Practice L. Dieter Voegele, MD, Charleston, South Carolina
Aubaniac [l ] first introduced subclavian vein catheterization to resuscitate combat casualties. Wilson [Z] and Dudrick and Wilmore [3,4] standardized the procedure and found it a convenient and desirable route for administration of fluids of high osmolar concentration, special measurements, or rapid resuscitation. It saved peripheral veins from the sclerotic effects of these solutions. However, this method of fluid administration has usually been reserved for severely ill patients in whom the risk of the procedure could not be interpreted as representing a greater risk than the conditions requiring treatment [5]. Peripheral vein catheterization, either percutaneously or by cutdown, certainly has its attendant risks. Phlebitis is seen quite often, especially when antibiotics are administered through plastic catheters. The danger of suppurative thrombophlebitis is a real one. The immobilization of the arm with cumbersome boards and copious amounts of tape are at least a source of irritation to the patient and often confine the patient needlessly. Complications from subclavian vein catheterization have been few under a great variety of circumstances when the procedure has been performed by trained personnel [6-81. Between May 1974 and March 1975, ninety-four consecutive patients with abdominal surgical procedures had subclavian vein catheters inserted routinely before operation. Approximately 10 per cent of these patients represented emergency interventions, such as upper gastrointestinal bleeding, peritonitis, or gunshot wounds. However, the great majority were elective abdominal procedures. (Table I.) The purpose of this study was to evaluate subclavian vein catheterization in routine operative patients and to determine if it was a safe technic with minimal morbidity. Fromthe Department of Surgery, Medical University of South Carolina, 80 Barre Street, Charleston, South Carolina. Reprint requests should be addressed to L. Dieter Voegele, MD, Department of Surgery, Medical University of South Carolina, 80 Barre Street, Charleston, South Carolina 29401.
170
Material and Methods From May 1974 to March 1975 ninety-four subclavian vein catheterizations were performed in patients under going abdominal surgery. All catheter insertions were carried out or closely supervised by senior surgical residents at the Medical University of South Carolina Hospital. Catheters were inserted in the operating room under sterile conditions. Immediately after induction and intubation, the patient is placed in a slight Trendelenburg position to maximally fill and dilate the subclavian veins. The right infraclavicular approach was preferred (but the left side or supraclavicular approach can just as easily be used). The right arrh of the patient is put in adduction along his side. The neck is not turned. The person who scrubs the patient stands on the left side of the patient and washes the proposed subclavian puncture site. This should result in a wide sterile field which is then draped off by a small-aperture drape sheet. The scrubber then addresses himself to his other scrubbing tasks and the operator proceeds with the insertion of the subclavian line. While the catheter is being passed through the introducing needle, the anesthetist should hold the patient’s breath to prevent any negative pressure drawing air into the vein. After the line is secured at the puncture site, Betadine ointment is applied and a gauze dressing is held in place with elastoplast. The patient’s standard operative site can now be draped in the usual fashion. Portable chest x-ray equipment in the recovery area was employed for each patient to ascertain correct placement of the catheter. The catheters were not used for blood sampling. Catheters were removed and tips cultured, and concomitant blood cultures were made if the patient had a temperature elevation that could not be explained and was therefore likely to be from the line.
Results Placement of the subclavian catheter was effected with very little morbidity. (Table II.) On one occasion, an arterial puncture was carried out. The needle was withdrawn, gentle compression was applied, and then the vein was cannulated
The American Journal of Surgery
Subclavian Vein Catheterization
TABLE I
Ultimate Use of SukIavien Procedure
Emergency procedure Elective procedure Parenteral nutrition Central venous pressure monitoring Administration of whole blood or red blood cells Routine intravenous
Line
TABLE II Number 9 85 12 20 2
60
without difficulty. On another occasion, a hematoma developed from an unsuccessful puncture. Compression was applied and no further attempts were carried out. The most significant problem encountered was an inability to find access to the subclavian vein. This could be on the basis of hypovolemia, positional or anatomic variations. This occurred in four instances. A maximum of three attempts were made. On one occasion, the supraclavicular approach was then substituted and this was successful. Eight patients had their catheters removed because of fever. Five patients had clinical evidence of sepsis. Streptococcus faecalis grew in blood cultures and catheter tip cultures from one patient with ascites and a disrupted pyloroplasty. Another patient with pseudomonas pneumonia on a respirator demonstrated growth of the organism on the catheter tip and in the blood cultures. However, one of the septic patients showed only Staphylococcus epidermidis on the catheter tip, and multiple blood cultures were negative. Two other patients who were definitely septic, one with a pancreatic abscess and the other with a pelvic abscess, had negative cultures of blood and catheter. Three patients had otherwise unexplained fevers. No organisms were recovered. No source of contamination was found and the temporal course of the febrile episode hardly corresponded to removal of the catheter. On one occasion the catheter passed upward into the jugular vein. This was spotted on the chest x-ray film taken in the recovery room and the catheter was withdrawn. There were no instances of pneumothroax, catheter embolism, or air embolism. Comments At one time or another, nearly every imaginable complication has been noted in the literature [9]. Nevertheless, in reviewing the experience with ninety-four patients who underwent routine preit is operative subclavian vein catheterization, clear that the ease of performance, the ready ac-
Vohmm 131, FoWary 1076
Complications Associated with Subolavian Lines Complication
Hematoma . Arterial puncture Jugular placement Unable to place Sepsis Fever only
Number
1 1 1 4
5 3
cessibility of a large flow venous channel and the comfort to the patient who does not have his arms or hands tied up with tapes and boards make this technic worthwhile. The relatively minor complications we have encountered represent no danger to the patient in addition to his underlying problems and do not detract from the desirable aspects of the technic. Because of the careful initial management, the units were easily converted to the lifeline hyperalimentation system. More commonly, however, the lines were used to administer postoperative fluids, antibiotics, or to measure central venous pressure On two occasions, blood was administered through the catheter. This method of intravenous access is functional and safe and provides added versatility for speed of administration and types of fluids administered, and above all it frees the patient from bandages, irksome tapes, and other immobilizing devices on the extremities. It avoids the risks of thrombophlebitis in peripheral veins. As others have noted [10,11], basic precautions and vigilant care of the subclavian unit must be taken. It would not be wise to treat lightly either the insertion or the follow-up care [6]. It should not be performed by the occasional operator. The catheters themselves cannot easily be indicted for infectious complications. However, as others have mentioned [7,10,12], in the face of established infections these foreign material cannulas can become foci of nidation. Neither heparin flushes nor amphotericin flushes were carried out in this group of patients [13]. Certain precautions need to be reemphasized: it is not a procedure for the operator who rarely employs it [11], and asepsis and a closed system between bottle and patient must be respected for the duration of the catheter use. The surgeon should perform a small, finite number of “sticks” if he or she experiences difficulty with finding the vein. The procedure should only be performed on one side or the other unless chest x-ray film is available. Chest x-ray film must be taken in each instance to confirm the position of the catheter tip.
179
Summary Ninety-four routine subclavian vein catheterizations in patients with abdominal surgical procedures were performed by the resident surgical staff at the Medical University of South Carolina Hospital over a ten month period. This was done primarily to have ready access to large veins during surgery and to free the patients’ extremities from uncomfortable immobilization and the risk of superficial thrombophlebitis in the postoperative period. The procedure is safe, and complications can be kept to a minimum if experienced personnel place and then care for the catheter. References 1. Aubaniac R: Une, novells voie d’injection ou de proncture veineuse: la Voie sous-claviculaire. Sem Hop Paris 28: 2445,1952. 2. Wilson JN, Crow JB, Defvlay CV, Prevedel A, Owens J: Central venous pressure in optimal blood volume maintenance. Arch Surg 85: 582, 1952. 3. Dudrick SJ, Wilmore DW: Long-term parenteral feeding.
180
Hasp Practice 3: 85, 1968. 4. Wilmore DW, Dudrick SJ: Safe long-term venous catheterization. Arch Surg 98: 256, 1969. 5. Dudrick SJ. Steiger E, Long JM: Role of parenteral hyperalimentation in the management of multiple catastrophic complications. Surg Clin North Am 50: 1031, 1970. 6. Merk ED, Rush B: Emergency subclavain vein catheterization and intravenous hyperalimentation. Am J Surg 129: 266, 1975. 7. Copeland EM Ill, MacFadyen BV Jr, M&own C, Dudrick SJ: The use of hyperalimentation in patients with potential sepsis. Surg Gynecol Obstet 138: 377, 1974. 8. Dennis C, Grosz CR: A quarter century of intracaval feeding. Surg Gynecol Obstet 135: 883, 1972. 9. Bernard RW, Stahl WM: Subclavian vein catheterizations: a prospective study, I Ann Surg 173: 184, 1971. 10. Curry CR, Quie PG: Fungal septicemia in patients receiving parenteral hyperalimentation. N fngl J Med 255: 1221, 1971. 11. Dudrick SJ, Rhoads JE: New horizons for intravenous feeding. JAMA 215: 939, 1971. 12. Freeman JB, Lemire A, MacLean LD: Intravenous alimentation and septicemia. Surg Gynecol Obstet 135: 708, 1972. 13. Brennan MF, Goldman MH, O’Connell RC. et al: Prolonged parenteral alimentation: Candida growth and the prevention of Candidemia by amphotericin instillation. Ann Surg 178: 265, 1972.
The Amerkan Jwnal of Sur9ery
