Journal of the Royal Society of Medicine Volume 72 April 1979
263
assessed. However, these preliminary results suggest that this type of system may be a more valid model than that provided by experimental animal tumours for the laboratory study of clinical response to chemotherapy. Acknowledgment: I am grateful to Dr Myrtle Gordon at the Institute of Cancer Research, Sutton, for allowing me to use her data in Figure 3. References Bruce W R, Meeker B E & Valeriote F E (1966) Journal of the National Cancer Institute 37, 233 Cobb L M & Mitchley B C V (1974) Cancer Chemotherapy Reports, part 1 58, 645 Courtenay V D, Smith I E, Peckham M J & Steel G G (1976) Nature 263, 771 Gordon M Y & Blackett N M (1976) Cancer Research 36, 2822 Kopper L & Steel G G (1975) Cancer Research 35, 2704 Moertel C (1973) In: Cancer Medicine. Ed. J F Holland and E Frei. Lea & Febiger, Philadelphia; p 1568 Phillips B & Gazet J-C (1970) British Journal of Cancer 24, 92 Pickard R G, Cobb L M & Steel G G (1975) British Journal of Cancer 31, 36 Rowe-Jones D C (1968) British Journal of Cancer 22, 155 Smith I E, Courtenay V D & Gordon M Y (1976) British Journal of Cancer 34, 476 Steel G G (1977) In: Growth Kinetics of Tumours. Ed. G G Steel. Clarendon, Oxford; p 258 van Putten L M & Lelieveld P (1970) European Journal of Cancer 6, 313
A practical method for ensuring long-term venous access' Professor Peter Jacobs MRCPath FACP Jack Jacobson MB FRCS University of Cape Town Leukaemia Centre and Departments ofHaematology, Clinical Science and Immunology, Groote Schuur Hospital, Observatory, Cape 7925, South Africa
Reliable venous access is of critical importance in the management of the chronically ill and debilitated patient. It is also indispensable during the period when cytotoxic chemotherapy is infused for induction of remission in patients with acute leukaemia and following bone marrow transplantation, when the patients may depend upon intravenous therapy continuously for 6 weeks or more. In these circumstances, consideration must be given to the risks of introducing infection that follow repeated venepunctures in immunocomprised patients, while movement for nursing procedures and physiotherapy inevitably disturb the safety of a peripherallylocated venous line. In an attempt to resolve these problems a technique was developed based on earlier studies in a rabbit model (Jacobs 1973, Jacobs & Adriaenssens 1970) where an entirely subcutaneous plastic system had been implanted; the reservoir remained available for intermittent sampling and provided intravenous access over a 3-month period. The same method is equally applicable to man, but we have recently modified this because, following irradiation and bone marrow transplantation, continuous as opposed to intermittent venous access is mandatory. 1 Accepted 2 June 1978
0 1 41-0768 /79/040263-03/$O 1.00/0
CO
1979 The Royal Society of Medicine
264
Journal of the Royal Society of Medicine Volume 72 April 1979
On the basis of our first 30 procedures, we report a simple technique that has been found helpful in this regard since it leaves the arms free, does not expose the patient to the risks of repeated venepunctures, and is suitable both for intravenous infusion and blood sampling over a long period of time. In contrast to percutaneous subclavian catheterization this approach has been totally free of any complications.
Technique The venous line can be placed under either general or local anaesthetic. A 10-gauge silastic paediatric nasogastric tube with a rounded solid tip and two side holes has been found to be most suitable. A 1 cm incision is made diagonally across the deltopectoral groove at the junction of its upper and middle third. To locate the groove the flat hand is placed on the anterior chest wall and moved laterally over the pectoralis major, when the tips of the fingers will palpate the medial fibres of the deltoid as a ridge. This manoeuvre identifies the position of the cephalic vein (Figure 1). It should be remembered that this groove harbours not only the cephalic vein but also the vessels from the acromiothoracic trunk which lies deep to the vein in that situation (Figure 2). The catheter is introduced subcutaneously through a small stab wound 3 cm lateral to the skin incision and enters the subclavian vein via a small incision in its cephalic tributory (Figure 3). In rare circumstances the basilic vein may have to be used instead of the cephalic, but the principle remains the same. The catheter is directed to lie with its tip 1 cm above the right atrium using radiologic control and is then secured in this position and the skin wound closed. The wound is sutured with 4 0 Dexon and the whole site sealed with a single strip of OpSite which does not require to be changed until the wound has healed. The proximal end of the catheter is connected to a three-way tap which allows continuous intravenous infusion and monitoring of central venous pressure. Blood for a variety of
Cephalic vein
Delto-pectoral i /\
Figure 1. Method for locating deltopectoral groove
| groove
w
vesl frmtsraco trunksA
f om thoraco-
scromial
Figure 2. Arrangements of the anatomical structures lying in the deltopectoral groove
Figure 3. Relationship of skin incision and catheter to the cephalic vein
investigations may be collected from the tap, and the technique employed is to precede specimen collection by the withdrawal of 20 ml of blood and to return this to the patient before recommencing the infusion. Discussion This simple technique provides practical and reliable venous access for periods in excess of 6 weeks and necessitates a minor surgical procedure for introduction of the catheter. The operation requires an experienced surgeon and approximately one hour for its completion and has a high degree of patient acceptability, particularly when compared to the alternative of multiple venepuncture. Furthermore, it avoids the hazards associated with repeatedly breaching the skin, thus reducing the risk of introducing exogenous organisms into the circulation with the development of septicaemia in the chronically ill and immunocompromised patient. This method offers substantial advantages over percutaneous introduction of a central venous line where thrombocytopenia may result in haemothorax: 2 recent patients
Journal of the Royal Society of Medicine Volume 72 April 1979
265
required platelet transfusion and pleural aspiration for this complication. Because of the position of the catheter the patient's arms are free for physiotherapy and for any manoeuvres that the individuals may wish to perform for themselves. For these reasons we consider that the investment of time, with the benefits for patient management, is more than justified. In those individuals where continued intravenous manipulation is anticipated, the simultaneous creation of an arteriovenous fistula or insertion of a plastic prosthesis under the same general anaesthetic has become our recent routine practice, and markedly reduces the difficulties experienced with venous access in subsequent management. Maintenance of the line is of paramount importance and, provided the catheter is flushed through with 3 ml of physiological saline every 4 hours, no problem in maintaining patency has been encountered. The development of infected thrombi at the end of the tubing and occlusion have not yet been encountered, even on removal of the catheter. In the experimental situation, thrombus in the catheter can be gently aspirated or lysed using low-dose infusion of streptokinase. One thousand units of heparin in each 1000 ml fluid should further reduce the risk of clot formation, and while we have used this regimen its efficacy has not been tested under controlled circumstances. A point of particular importance is the ability to sample blood directly from the centrallyplaced catheter. While it might be anticipated that differences would occur between blood collected from this plastic line and from clean puncture of a peripheral vessel, numerous comparisons of electrolytes, biochemical profiles, haematologic tests and blood cultures have consistently failed to show any difference between samples obtained from the two sites. The ability to avoid repeated venepunctures is considered a major benefit by patients who have personally experienced both approaches. It is unlikely that this procedure is new, but we feel that its redescription is justified at a time when an increasing number of patients are undergoing intensive chemotherapy and bone marrow transplantation, and are thus dependent upon reliable venous access for long periods of time.
Summary A simple method of creating dependable long-term venous access is described. This method is suitable both for infusion and repeated blood sampling. Complications have thus far not been encountered.
Acknowledgment: We are grateful to Jeanne Walker for the illustrations. References Jacobs P (1973) PhD Thesis, University of the Witwatersrand Jacobs P and Adriaenssens L (1970) Journal of Laboratory and Clinical Medicine 75, 1013-1016
263
assessed. However, these preliminary results suggest that this type of system may be a more valid model than that provided by experimental animal tumours for the laboratory study of clinical response to chemotherapy. Acknowledgment: I am grateful to Dr Myrtle Gordon at the Institute of Cancer Research, Sutton, for allowing me to use her data in Figure 3. References Bruce W R, Meeker B E & Valeriote F E (1966) Journal of the National Cancer Institute 37, 233 Cobb L M & Mitchley B C V (1974) Cancer Chemotherapy Reports, part 1 58, 645 Courtenay V D, Smith I E, Peckham M J & Steel G G (1976) Nature 263, 771 Gordon M Y & Blackett N M (1976) Cancer Research 36, 2822 Kopper L & Steel G G (1975) Cancer Research 35, 2704 Moertel C (1973) In: Cancer Medicine. Ed. J F Holland and E Frei. Lea & Febiger, Philadelphia; p 1568 Phillips B & Gazet J-C (1970) British Journal of Cancer 24, 92 Pickard R G, Cobb L M & Steel G G (1975) British Journal of Cancer 31, 36 Rowe-Jones D C (1968) British Journal of Cancer 22, 155 Smith I E, Courtenay V D & Gordon M Y (1976) British Journal of Cancer 34, 476 Steel G G (1977) In: Growth Kinetics of Tumours. Ed. G G Steel. Clarendon, Oxford; p 258 van Putten L M & Lelieveld P (1970) European Journal of Cancer 6, 313
A practical method for ensuring long-term venous access' Professor Peter Jacobs MRCPath FACP Jack Jacobson MB FRCS University of Cape Town Leukaemia Centre and Departments ofHaematology, Clinical Science and Immunology, Groote Schuur Hospital, Observatory, Cape 7925, South Africa
Reliable venous access is of critical importance in the management of the chronically ill and debilitated patient. It is also indispensable during the period when cytotoxic chemotherapy is infused for induction of remission in patients with acute leukaemia and following bone marrow transplantation, when the patients may depend upon intravenous therapy continuously for 6 weeks or more. In these circumstances, consideration must be given to the risks of introducing infection that follow repeated venepunctures in immunocomprised patients, while movement for nursing procedures and physiotherapy inevitably disturb the safety of a peripherallylocated venous line. In an attempt to resolve these problems a technique was developed based on earlier studies in a rabbit model (Jacobs 1973, Jacobs & Adriaenssens 1970) where an entirely subcutaneous plastic system had been implanted; the reservoir remained available for intermittent sampling and provided intravenous access over a 3-month period. The same method is equally applicable to man, but we have recently modified this because, following irradiation and bone marrow transplantation, continuous as opposed to intermittent venous access is mandatory. 1 Accepted 2 June 1978
0 1 41-0768 /79/040263-03/$O 1.00/0
CO
1979 The Royal Society of Medicine
264
Journal of the Royal Society of Medicine Volume 72 April 1979
On the basis of our first 30 procedures, we report a simple technique that has been found helpful in this regard since it leaves the arms free, does not expose the patient to the risks of repeated venepunctures, and is suitable both for intravenous infusion and blood sampling over a long period of time. In contrast to percutaneous subclavian catheterization this approach has been totally free of any complications.
Technique The venous line can be placed under either general or local anaesthetic. A 10-gauge silastic paediatric nasogastric tube with a rounded solid tip and two side holes has been found to be most suitable. A 1 cm incision is made diagonally across the deltopectoral groove at the junction of its upper and middle third. To locate the groove the flat hand is placed on the anterior chest wall and moved laterally over the pectoralis major, when the tips of the fingers will palpate the medial fibres of the deltoid as a ridge. This manoeuvre identifies the position of the cephalic vein (Figure 1). It should be remembered that this groove harbours not only the cephalic vein but also the vessels from the acromiothoracic trunk which lies deep to the vein in that situation (Figure 2). The catheter is introduced subcutaneously through a small stab wound 3 cm lateral to the skin incision and enters the subclavian vein via a small incision in its cephalic tributory (Figure 3). In rare circumstances the basilic vein may have to be used instead of the cephalic, but the principle remains the same. The catheter is directed to lie with its tip 1 cm above the right atrium using radiologic control and is then secured in this position and the skin wound closed. The wound is sutured with 4 0 Dexon and the whole site sealed with a single strip of OpSite which does not require to be changed until the wound has healed. The proximal end of the catheter is connected to a three-way tap which allows continuous intravenous infusion and monitoring of central venous pressure. Blood for a variety of
Cephalic vein
Delto-pectoral i /\
Figure 1. Method for locating deltopectoral groove
| groove
w
vesl frmtsraco trunksA
f om thoraco-
scromial
Figure 2. Arrangements of the anatomical structures lying in the deltopectoral groove
Figure 3. Relationship of skin incision and catheter to the cephalic vein
investigations may be collected from the tap, and the technique employed is to precede specimen collection by the withdrawal of 20 ml of blood and to return this to the patient before recommencing the infusion. Discussion This simple technique provides practical and reliable venous access for periods in excess of 6 weeks and necessitates a minor surgical procedure for introduction of the catheter. The operation requires an experienced surgeon and approximately one hour for its completion and has a high degree of patient acceptability, particularly when compared to the alternative of multiple venepuncture. Furthermore, it avoids the hazards associated with repeatedly breaching the skin, thus reducing the risk of introducing exogenous organisms into the circulation with the development of septicaemia in the chronically ill and immunocompromised patient. This method offers substantial advantages over percutaneous introduction of a central venous line where thrombocytopenia may result in haemothorax: 2 recent patients
Journal of the Royal Society of Medicine Volume 72 April 1979
265
required platelet transfusion and pleural aspiration for this complication. Because of the position of the catheter the patient's arms are free for physiotherapy and for any manoeuvres that the individuals may wish to perform for themselves. For these reasons we consider that the investment of time, with the benefits for patient management, is more than justified. In those individuals where continued intravenous manipulation is anticipated, the simultaneous creation of an arteriovenous fistula or insertion of a plastic prosthesis under the same general anaesthetic has become our recent routine practice, and markedly reduces the difficulties experienced with venous access in subsequent management. Maintenance of the line is of paramount importance and, provided the catheter is flushed through with 3 ml of physiological saline every 4 hours, no problem in maintaining patency has been encountered. The development of infected thrombi at the end of the tubing and occlusion have not yet been encountered, even on removal of the catheter. In the experimental situation, thrombus in the catheter can be gently aspirated or lysed using low-dose infusion of streptokinase. One thousand units of heparin in each 1000 ml fluid should further reduce the risk of clot formation, and while we have used this regimen its efficacy has not been tested under controlled circumstances. A point of particular importance is the ability to sample blood directly from the centrallyplaced catheter. While it might be anticipated that differences would occur between blood collected from this plastic line and from clean puncture of a peripheral vessel, numerous comparisons of electrolytes, biochemical profiles, haematologic tests and blood cultures have consistently failed to show any difference between samples obtained from the two sites. The ability to avoid repeated venepunctures is considered a major benefit by patients who have personally experienced both approaches. It is unlikely that this procedure is new, but we feel that its redescription is justified at a time when an increasing number of patients are undergoing intensive chemotherapy and bone marrow transplantation, and are thus dependent upon reliable venous access for long periods of time.
Summary A simple method of creating dependable long-term venous access is described. This method is suitable both for infusion and repeated blood sampling. Complications have thus far not been encountered.
Acknowledgment: We are grateful to Jeanne Walker for the illustrations. References Jacobs P (1973) PhD Thesis, University of the Witwatersrand Jacobs P and Adriaenssens L (1970) Journal of Laboratory and Clinical Medicine 75, 1013-1016
