Intensive Care M e d i c i n e
Intens. Care Meal. 5, 37-39 (1979)
9 by Springer-Verlag 1979
Methods and Devices
Guide Wire-Sheath Technique for Pulmonary Artery Catheterization and Central Vein Cannulation John C. McMichan and Luc Michel Section of Respiratory and Intensive Care, Department of Anaesthesiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55901, USA
Abstract. The combination of a spring guide wire with a sheath introducer system has been successfully used for the routine placement of pulmonary artery and central venous catheters. The method, which is described is simple, quick, and safe. It is applicable to the initial placement of the catheter, to any necessary alterations in its position, and to its eventual replacement with a central venous cannula.
With the use of strict aseptic technique and full sterile draping of the patient, the soft, flexible end of a spring guide wire ~ is introduced into the superior vena cava either via a needle puncture of the subclavian or right internal jugular vein or via a cannula already in place in
one of these veins. In the latter case, the cannula is then removed. After the position of the guide wire has been checked by radiography, a sheath-introducer system 2 is passed over it (Fig. 1). This device consists of a vein dilator and a 10-cm sheath. The dilator is introduced into the sheath at its hub, which contains a one-way valve to prevent the entry of air into the venous circulation or the loss of blood from the sheath. A side arm attached to the hub allows the sheath to be flushed with infusion fluid before its insertion. For infusion fluid, we use 5% dextrose solution containing 10,000 units of heparin per litre. The sheath and dilator are advanced over the guide wire until the hub lies at the skin puncture site. The guide wire and vein dilator are then removed, and this leaves the sheath in the vein. Withdrawal of blood into a syringe attached to the side arm confirms this position. A standard intravenous fluid administration set is attached to the side arm to provide a continuous flow of dextroseheparin solution at 3 ml/h, A balloon flotation (SwanGanz) catheter can then be passed through the sheath into the venous system and on into the pulmonary artery [3]. Both the catheter and the sheath are retained in place by skin sutures while an antiseptic ointment is applied to the skin puncture site. The correct placement of the catheter is verified with chest radiography. At times it may be necessary to ad~rance, withdraw, or change (because of balloon rupture) the Swan-Ganz catheter. All of these manipulations can be simply, and safely, performed through the sheath, provided that strict aseptic precautions are taken. When the Swan-Ganz catheter is no longer required, it can be replaced by a central venous cannula. The catheter is withdrawn from the sheath and its tip is removed for microbiologic culture. Under sterile conditions, a spring guide wire is passed a distance of about 20 cm through the sheath into the superior vena cava, and the sheath is removed. A 16-gauge venous cannula is then introduced over the guide wire, and the guide wire is removed. The position of the cannula is checked by chest radiography. As
1USCI, Billerica, Massachusetts, USA
2 CordisCorporation, Miami, Florida, USA
Key words: Pulmonary artery catheter, Central venous cannula, Guide wire-sheath technique, Method for insertion.
Introduction Recent acceptance of pulmonary artery catheterization as a safe and valuable procedure has led to the development of techniques to simplify its use. On many occasion the catheter can be introduced into the pulmonary artery by either percutaneous or direct puncture of a cubital vein. However, there are instances in which the subclavian vein on either side or the right internal jugular vein provides a more appropriate approach--for example, when a subclavian cannula is already in place. For such circumstances, we use a technique employing two specialized but easily obtainable items of equipment--a spring guide wire and a sheath-introducer system. This paper reports the details and our use of this technique.
Method
0342-4642/79/0005/0037/$ 01.00
38
J.C. Me Michan and L. Michel: Guide Wire-Sheath Technique for Catheterization and Cannulation
Fig. 1. Sheath4ntroducer system. Vein dilator is above sheath
Fig. 2. Guide wire is present in a cannula inserted into left subclavian vein. Cannula is seen to cross midline and enter right subclavian vein, into which has been inserted a SwanGanz catheter dictated by the clinical needs, these procedures can be repeated several times with the use of the same central vein, according to the evolution of the haemodynamic status of the patient.
Discussion The combination of a spring guide wire with a sheath is of significant benefit for the placement of a pulmonary artery catheter, particularly if a central venous line is already present. Such is often the case in surgical patients or those with sepsis or trauma in whom the measurement of central venous pressure has proved inadequate for accurate monitoring of the haemodynamic status. During a period of 7 months, 77 catheters were inserted into 60 such patients. The guide wire-sheath technique was used successfully for the placement of each catheter and for its substitution by a central venous cannula. Fifty-two (68%) of these catheters were introduced through either subclavian vein. Five patients required multiple catheters because of defects in manufacture of the catheters. The presence of the sheath made these changes a simple matter, and no complications have been noted with
its use. Instead, the following advantages have emerged. First, at the initial central venous puncture site, a central venous cannula can be replaced by a pulmonary artery catheter, and vice versa, without the loss of the insertion site. The is of particular importance in critically ill patients in whom the sites for introduction of venous catheters are at a premium. Second, the insertion of the introducer sheath over the guide wire is simple, quick, and safe. Third, by removal of the needle accompanying the central venous cannula before the cannula is introduced over the guide wire, the risk that the needle will lacerate the cannula is eliminated. One recent report has mentioned this advantage while advocating the use of a guide ",~'~: for the insertion of all central venous carl, : ':' The guide wire can also be used to overco~,v~ some mechanical problems associated with r entral veneus catheters. We have described a case in which a , o t occurring in a superior vena cava catheter was successfully undone by passing a guide wire along the catheter [2]. A more common problem is that of a catheter introduced into one subclavian vein passing into the opposite subclavian vein or turning rostrally to enter the internal jugular vein (Fig. 2). Such malpositions are prevented by passing the soft and flexible end of a guide wire within
LC. Mc Michan and L. Michel: Guide Wire-Sheath Technique for Cathererization and Cannulation the catheter to its tip. The length of guide wire required is estimated from an :C-ray film or from the length of the catheter remaining outside the patient. Both the catheter and the guide wire are withdrawn into the subclavian vein. The guide wire alone is then advanced, and because of its soft and freely flexible end, it will enter the superior vena cava. Advancement of the catheter over the guide wire will thus ensure its correct placement. An objection to the placement of multiple catheters via the same venous puncture site is that this increases the risk of infection. We have attempted to associate the detection of pathogens by culture of the catheter tip with the development of septicaemia, but this has not been possible. In the few cases in which the same pathogen was grown from the catheter tip and from the blood, it was also cultured from another site. It was thus possible that results of culture of the catheter were providing confirmatory evidence of septicaemia rather than evidence of its source. Nevertheless, being fully aware of the potential for infection, we emphasize careful atten-
39
tion to sterile technique and the use of an antiseptic ointment and sterile dressing applied daily t o the skin puncture site.
References 1. Goy, J. A. E.: Guide-wire technique for central vein cannulation. Br. Med. J. 2, 21 (1976) 2. McMichan, J. C., Michel, L: Knotting of central venous catheters: non-surgical correction. Chest, 74,572 (1979) 3. Swan, H. J. C., Ganz, W., Forrestex, J., Marcus, H., Diamond, G., Chonette, D.: Catheterization of the heart in man with the use of a flow-directed balloon-tipped catheter. N. Engl. J. Med. 283, 447 (1970) Dr. J. Mc Michan Department of Anesthesiology Mayo Clinic 200 First Street, SW Rochester, MN 55901 USA
Intens. Care Meal. 5, 37-39 (1979)
9 by Springer-Verlag 1979
Methods and Devices
Guide Wire-Sheath Technique for Pulmonary Artery Catheterization and Central Vein Cannulation John C. McMichan and Luc Michel Section of Respiratory and Intensive Care, Department of Anaesthesiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55901, USA
Abstract. The combination of a spring guide wire with a sheath introducer system has been successfully used for the routine placement of pulmonary artery and central venous catheters. The method, which is described is simple, quick, and safe. It is applicable to the initial placement of the catheter, to any necessary alterations in its position, and to its eventual replacement with a central venous cannula.
With the use of strict aseptic technique and full sterile draping of the patient, the soft, flexible end of a spring guide wire ~ is introduced into the superior vena cava either via a needle puncture of the subclavian or right internal jugular vein or via a cannula already in place in
one of these veins. In the latter case, the cannula is then removed. After the position of the guide wire has been checked by radiography, a sheath-introducer system 2 is passed over it (Fig. 1). This device consists of a vein dilator and a 10-cm sheath. The dilator is introduced into the sheath at its hub, which contains a one-way valve to prevent the entry of air into the venous circulation or the loss of blood from the sheath. A side arm attached to the hub allows the sheath to be flushed with infusion fluid before its insertion. For infusion fluid, we use 5% dextrose solution containing 10,000 units of heparin per litre. The sheath and dilator are advanced over the guide wire until the hub lies at the skin puncture site. The guide wire and vein dilator are then removed, and this leaves the sheath in the vein. Withdrawal of blood into a syringe attached to the side arm confirms this position. A standard intravenous fluid administration set is attached to the side arm to provide a continuous flow of dextroseheparin solution at 3 ml/h, A balloon flotation (SwanGanz) catheter can then be passed through the sheath into the venous system and on into the pulmonary artery [3]. Both the catheter and the sheath are retained in place by skin sutures while an antiseptic ointment is applied to the skin puncture site. The correct placement of the catheter is verified with chest radiography. At times it may be necessary to ad~rance, withdraw, or change (because of balloon rupture) the Swan-Ganz catheter. All of these manipulations can be simply, and safely, performed through the sheath, provided that strict aseptic precautions are taken. When the Swan-Ganz catheter is no longer required, it can be replaced by a central venous cannula. The catheter is withdrawn from the sheath and its tip is removed for microbiologic culture. Under sterile conditions, a spring guide wire is passed a distance of about 20 cm through the sheath into the superior vena cava, and the sheath is removed. A 16-gauge venous cannula is then introduced over the guide wire, and the guide wire is removed. The position of the cannula is checked by chest radiography. As
1USCI, Billerica, Massachusetts, USA
2 CordisCorporation, Miami, Florida, USA
Key words: Pulmonary artery catheter, Central venous cannula, Guide wire-sheath technique, Method for insertion.
Introduction Recent acceptance of pulmonary artery catheterization as a safe and valuable procedure has led to the development of techniques to simplify its use. On many occasion the catheter can be introduced into the pulmonary artery by either percutaneous or direct puncture of a cubital vein. However, there are instances in which the subclavian vein on either side or the right internal jugular vein provides a more appropriate approach--for example, when a subclavian cannula is already in place. For such circumstances, we use a technique employing two specialized but easily obtainable items of equipment--a spring guide wire and a sheath-introducer system. This paper reports the details and our use of this technique.
Method
0342-4642/79/0005/0037/$ 01.00
38
J.C. Me Michan and L. Michel: Guide Wire-Sheath Technique for Catheterization and Cannulation
Fig. 1. Sheath4ntroducer system. Vein dilator is above sheath
Fig. 2. Guide wire is present in a cannula inserted into left subclavian vein. Cannula is seen to cross midline and enter right subclavian vein, into which has been inserted a SwanGanz catheter dictated by the clinical needs, these procedures can be repeated several times with the use of the same central vein, according to the evolution of the haemodynamic status of the patient.
Discussion The combination of a spring guide wire with a sheath is of significant benefit for the placement of a pulmonary artery catheter, particularly if a central venous line is already present. Such is often the case in surgical patients or those with sepsis or trauma in whom the measurement of central venous pressure has proved inadequate for accurate monitoring of the haemodynamic status. During a period of 7 months, 77 catheters were inserted into 60 such patients. The guide wire-sheath technique was used successfully for the placement of each catheter and for its substitution by a central venous cannula. Fifty-two (68%) of these catheters were introduced through either subclavian vein. Five patients required multiple catheters because of defects in manufacture of the catheters. The presence of the sheath made these changes a simple matter, and no complications have been noted with
its use. Instead, the following advantages have emerged. First, at the initial central venous puncture site, a central venous cannula can be replaced by a pulmonary artery catheter, and vice versa, without the loss of the insertion site. The is of particular importance in critically ill patients in whom the sites for introduction of venous catheters are at a premium. Second, the insertion of the introducer sheath over the guide wire is simple, quick, and safe. Third, by removal of the needle accompanying the central venous cannula before the cannula is introduced over the guide wire, the risk that the needle will lacerate the cannula is eliminated. One recent report has mentioned this advantage while advocating the use of a guide ",~'~: for the insertion of all central venous carl, : ':' The guide wire can also be used to overco~,v~ some mechanical problems associated with r entral veneus catheters. We have described a case in which a , o t occurring in a superior vena cava catheter was successfully undone by passing a guide wire along the catheter [2]. A more common problem is that of a catheter introduced into one subclavian vein passing into the opposite subclavian vein or turning rostrally to enter the internal jugular vein (Fig. 2). Such malpositions are prevented by passing the soft and flexible end of a guide wire within
LC. Mc Michan and L. Michel: Guide Wire-Sheath Technique for Cathererization and Cannulation the catheter to its tip. The length of guide wire required is estimated from an :C-ray film or from the length of the catheter remaining outside the patient. Both the catheter and the guide wire are withdrawn into the subclavian vein. The guide wire alone is then advanced, and because of its soft and freely flexible end, it will enter the superior vena cava. Advancement of the catheter over the guide wire will thus ensure its correct placement. An objection to the placement of multiple catheters via the same venous puncture site is that this increases the risk of infection. We have attempted to associate the detection of pathogens by culture of the catheter tip with the development of septicaemia, but this has not been possible. In the few cases in which the same pathogen was grown from the catheter tip and from the blood, it was also cultured from another site. It was thus possible that results of culture of the catheter were providing confirmatory evidence of septicaemia rather than evidence of its source. Nevertheless, being fully aware of the potential for infection, we emphasize careful atten-
39
tion to sterile technique and the use of an antiseptic ointment and sterile dressing applied daily t o the skin puncture site.
References 1. Goy, J. A. E.: Guide-wire technique for central vein cannulation. Br. Med. J. 2, 21 (1976) 2. McMichan, J. C., Michel, L: Knotting of central venous catheters: non-surgical correction. Chest, 74,572 (1979) 3. Swan, H. J. C., Ganz, W., Forrestex, J., Marcus, H., Diamond, G., Chonette, D.: Catheterization of the heart in man with the use of a flow-directed balloon-tipped catheter. N. Engl. J. Med. 283, 447 (1970) Dr. J. Mc Michan Department of Anesthesiology Mayo Clinic 200 First Street, SW Rochester, MN 55901 USA
