Central Venous Catheters (Wiley Series in Nursing)

Thông tin sách: Central Venous Catheters (Wiley Series in Nursing) (Paperback, 272 trang) – Wiley, 2009. Ngôn ngữ: Tiếng Anh.

This book addresses all the issues a patient may experience prior to receiving a VAD. Selection of equipment, practical aspects of technique, the pros and cons of the various veins, and modifications of technique for certain circumstances are examined. Covereage also includes the roles played by radiologists, anaesthetists, surgeons, nurses, and other team memebers. Throughout the chapters a reference is made to the IV Therapy Standards published by the Royal College of Nursing IV Therapy Forum in 2003. Each chapter is evidence based and fully referenced. Editorial Reviews About the Author Helen Hamilton, Clinical Director, Department of Parenteral Nutrition and Vascular Access, Oxford Radcliffe Hospitals Trust, Headington. Oxford. Excerpt. © Reprinted by permission. All rights reserved. Central Venous CathetersJohn Wiley & SonsCopyright © 2007 Helen Hamilton
All right reserved.
ISBN: 978-0-470-01994-8

Chapter OneThe history of central venous access

J.L. Peters

Introduction

Techniques and indications for venous access are rapidly changing with huge advances in the last 60 years. An appreciation of such developments and earlier historical endeavours in this field allow the reader insight into the origins of many modern-day practices and the devices in use.

The origins of venous access

Up to the time of William Harvey (1578-1657), there was considerable debate about the circulation. Shortly after Harvey's discovery, Sir Christopher Wren (1971) made the first attempts at providing intravenous nutrition and injecting drugs. In 1656, using a goose quill attached to a pig's bladder, he infused a mixture of wine, ale and opium into dogs. He was not alone in this field of inquiry, for Lower and King (1662), Lower (1932) and Major (1667) performed intravenous infusions and transfusions on animals. Major also used the silver cannula and a pig's bladder to infuse saline via the antecubital fossa veins in a human being. An illustration of this technique can be found in the Wellcome History of Medicine Museum in London. Robert Boyle described the work of Wren, and he performed experiments using intravenous infusion from animals to humans (Birch 1744, Wheatley 1966). Denys (1667) transfused blood from a lamb into a human being in 1667 in Paris, and Lower performed the first successful transfusion of animal blood into a human being in the same year. These practices soon fell into disrepute, as fatal reactions occurred. A church and parliamentary edict prevented further transfusions until 1818, when Blundell (1818), an English obstetrician, saved the lives of several patients with postpartum haemorrhage by injecting blood using a syringe.

In 1733, Stephen Hales conceived the idea of introducing a glass tube into the venous and arterial systems of a live mare in order to measure blood pressure. He also made the first attempts to estimate the cardiac output by bleeding the animal to death and filling its left ventricle with melted beeswax. He multiplied the volume of the solidified wax by the normal resting heart rate in order to achieve figures for the cardiac output of dogs, oxen, sheep and humans (Hales 1974).

Cardiac catheterisation was first performed by Claude Bernard in France to determine the temperature of the blood in the right and left ventricles. Hoff et al. (1965) had suggested that animal heat was produced as a result of respiratory gas exchange in the lungs, whilst Magnus (1837) had advanced the alternative hypothesis that 'combustion' took place in the tissues. In 1844, Bernard (1876) operated on a horse and cannulated the carotid artery and left ventricle, followed by the internal jugular vein and right ventricle, using a long mercury thermometer. He disproved the pulmonary combustion theory, and later he went on to measure intracardiac pressures using glass tubes. Bernard (1876) also noted in an autopsy on a dog that the right ventricle had been perforated by the tube, causing intrapericardial haemorrhage, and thus he recorded the first complication of central venous catheterisation. The thrust of these investigations was to try and determine why the living body was warm compared to the coldness of a corpse.

The first systemic study, description and interpretation of intracardiac pressure recordings were made by Chauveau and Marey (1863) after working at the School of Veterinary Medicine of Alfort near Paris. They developed a special double lumen catheter, and Marey wrote:

one can be reassured of the innocuity of this method by examining the horse, who is scarcely disturbed, walks and eats as usual. In only a few instances is the pulse rate slightly increased, especially at the time of the catheter's introduction within the heart cavities.

Thus, he first noted the potential for arrhythmias to occur as a complication of insertion. He also emphasised the importance of extending the clinical examination to include the exploration of many cavities and canalicular systems with catheters; however, neither he nor Chauveau extended their investigations to humans. During the following years cardiac catheterisation developed rapidly as an investigation in circulatory physiology and new manometric systems were developed. Rolleston (1887) pointed out the role of friction along the tube from the exploring cannula to the manometer. Porter (1892) studied the canine heart using silver-plated brass tubes with a single or double lumen and an internal diameter of 3 mm, connected by a 30-40-cm-long rubber tubing with the same diameter as the manometer. At this time, arguments surrounded the question of whether or not such catheters and manometers accurately reflected the intracardiac pressures. These questions were finally resolved by Franck (1903, 1905) when he published his classic papers.

Controversy surrounds the earliest pioneers of central venous catheterisation in humans. Werner Forssmann, Andr Cournand and Dickinson Richards jointly shared the 1956 Nobel Prize for Medicine. The first to report the use of a catheter in humans for obtaining mixed venous blood for the measurement of right atrial pressure or cardiac output were Cournand and Ranges (1941). They mention Forssmann (1929) as the originator of central venous catheterisation technique. In 1929, shortly after the publication of Forssmann's paper in which he described his self-catheterisation experiment, an addendum was published in which Forssmann referred to a communication stating:

Professor E Unger informs me that Bleichroeder, Unger and Loeb carried out the same experiment in 1912. This was published under the title - 'Intra-arterielle Therapie'. He [Unger] had passed a ureteric catheter into the arm veins up to the axilla on four human subjects, among them Dr Bleichroeder, and also from the thigh to the vena cava. To judge from the length of the catheter and a stabbing pain, he believed that in the case of Dr Bleichroeder, the catheter must reach the right heart. This latter experiment was not published.

The reference provided by Unger alluded to presentations by Bleichroeder, Unger and Loeb (1912) before the Hufeland Medical Society in Berlin. Bleichroeder reported in 1905 that he had passed catheters into the arteries and veins of dogs as well as of human beings. He did not believe the experiments to be of any practical value and left them unpublished. However, in 1912, with the opening of the 'chemotherapeutic era', he perceived a use for his method, as it was believed at the time that a chemotherapeutic agent should be applied as near as possible to the diseased organ. Thus, in four patients with puerperal sepsis, Bleichroeder and Unger inserted a catheter via the femoral artery up to the region of the aortic bifurcation and injected 'collargol'. In his address, Bleichroeder (1904) did not specify the nature of his experiments, but remarked that he had used the catheter to obtain blood from the inferior vena cava close to the hepatic vein. He was interested in the morbid anatomy of cirrhosis, and these investigations may have been related. In his paper concerning intra-arterial therapy, he stated that he had passed the catheter well over a hundred times through the femoral vein and left it in place for several hours without clot formation or other ill-effects. Naturally, he was unable to verify the exact position of catheters using contrast radiology.

Forssmann (1931) conceived the idea of introducing a catheter into the right heart in order to administer emergency drugs on the operating table, in the most rapid and effective way, during episodes of sudden cardiac failure. He was opposed to percutaneous intracardiac injections because of the risks of cardiac tamponade, from either a coronary vessel laceration caused by the needle or leakage of blood from the heart itself, and of pneumothorax from pleural laceration. He first attempted the approach on cadavers using a vein in the antecubital fossa of the left arm. He chose the left arm because the catheter had to make less of a curve when it passed through the subclavian and innominate veins. He also realised that this occurred because of the relatively acute angle at which various tributaries entered the main brachial, axillary and subclavian veins, pointing always in the direction of blood flow.

At the time, Forssmann was working in the small town of Eberswalde, 50 miles northeast of Berlin, as assistant in the surgical department under Dr Schneider. Although a friend and mentor, Schneider denied permission for Forssmann's plans to attempt the procedure on patients or on himself. Forssmann could not be deterred, however, and he decided to carry out the experiment upon himself. A wide-bore needle was inserted into a right cubital fossa vein, through which a ureteric catheter (4 French) was passed for 35 cm without difficulty. His colleague, who performed the operation, flinched and abandoned the procedure. One week later, Forssmann anaesthetised his own left cubital fossa, advanced the catheter into his right atrium and then climbed several flights of stairs to the X-ray department and documented his achievement. This account was published on 5 November 1929. The first and only clinical application in which he used his catheter was to administer glucose, epinephrine hydrochloride and strophanthin to a woman with terminal purulent peritonitis following perforation of the appendix. After a temporary improvement, the patient relapsed and died; at autopsy, the catheter was found to have passed through the right atrium and its tip was situated in the inferior vena cava.

Forssmann (1931) pointed out that such a catheter could be used for central venous blood sampling as well as for injections. He also realised that the technique he had pioneered provided many possibilities for future metabolic studies and investigations into cardiac function. Later he was the first to inject a radio-opaque substance directly into the right heart via both arm and thigh veins (on himself) using uroselectan. Thus, he demonstrated that a well-known experimental technique could be applied to the study and treatment of disease in humans.

His enthusiasm for this discovery did not extend to his contemporary German colleagues, and little interest was shown in his work. He spent 6 years as an army surgeon in Germany, Norway and Russia and returned weary and malnourished to civilian medical practice. He turned to urology before receiving his unexpected and belated academic reward.

A short hiatus in this field of clinical physiology occurred until the systemic physiological investigations of Cournand, Richards and others commenced in 1936. A new flexible radio-opaque catheter was designed to enable intravenous and intracardiac blood sampling to be performed together with pressure recordings in the right atrium and pulmonary artery. They performed studies in heart failure, valvular heart disease and shock, and stimulated many other workers in this field around the world. For those who may be particularly interested, a definitive account of this period has been provided by Cournand (1975).

The introduction of flexible polyethylene cannulas for intravenous feeding in children was introduced by Meyers (1945) and Zimmerman (1945), and this innovation from the plastics industry heralded the beginning of an era in intravenous therapy and diagnostic intervention. Surgeons adapted the tubing with ingenuity; for example, the palliative treatment of obstructive hydrocephalus became a reality in May 1949, when Nulsen and Spitz (1952) established a valved shunt between the right lateral ventricle and the right internal jugular vein. They recognised the failure of the intravascular prosthesis caused by thrombosis inside the shunt and the jugular vein. The techniques derived from this procedure are now applicable for the direct cannulation of the internal jugular vein in the most difficult cases requiring parenteral nutrition.

The mass production of cannulas and central catheters consisting of polyvinyl chloride was inevitably followed by numerous clinical case reports and series describing local and systemic complications (Morris 1955, Moncrief 1958, Crane 1960, Doering et al. 1967, Neuhof and Seley 1974). Indar (1959) pointed out the problem of thrombosis which occurred when polyethylene catheters were used in the deep veins. Industry thus continued to research for improved inert materials for use as intravascular prostheses. Tetrafluoroethylene (TFE) and fluoroethylenepolypropylene (FEP) have been used and the incidence of thrombosis reduced as a result.

Quinton et al. (1960) jointly developed a Teflon and subsequently a Silastic arteriovenous shunt for use in haemodialysis. This advance has proved to be of tremendous significance in the achievement of safe chronic venous access. A Silastic intravenous catheter was introduced (Stewart and Sanislow 1961) at Ann Arbor Hospital, Michigan. The tubing they used was extruded and cured at 480F for 16 hours, the cannula being connected to the intravenous administration set by a 20-gauge needle after the point had been removed by grinding. Herein lies a problem of the inertness of silicone; namely, it is extremely difficult to bond the catheter to the hub securely. Mechanical catheter-related problems have now assumed importance in the care of patients receiving prolonged intravenous therapy (Fleming et al. 1980). Design alterations are still needed in order to make further improvements in this aspect of patient care.

Current central venous access devices are fabricated from silicone, polyurethane or polyamide and research continues to provide reduced thrombogenicity of the intravascular portion of the device and at the same time provide a strengthened durability of the extravascular and extracorporeal segment of the infusion system.

Venous access and the development of parenteral nutrition

During the past 30 years, there has been a substantial increase in the number of patients who have received parenteral nutritional support in hospital. The terminology emerging from the scientific literature includes such new abbreviations as IVH (intravenous hyperalimentation) and TPN (total parenteral nutrition). Following the refinement of long-life silicone tunnelled catheters introduced by Scribner et al. (1970) and Broviac et al. (1973), home parenteral nutrition (HPN) has emerged as a reality for a few carefully selected patients. The infusion of energy substrates and nitrogen has been established as an integral feature of the supportive medical care of patients during severe medical or surgical illness.

The progress from the experiments by Sir Christopher Wren in 1656, when he infused wine, ale and opium into dogs, follows a fascinating path. John Hunter made some poignant observations throughout his surgical career; in his Treatise on the Blood, Inflammation and Gun-Shot Wounds published in 1794, Hunter discussed the aspect of wound healing which he termed `union by the first intention'. The words he used then and which have often been quoted since are:

It will be proper to observe here that there is a circumstance attending accidental injury which does not belong to the disease, viz. that the injury done, has in all cases a tendency to produce both the disposition and means of cure. (Hunter 1794)

Central venous catheters have played a vital role in current medical and surgical practice enabling clinicians to monitor, augment and support the efforts of the body to stabilise the circulation during (or following) major surgery and provide nutritional supplements in order to fire the `disposition and means of cure'.

Following its isolation and purification, glucose was used intravenously in animals by Bernard (1843). Latta (1831) administered an infusion of water and saline to an elderly victim of cholera. Six pints were given intravenously in 6 minutes and the first complication of intravenous therapy recorded - circulatory overload. The populations of Asia, Europe and North America were intermittently attacked by epidemics of cholera and typhoid throughout the eighteenth century, and some of the earliest crude attempts at providing fluids and nutrition were made on the unfortunate victims of this disease.

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Excerpted from Central Venous Catheters Copyright © 2007 by Helen Hamilton. Excerpted by permission.
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