The tale of central venous line
- On December 29, 1831, William Brooke O’Shaughnessy who was a young medical graduate wrote to The Lancet one of the shortest and yet most significant letter ever sent to the journal. He presented the results of his own blood analyses and showed that the “copious diarrhoea of cholera leads to dehydration, electrolyte depletion, acidosis and N2 retention”, and that “treatment must depend on intravenous replacement of deficient salt and water. Doctors began testing his suggestions, leading to successfully saving lives of nearly half of their patients
- Thomas Latta, also known as the father of intravenous fluid therapy, was a GP from Leith who, in 1832, treated patients with his own fluid formula ( Na+ 134 , K+ 0, Ca++ 0,Cl_ 118 and HCO3– 16 mmol/L) and saved the lives of many patients. There were no needles at that time, so he cannulated the vein with a quill and used the veins from a pig as a conduit for infusion. He infused 6 pints of Latta’s solution and the patient showed signs of improvement and survived. Dr Latta did all this in Edinburgh Cholera Hospital.
- In1844, Frances Rynd introduced metallic needles.
- In 1852, Charles Pravas introduced his syringe which was made of silver.
- In 1929, Werner Forssmann was the first physician to use a trocar to cannulate the central veins. The applications and techniques have been progressively improved since then.
- In 1945, David Masa, an anaesthetist at the Mayo clinic, introduced a plastic needle, this in combination with the introduction of the aseptic technique by Walters in the same years and the autoclave in the 1950s, resulted in an explosion in the use of intravenous fluids.
- In 1953, Sven Ivar Seldinger, a Swedish Radiologist introduced his Seldinger technique for vascular access and this has become the dominant method in use. For this achievement he was awarded with the Noble prize in 1956.
- For the last two decades, central venous catheterisation has been made easier and safer by the availability of ultrasound.
- Central venous catheterisation is a form of invasive monitoring widely used in critical care, anaesthesia, emergency medicine, cardiology and other specialties. The most commonly used vessels are internal jugular vein and subclavian or femoral veins.
The following description is mainly for trainees, but may be of use to anyone involved in placing these devices. The acronyms are created in such a way that they could be remembered easily. For the sake of completion, Peripherally inserted central catheter lines are briefly mentioned also.
Practical steps while doing Seldinger’s technique, just remember”CVP”
(please see the diagram)
C Confirm patient’s ID
Consent checked
Contraindications looked for!
Competent ODA present
Check equipment eg Ultrasound and monitors
Convenient in supine/head down
Cervical area selected (usually)
Chlorhexidine 2% used to clean
Clean drapes
Cutaneous LA injected if awake
V Visualise (US Guidance) IJV
Vein cannulated
Venous blood aspirated
P Push J wire into the cannula
Pull the needle out
Puncture site dilated
Plastic multilumen line railroaded
Prove that line is in the vein(USG)
Plaster dressing/stitching done
Pressure transducer attached
Post-procedure X-ray chest
Pneumothorax looked for
Procedure documented
Indications for Central venous catheterisation
To mention the indications for CVP line insertion,