623

VENA CAVAL INFUSIONSJ. K. Ross, M.B., B.S., F.R.C.S.

Department of Surgical Studies, The Middlesex Hospital, London. W. I

General PrinciplesIntravenous fluid administration direct into the

venae cavae is a useful refinement of more orthodoxmethods involving the use of peripheral veins andis now a well-tried procedure which has beenshown to be both safe and reliable.The underlying principle on which the success

of the technique depends is that of instant dilutionof the infused fluid as it enters the vena cava. Thisensures minimal intimal reaction at the site ofdelivery of the fluid and enables solutions of highconcentration to be given which, if delivered intoa peripheral vein, would cause a brisk chemicalinflammatory response and rapid thrombosis ofthe vein.

This same underlying principle, as might beexpected, facilitates prolonged administration ofstandard strength solutions and, in fact, vena cavalinfusions can be maintained for long periods withno ill effects, a fact appreciated equally by thepatient and the house surgeon, who are bothspared the consequences of repeated thrombosisof recipient superficial veins.

Using this technique, the patient's activity isscarcely restricted and, beyond the supervisionneeded for any intravenous infusion, it in no wayincreases the nursing problems and often makesthem easier.

It is possible, using suitable veins of entry, tointroduce a polythene cannula into the superior orinferior vena cava. In our experience the superioris preferable to the inferior vena caval route, as theincidence of complications in the former isappreciably less.

IndicationsVena caval infusions are of great value under

any circumstances when intravenous fluids mustbe given for a long time and may be used withadvantage in complicated cases requiring intensiveor prolonged preparation for operation, possiblyblood transfusion, and intravenous fluids afteroperation. In this context vena caval infusionshave been found useful in the accurate replacementof sustained fluid and electrolyte loss and in themanagement of patients who, for varied reasons,

can have no fluids or other nourishment by mouthfor long periods of time.Vena caval infusions enable strong dextrose

solutions to be given, if necessary at a very slowrate, and thus represent a valuable, if not the only,method for giving hypertonic dextrose in thetreatment of anuria.A further application for this technique is found

in those patients whose superficial veins have beenused up by previous infusions.

TechniqueAll vena caval infusions should be set up in the

operating theatre, using full aseptic technique.Local anaesthesia is used unless it is decided tostart the infusion immediately before or afteroperation, when it can conveniently be done undergeneral anaesthesia.The first step is to prepare the polythene cannula,

which is sterilized by boiling. All coils should beremoved from the tubing by stretching it while itis still warm. The tubing used is 2.5-mm. indiameter and of I.5-mm. bore, and this is con-nected to a standard infusion apparatus by apentothal mixer, which fits the tubing exactly,giving a watertight and airtight junction. The endof the tubing to be introduced into the vein is cuttransversely and its edges rounded by rubbing itrapidly to and fro on one of the sterile towels.

Superior Vena Caval InfusionThe vein of entry used in this instance is the

basilic, the cephalic vein being less satisfactoryowing to the angle at which it joins the axillaryvein. The basilic vein is exposed before it piercesthe deep fascia by a short transverse skin incisionI-' to 2 in. above and anterior to the medial epi-condyle of the humerus, and proof of its identity isafforded by the medial cutaneous nerve of theforearm, which is nearly always found closelyrelated to the vein and which must be dissectedfree.Having exposed the vein, the length of tubing to

be inserted may be estimated by measuring thedistance from the incision to the mid point of theclavicle and from there to the angle of Louis; the

624 POSTGRADUATE MEDICAL JOURNAL December I957

..

C:; ;DD .:f:f:EI.

FIG. i.-The photograph shows the pentothal mixer and its junction above with theinfusion tubing and below with the polythene cannula. The cross marks the tipof the medial epicondyle of the humerus. The black silk marker on the polythenejust below the incision indicates that the full estimated length of tubing has beenintroduced.

length of tubing used is usually between I4 in. andi6 in. (36.5 to 41.5 cm.). Having decided thelength of tubing to be used, it is marked off at theappropriate point. The vein is then ligated distally,incised and the cannula inserted with the infusionrunning slowly.Once the full length of polythene has been

entered it may be possible to see a variation in driprate with the phases of respiration, indicating thatthe tip of the cannula is in a major vessel subjectto changes in intrathoracic pressure. It may, how-ever, prove impossible to introduce the last fewinches of polythene, although this difficulty cansometimes be overcome by more fully abducting

ROSS: Vena Caval Infusions

the arm and slightly flexing the shoulder. If thereis a persistent hold-up,, which when met alwaysstops the drip, it has been found quite satisfactoryto insert the tubing as far as possible compatiblewith efficient running of the infusion and leave itthere, as the fluids are still being introduced into amajor'vessel and the principle of instant dilutionstill applies.When the tubing is in position it is fixed by

tying a ligature round both vein and cannula, theskin edges are approximated on either side of thetubing and any extra polythene and the pentothalmixer are fixed to the fore or upper arm byadhesive plaster (Fig. i).

It should be mentioned that on two occasionsthere has been clear evidence that the polythenetubing has turned upwards, entering the internaljugular vein instead of the superior vena cava. Inneither instance were there any resultant ill effects,but if this state of affairs is recognized the tubingshould be'withdrawn.

Inferior Vena Caval InfusionThe technique for this route is identical, the

vein of entry used in this instance being the longsaphenous, which is exposed a short distance belowthe sapheno-femoral junction.

Addition of Heparin to the FluidsAs an added safeguard in the prevention of

thrombosis at the site of delivery of the fluids intothe venae cavae, it is wise to add heparin to thefluids in a dosage of one unit per milliletre (i.e.500 units of heparin to each standard half-litrebottle). The heparin in this dosage has a purelylocal anticoagulant effect around the tip of thecannula; this appears true regardless of thevolume of fluid given.

Fluids UsedAll fluids in common use for intravenous therapy

can be given by the vena caval route. This includespotassium and hypertonic dextrose solutions,which have a known tendency to cause an in-flammatory response in superficial veins.The rate at which the fluids are given can be

varied very considerably, both rapid and very slowdrip rates being possible.

Antibiotics, vitamin preparations and anaes-thetic agents have also all been given via establishedvena caval infusions, but in regard to the lattersome drugs used in anaesthesia (e.g. prostigmine)are better given diluted or in the ordinary way bya peripheral vein.

ResultsVena caval infusions have been used in the

treatment of over 50 patients under our care, ofwhich careful records have been kept in 36.

In 27 cases the polythene cannula was insertedinto the superior vena cava and in nine the inferiorvena cava was used.

In all instances when such an infusion has beenused a careful watch has been kept for any signsof inflammatory reaction along the course of thevein carrying the polythene tubing and also forany signs of swelling of the limb. If any such signswere found, the tubing was immediately with-drawn. In three of the nine cases in which theinferior vena cava was used there was clinicalevidence of femoral vein thrombosis, indicated byswelling of the leg, after the infusions had beenrunning for four, six and eight and a half daysrespectively. There were no serious consequencesand the swelling rapidly subsided oua each occasionfollowing the withdrawal of the tubing. As aresult of the relatively high incidence of complica-tions met with in this small number of inferior venacaval infusions, the route was abandoned in favourof the superior vena caval method and this accountsfor the much larger number of the latter type inthe series as a whole.Of the 27 patients receiving superior vena caval

infusions, swelling of the arm developed in three;in two of these the Swelling was transitory, sub-siding rapidly after stopping the infusions whichhad run for four and 12 days respectively. Thethird case had more definite evidence of axillaryvein thrombosis after eight days, but again therewere no serious sequelae and there was no residualoedema of the arm.Vena caval infusions have been maintained for

from four to 22 days, the average length of timebeing eight days, and 40 or 50 1. of fluid have beengiven on several occasions without difficulty, theaverage volume given in the series being 26.5 1.

Illustrative Case HistoryMrs. M. W., aged 32. Presenting with recurrent

diarrhoea, fatigue and abdominal pain, this patientwas found to have Crohn's disease affecting theterminal ileum, for which a right hemicolectomywas performed in November 1956.

She made a good recovery and remained welluntil March 1957, when diarrhoea of some severityrecurred and she was readmitted with very obvioussigns of fluid and electrolyte depletion. At thattime she was losing between 2 and 3 1. of fluiddaily from her bowel. She was anaemic and waspassing fluid motions containing unaltered bile.

In order to prepare her for a second operation,water and electrolyte replacement and blood trans-fusion were needed, and a superior vena cavalinfusion was therefore set up. This enabledaccurate day-to-day replacement of her observed

December I957 62,5

626 POSTGRADUATE MEDICAL JOURNAL December 1957

abnormal losses, the making good of her estab-lished deficit, blood transfusion and ultimately thegiving of her post-operative fluid requirements.At her second operation recurrence of the

disease was found in the terminal ileum and thesigmoid colon was also severely affected. A ter-minal ileostomy was therefore established, whichfurther increased the need for intravenous fluidreplacement.

This infusion was maintained for a total of 17days and transmitted a total of 50 1. of fluid,including blood. There were no complicationsand the patient was intensely grateful for her vena

caval infusion, having had the experience of aconventional superficial vein infusion at the timeof her first operation.

SummaryI. The technique of introducing intrav'enous

fluids direct into the venae cavae by means of apolythene cannula is described.

2. The indications for using this technique andits advantages are discussed.

3. The results are given of a series of cases inwhich this method has been used.

CARCINOMA OF THE BRONCHUS(Postgraduate Medical Journal)

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INTRODUCTORY UNUSUAL MANIFESTATIONSMaurice Davidson, D.M., F.R.C.P. J. Smart, M.D., F.R.C.P.

THE INCIDENCE AND AETIOLOGY OF CYTOLOGICAL EXAMINATION OF THEPRIMARY CARCINOMA OF THE LUNG SPUTUM AND PLEURAL EFFUSIONC. E. Drew, M.V.O., F.R.C.S. J. L. Pinniger, D.M., M.R.C.P.

THE SCOPE OF RADIOTHERAPYMEDICAL ASPECTS Gwen Hilton, D.M.R.E., F.F.R.

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