Central Venous Access and Catheters. Their indications and contraindications, Different types of central catheters and their advantages and disadvantages, Technique of insertion, and Complications related to central venous lines.

1. Central Venous Access &
Catheters
G.D.A.Samaranayaka

2. Definition
A Central Venous Catheter (CVC) is an indwelling
intravenous device that is inserted into a vein of
the central vasculature.

3. Uses
1. Difficult Peripheral Vascular Access
Ex - patients with burns, previous vein injuries (such as
IV drug use)
2. Volume Loading
Time-consuming to insert and are associated with
high complication rates.
Flow rate is determined by the calibre and length of
the catheter (Poiseuille’s law)
Shorter and greater calibre catheters delivering
greater volumes over equivalent amounts of time

4. 3. Provision of Caustic Medications or Solutions
Vasoactive medications (vasopressors or inotropes)
Irritant substances (chemotherapeutic agents,
cytotoxic drugs or high concentration solutions)
Total parenteral nutrition

5. 4. Central Venous Pressure Monitoring
The central venous pressure (CVP) is the pressure
measured in the central veins close to Right atrium.
It indicates mean right atrial pressure and is
frequently used as an estimate of right ventricular
preload.
Being used as a guide for fluid management, though
some researches suggest otherwise
(http://www.ncbi.nlm.nih.gov/pubmed/18628220)

6. 5.Repeated Blood Sampling
6. Introduction of Pacemakers or Pulmonary Artery
Catheters
7.For haemodialysis/haemofiltration - For acute and chronic
haemodialysis access

7. Contraindications
Absolute
Overlying skin or soft tissue infection
Thrombophlebitis

8. Contraindications .cont
Relative
1. Distorted Anatomy – Trauma, deformity, burns.
2. Infection at the Site of Access – cellulitis
3. Uncooperative patients
4. Proximal Vascular Injury
5. Bleeding disorders & anticoagulation or thrombolytic
therapy.
3% complication rate as long as there are no arterial punctures (Mumatz
et al)
Absolute contraindication for subclavian access
Ultrasound guidance is recommended

9. Types Of Central Venous Catheters
1. Non-tunneled central catheters
2. Tunneled central catheters
3. Peripherally inserted central catheters (PICC)
4. Implantable ports

10. Types Of CentralVenous Catheters.cont
Single & multi-lumen catheters are available in
all catheter types
Each lumen must be treated as a separate
catheter

11. Types Of CentralVenous Catheters.cont
Open–ended
The catheter is open at the distal tip
The catheter requires clamping before entry into the
system
Clamps are usually built into the catheter
Requires periodic flushing

12. Types Of CentralVenous Catheters.cont
Closed-ended
A valve is present at the tip of the catheter (eg.
Groshong®) or at the hub of the catheter(eg. PAS-V®)
Clamping is not required as the valve is closed except
during infusion or aspiration

13. Types Of CentralVenous Catheters.cont
Composition
Silicone
Polyurethane
Coatings
♦ Antimicrobial or antiseptic coating
♦ Heparin coating
♦ Radiopaque to confirm tip placement

14. The type of CVC inserted depends on the
Type of therapy to be administered
Length of therapy (Short term or Long term)
Previous devices and complications
Patient preference

15. Non Tunnelled Catheters

16. Polyurethane
Single or multiple lumens
Flow varies depending on size and ID
Inserted percutaneously
Internal jugular vein
Subclavian vein
Femoral vein

17. Advantages
Easier placement, removal and replacement
Economical
Disadvantages
Highest risk of infections
Unused ports must be routinely flushed with
heparin solution and clamped
Dislodged more easily
Temporary - requires frequent exchanges

18. Insertion
Informed Consent
Sterile technique
Adequate skin preparation with
sterilizing solution
Setup of Equipment
Positioning and identifying the landmarks
Adequate local analgesia

19. Internal Jugular Vein
Right side preferred-lower pleural dome and thoracic duct on
left
Trendelenburg position(10-15 degrees)
Head rotated approximately 150 to the left
At the cricoid level while palpating the carotid pulse,
introducer needle into the apex of the sternocleidomastoid-
clavicular triangle at a 30-400 angle to the skin. Aim the needle
caudally towards the patient’s ipsilateral nipple.

20. Subclavian Vein
Right side preferred
- Supine position, head neutral, arm abducted
- Trendelenburg position (10-15 degrees)
- Shoulders neutral with mild retraction
Junction of the medial and middle thirds of the clavicle.
The site of needle insertion lies about 1 cm inferior to the
clavicle allowing for the needle to pass under the clavicle.
• Needle should be parallel to skin
• Aim towards the supraclavicular notch

21. Femoral Vein
Supine/Flat position
Palpate the femoral artery’s pulse just distal to
the inguinal ligament.
The femoral vein lies just medial to this.

22. Seldinger technique
Use introducing needle to
locate vein
Wire is threaded through
the needle
Needle is removed
Skin and vessel are dilated
Catheter is placed over
the wire
Wire is removed
Catheter is secured in
place

23. Post-Catheter Placement
Aspirate blood from each port
Flush with saline or sterile water
Secure catheter with sutures
Cover with sterile dressing (tega-derm)
Obtain chest x-ray for IJ and SC lines

24. Location Advantage Disadvantage
Internal
Jugular
• Bleeding can be recognized
and controlled
• Malposition is rare
• Less risk of pneumothorax
• Risk of carotid artery puncture
• Pneumothorax is possible
Subclavian • Most comfortable for
conscious patient
• Highest risk of bleeding
• Vein is non-compressible/deep vein
• Highest risk of Pneumothorax
Femoral • Easy to find vein
• No risk of Pneumothorax
• Preferred site for
emergencies
•Highest risk of infection
• Risk of DVT
• Not good for ambulatory
patients

25. Tunnelled Catheters

26. Single or multiple lumens
Used for long term therapy
Inserted surgically
Small Dacron (Polyethylene terephthalate) cuff sits in
subcutaneous tunnel facilitates anchoring of the catheter
through granulation and acts as a barrier to infection

27. Advantages
Can be left in place indefinitely (if no infection,
blockage or thrombosis)
Self-care by patient
External portion can be repaired

28. Disadvantages
Inserted in the OR
Requires a dressing & frequent assessments
External device
Physician must remove

29. Peripherally Inserted Central
Catheters

30. Silicone or polyurethane
Single or multi-lumen
Approximately 40-60 cm long
Used for intermediate to long term therapy
Inserted percutaneously
Basalic vein
Cephalic vein
The tip rests in the superior vena cava at the cavo-atrial junction.

31. Advantages
Can remain in place for several weeks to a year
Can be easily removed
Low infection rates
External portion can be repaired

32. Disadvantages
Low flows
Requires a dressing & frequent assessments
External device
Small gauge PICC not recommended for blood
sampling

33. IMPLANTABLE VENOUS ACCESS
DEVICE
(IVAD)

34. long-term (months to years) single or dual chamber
“port” surgically implanted in the subcutaneous
tissue, usually in the upper chest
Single or double lumen.
Each chamber must be managed separately.

35. A non-coring point needle is required to access
the device
Unused port is flushed every 28 days with
Heparin solution

36. Advantages
Internal device, no dressing or site care
Can be permanent
Unrestricted activity
Decreased risk of infection
No external components to break
May be used as long as the device is required,
functional.

37. Disadvantages
Needle access is required
Surgical procedure required to insert/remove
Cost

38. Complications Associated
With
Central Venous Catheters

39. Complications
Acute
Chronic
Complication rate depends on
Site
Patient factors (illnesses, variations in anatomy)
Operator skill and experience.

40. Acute complications
Cardiac Dysrhythmias
Due to cardiac irritation by the wire or catheter tip.
Withdraw the line into the superior vena cava.
Always use a cardiac monitor.
Haematoma formation – Arterial/Venous puncture
Mechanical injury to nearby structures
Pneumothorax/Haemothoarx
Atrial wall puncture - pericardial tamponade.
Bowel penetration, Bladder puncture, Femoral nerve
injury
Air embolus
Malposition
Lost Guide-wire

41. Chronic complications
Infections
Catheter fragmentation
Non-function/Blockage - fibrin builds on and
around the catheter and vessel, drug
precipitates, lipid deposits
Thrombosis/Thromboembolism

42. Air embolism
Deadly complication associated with CVC’s
Signs and Symptoms
Respiratory changes: sudden shortness of breath,
cyanosis
CVS changes: sudden onset of chest pain, ↑HR,
↓BP
CNS changes: altered neurological signs, dizziness,
confusion, loss of Consciousness

43. Management
Left lateral decubitus with head low Position (Durant
maneuver and Trendelenburg position)
Clamp the Central Venous Catheter
100% O2
Direct removal of air from the venous circulation by
aspiration from a central venous catheter in the right
atrium may be attempted

44. To minimize the chance of air entering the
system:
Ensure the lumen is clamped prior to opening the
system
Position the patient so that the insertion site is at
or below the level of the heart during insertion
and removal of catheter

45. Infections
Most frequent and serious complications.
Types
Local infection – Cellulitis
Central Line-Associated Bloodstream Infections
(CLABSI)

46. Causative Organisms
Staph epidermidis 25-50%
Staph aureus 25%
Candida 5-10%
Risk Factors
Cutaneous colonization of the insertion site
Moisture under the dressing
Prolonged catheter time
Technique of care and placement of the central
line

47. Evidence-BasedStrategiesSelected to
Reduce CLA-BSIs
1. Hand hygiene
2. Maximal sterile barriers
3. Chlorhexidine for skin asepsis
4. Avoid femoral lines
5. Avoid/remove unnecessary lines

48. Thank You
Refenrences
1. http://emedicine.medscape.com/article/80336-overview#a05
2. http://emedicine.medscape.com/article/80355-overview#aw2aab6c10
3. http://emedicine.medscape.com/article/80279-overview
4. Central Venous Access (Ian Rigby, Daniel Howes, Jason Lord, Ian
Walker, Resuscitation Education Consortium/Kingston Resuscitation
Institute)