2. CENTRAL VENOUS CANNULATION
Central venous cannulation is the
placement of a catheter in a vein that
leads directly to the heart, e.g.;
internal jugular vein subclavian vein
etc.
3. Indications for central venous Cannulation
Central venous pressure monitoring
Pulmonary artery catheterization and monitoring
Transvenous cardiac pacing
Temporary hemodialysis
Drug administration
Vasoactive drugs
Hyperalimentation [TPN]
Chemotherapy
Drugs irritating to peripheral veins
Prolonged antibiotic therapy
4. Rapid infusion of fluids (through large cannulas)
Trauma
Major surgery
Aspiration of air emboli
Inadequate peripheral intravenous access
Sampling site for repeated blood testing
5. CONTRAINDICATIONS TO CENTRAL
VENOUS CANNULATION
A. Renal cell tumor extension into right atrium.
B. Large tricuspid valve vegetations.
C. Anticoagulant therapy.
D. Severe coagulopathy – femoral preferred
E. Previous ipsilateral end arterectomy.
F. IVC filter - in case femoral is planned
G. Ipsilateral AV fistula
7. CHOICE OF SITES
Easy cannulation – basilic v.;Internal jugular v.
Long term use – subclavian v. Internal jugular v.
Success rate ( pulmonary artery catheterization)
internal jugular v.;Subclavian v.
Complications – basilic v. ; External jugular v.
8. DIFFERENT METHODS OF INSERTION
Catheter over the
needle
Catheter over
guidewire (Seldinger
technique).
Catheter through the
cannula.
9. EQUIPMENTS
Tilting table
Sterile pack and antiseptic solution
Local anaesthetic
Appropriate CV catheter for age/route/purpose
Syringes and needles
Saline
Suture material
Sterile dressing
Facility for chest X-ray if available
10.
11. INTERNAL JUGULAR VEIN
CANNULATION
Most commonly chosen;
Consistent and predictable anatomic
location,
Palpable surface landmarks,
Short, straight and valveless course to
SVC and right atrium.
15. COMMON APPROACHES AND LANDMARKS
INTERNAL
JUGULAR
POSITION NEEDLE
INSERTION
ANGLE OF
NEEDLE
ANTERIOR -Trendelenburg
-Head turned to
opposite side
Anterior border of
SCM midway
between angle of
mandible & clavicle
Advance needle
towards medial
aspect of ipsilateral
nipple at 30-45˚
MIDDLE -Trendelenburg
-Head turned to
opposite side
Apex of the triangle
formed by the two
heads of SCM
Advance needle
towards ipsilateral
nipple at 30-45˚
POSTERIOR -Trendelenburg
-Head turned to
opposite side
1cm above the point
where external
jugular vein crosses
lateral edge of SCM
Advance needle
towards sternal
notch at 30˚
18. TURN THE HEAD
SLIGHTLY TO LEFT
( 20-30 degrees)
GENTLY PALPATE
THE CAROTID
ARTERY
19. Infiltrate the skin at the
level of cricoid with local
anaesthetic
25 g locator needle at 30
degree angle to skin in
sagittal plane
At the medial border of
lateral head of sternomastoid
pointing towards the
ipsilateral nipple
20. Negative pressure to be
maintained in syringe
IJV is encountered at a
depth of 2-4 cm
Blood splash may not
occur until the needle
is withdrawn
21. Once IJV is located,
18G needle is placed
immediately adjacent
to locator needle
Continuous aspiration
technique employed
22. Once position
confirmed a guide-
wire is placed through
it ;not more than 18
cms
Monitor pulse & ECG
tracing
Remove the needle
over guide-wire
23. A dilator is introduced
and removed
Catheter is threaded
over the guide-wire to a
depth of 12-15 cms
Monitor pulse & ECG
tracing
Guide-wire is withdrawn
24. Aspirate blood from catheter
Attach a three-way connector & tubing
Suture in place and apply sterile dressing
Get x-ray chest to rule out pneumothorax and
to localize tip of catheter.
25. SUBCLAVIAN VEIN CANNULATION
Infra-clavicular and supra-clavicular approach,
Position – head down with head turned towards
contralateral side ; rolled up sheet between
shoulder blades longitudinally ; arms by side
assistant giving traction to arm of same side,
26. COMMON APPROACHES AND
LANDMARKS
SUBCLAVIAN
POSITION NEEDLE
INSERTION
ANGLE OF
NEEDLE
INFRACLAVICULAR -Trendelenburg
-Head turned to
opposite side
-Ipsilateral arm
adducted
2 cm inferior to
midportion of the
clavicle, ”walk”
down clavicle and
advance just deep
to the clavicle
Advance the needle
under the clavicle
towards the sternal
notch
SUPRACLAVICULAR -Trendelenburg
-Head turned to
opposite side
-Ipsilateral arm
adducted
Just above the
clavicle , lateral to
the clavicular head
of the SCM
Advance the needle
at a 45˚ angle, just
under the clavicle
towards the
contralateral nipple
28. STEPS
Local infiltration 1-2
cms below inferior
border of clavicle in
midclavicular line,
18 G needle inserted at
infiltrated site 2 cm
inferior to midportion
of the clavicle, ”walk”
down clavicle and
advance just deep to the
clavicle
29. Advance the needle
under the clavicle
towards the sternal notch
Needle is kept horizontal
at all times (10 degree
upward bend on needle
adjacent to hub maybe
applied)
Continuous aspiration
technique applied
35. Advantages of USG guided CVP cannultion
Easy identification of any variation in anatomy
Direct visualization of important structures
Decreases the rate of complications.
Ensures faster placement of central catheters
36.
37. Indirect calculation of CVP
through physical
examination of the neck
veins is a fundamental
aspect of cardiovascular
assessment, but the bedside
diagnosis of low, normal, or
high CVP is often
inaccurate, particularly in
critically ill patients.
CVP MEASURMENT
38. PROCEDURE FOR CVP MEASUREMENT IS
ZERO MANOMETER AT THE
LEVEL OF RT. ATRIUM
[level of the 4th intercostal space
in the mid-axillary line while the
patient is lying supine]
FILL MANOMETER WITH
SALINE USING A THREE
WAY TAP
39. CLOSE OFF TAP FROM
SOLUTION BAG
OPEN TAP TO PATIENT
OBSERVE FALLING
FLUID IN MANOMETER
RECORD MEAN LEVEL
40. PERIPHERALLY INSERTED CENTRAL
CATHETER
Originally used by cardiologists,
adapted for intensivist usage.
Inserted via basilic or cephalic veins in
the ante-cubital fossa
The catheter is advanced upto the
central veins
Conflicting studies regarding
superiority as compared to centrally
inserted catheters
41. ADVANTAGES AND DISADVANTAGES OF PERIPHERALLY
INSERTED CENTRL CATHETERS
ADVANTAGES
Easy placement
Faster
Long lasting
Low infection
Ambulatory
Low cost
Low complications
DISADVANTAGES
CVP monitoring
inadequate
Inadequate for rapid bolus
injections
Inadequate for
resuscitation
42. COMPLICATION
Early
Arterial puncture- 10%
Pneumothorax- 1-3%
Bleeding
Cardiac arrhythmias
Injury to the thoracic duct
Injury to surrounding
nerves
Air embolism - 0.1%
Catheter embolus
Late
Venous thrombosis
Cardiac perforation
and tamponade
Infection
Hydrothorax