Central venous catheterization

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Lecture by Dr.Sayed Inaytalla
Head of ICU MGH.

Published in: Education, Health & Medicine
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  • Basic materials section involves going through an actual catheter kit with them and demonstrating technique
  • Central venous pressure monitoring – for those whose volume status needs to be managed closely Volume loading – flow rate through a 14 gauge peripheral line is twice that of a 20cm 16 gauge central venous catheter Concentrated solutions – potassium chloride, hyperosmolar saline, chemo agents. Or vasoactive substances like epi, dopamine. All can cause tissue irritation or necrosis if extravasated in peripheral line
  • Bleeding disorders – even with platelet counts <50,000, bleeding is uncommon and easily managed, in the absence of arterial puncture Distorted local anatomy – ultrasound may help
  • Seldinger originally described this technique in 1953 for percutaneous arteriography.
  • UNC preferred site – in the hospital manual
  • Arm abduction flattens the deltoid bulge Trendelenburg reduces incidence of air embolism Shoulders – as the shoulder falls backward, the space between the clavicle and first rib narrows, making the subclavian vein less accessible Right side preferred – lower pleural dome and thoracic duct on left Junction of the middle and medial thirds of the clavicle – here the vein in just posterior to the clavicle and just above the first rib which acts as a barrier to the pleura.
  • Right side preferred – left IJ is more circuitous, thoracic duct on left Trendelenburg – IJ is distensible Central approach is most common Anterior approach has highest risk of puncturing carotid artery
  • The more distal you are from the inguinal ligament, the closer the vein is to the artery as the femoral vein begins to dive behind the artery and the saphenous vein comes off the femoral vein.
  • NAVEL – N = nerve, A = artery, V = vein, E = empty space, L = lymphatics (must be read from right side of body, L is always medial. So it is spelled backwards from the left side approach
  • Resistance during wire advancement comes from incorrect placement or from valves and tortuous vessels which can be overcome with GENTLE manipulation of the guide wire
  • Go over kits and demonstrate procedure with students
  • Central venous catheterization

    1. 1. Central VenousCentral Venous CatheterizationCatheterization ‫ال‬ ‫ية‬ ‫عنا‬ ‫سيد‬ ‫د‬
    2. 2. ObjectivesObjectives Indications and Contraindications Complications Technique Basic principles Specifics by Site Tips Basic materials
    3. 3. IndicationsIndications  Central venous pressure monitoring  Volume resuscitation  Cardiac arrest  Lack of peripheral access  Infusion of hyperalimentation  Infusion of concentrated solutions  Placement of transvenous pacemaker  Cardiac catheterization, pulmonary angiography  Hemodialysis
    4. 4. Relative ContraindicationsRelative Contraindications Bleeding disorders Anticoagulation or thrombolytic therapy Combative patients Distorted local anatomy Cellulitis, burns, severe dermatitis at site Vasculitis
    5. 5. ComplicationsComplications  Vascular – Air embolus – Arterial puncture – Arteriovenous fistula – Hematoma – Blood clot  Infectious – Sepsis, cellulitis, osteomyelitis, septic arthritis  Miscellaneous – Dysrhythmias – Catheter knotting or malposition – Nerve injury – Pneumothorax, hemothorax, hydrothorax, hemomediastinum – Bowel or bladder perforation
    6. 6. TechniqueTechnique 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
    7. 7. Basic PrinciplesBasic Principles  Decide if the line is really necessary  Know your anatomy  Be familiar with your equipment  Obtain optimal patient positioning and cooperation  Take your time  Use sterile technique  Always have a hand on your wire  Ask for help  Always aspirate as you advance as you withdraw the needle slowly  Always withdraw the needle to the level of the skin before redirecting the angle  Obtain chest x-ray post line placement and review it
    8. 8. Location Advantage Disadvantage Internal Jugular • Bleeding can be recognized and controlled • Malposition is rare • Less risk of pneumothorax • Risk of carotid artery puncture • PTX possible Femoral • Easy to find vein • No risk of pneumothorax • Preferred site for emergencies and CPR • Fewer bad complications • Highest risk of infection • Risk of DVT • Not good for ambulatory patients Subclavian • Most comfortable for conscious patients • Highest risk of PTX, should not do on intubated pts • Should not be done if < 2 years • Vein is non-compressible
    9. 9. Subclavian ApproachSubclavian Approach  Positioning – Right side preferred – Supine position, head neutral, arm abducted – Trendelenburg (10-15 degrees) – Shoulders neutral with mild retraction – Right side preferred  Needle placement – Junction of middle and medial thirds of clavicle – At the small tubercle in the medial deltopectoral groove – Needle should be parallel to skin – Aim towards the supraclavicular notch and just under the clavicle
    10. 10. Internal Jugular ApproachInternal Jugular Approach  Positioning – Right side preferred – Trendelenburg position – Head turned slightly away from side of venipuncture  Needle placement: Central approach – Locate the triangle formed by the clavicle and the sternal and clavicular heads of the SCM muscle – Gently place three fingers of left hand on carotid artery – Place needle at 30 to 40 degrees to the skin, lateral to the carotid artery – Aim toward the ipsilateral nipple under the medial border of the lateral head of the SCM muscle – Vein should be 1-1.5 cm deep, avoid deep probing in the neck
    11. 11. Internal Jugular Central Approach
    12. 12. Femoral ApproachFemoral Approach Positioning – Supine Needle placement – Medial to femoral artery – Needle held at 45 degree angle – Skin insertion 2 cm below inguinal ligament – Aim toward umbilicus
    13. 13. Femoral artery Femoral nerve Femoral Vein NAVEL
    14. 14. Post-Catheter PlacementPost-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 Write a procedure note
    15. 15. Procedure NoteProcedure Note Name of procedure Indication for procedure Comment on consent, if applicable Describe what you did, including prep Comment on aspiration/flushing of ports How did patient tolerate procedure Any complications
    16. 16. TipsTips  After 3-4 tries, let someone else try  Get chest x-ray after unsuccessful attempt  If attempt at one site fails, try new site on same side to avoid bilateral complications  Halt positive pressure ventilation as the needle penetrates the chest wall in subclavian approach  If you meet resistance while inserting the guide wire, withdraw slightly and rotate the wire and re-advance  Align the bevel with the syringe markings  Use the vein on the same side as the pneumothorax  Withdraw slowly, you will often hit the vein on the way out
    17. 17. Ultrasound-Guided CentralUltrasound-Guided Central Venous AccessVenous Access  Becoming standard of care  Vein is compressible  Vein is not always larger  Vein is accessed under direct visualization  Helpful in patients with difficult anatomy
    18. 18. Needle entering IJ
    19. 19. Femoral Vein Femoral Artery Compression of vein with US probe
    20. 20. Catheterization KitsCatheterization Kits
    21. 21. Thank youThank you

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