central venous access is very important skill for all doctors especially those working in ER, OR or ICU

1. ZIKRULLAH
CENTRAL VENOUS LINE

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

6. SITES
1) Internal jugular vein
2) Subclavian vein
3) External jugular vein
4) Femoral vein
5) Axillary vein
6) Basilic vein,cephalic vein (peripherally inserted
catheters)

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

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.

12. LANDMARK

13. ANATOMY

14. INTERNAL JUGULAR APPROACH
 APPROACHES
ANTERIOR
CENTRAL-Common
POSTERIOR

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˚

16. PT IS PLACED IN A TRENDELENBURG
POSITION

17. CLEAN THE AREA UNDER STRICT
STERILE PRECAUTION

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

27. INFRA CLAVICULAR APPROACH

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

30. STEPS

31. ULTRASOUND-GUIDED CENTRAL
VENOUS CANNULATION
 The veins appear as
 Non-pulsatile
 Easily compressible
 Undergo Marked
enlargement with
valsalva maneuver

32. APPEARANCE

33. INSERTION OF THE NEEDLE-
visual confirmation

34. GUIDEWIRE INSERTED UNER
DIRECT VISION

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

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

43. THANX