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Central venous catheterization
This document provides information on central venous catheterization, including indications, contraindications, complications, techniques, and tips. It discusses the Seldinger technique for placement and locations for catheter insertion, including the internal jugular, subclavian, and femoral veins. Precautions are outlined for each approach. Ultrasound guidance is becoming standard to visualize the vein and compress it during insertion.
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Central venous catheterization
- 1. Central VenousCentral Venous CatheterizationCatheterization الية عنا سيد د
- 2. ObjectivesObjectives Indications and Contraindications Complications Technique Basicprinciples Specifics by Site Tips Basic materials
- 3. IndicationsIndications Central venouspressure 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. Relative ContraindicationsRelative Contraindications Bleedingdisorders Anticoagulation or thrombolytic therapy Combative patients Distorted local anatomy Cellulitis, burns, severe dermatitis at site Vasculitis
- 5. ComplicationsComplications Vascular – Airembolus – 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. TechniqueTechnique Seldinger technique – Useintroducing 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
- 8. 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
- 9. 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
- 10. 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
- 12. Internal Jugular ApproachInternalJugular 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
- 14. Internal Jugular CentralApproach
- 15. 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
- 16. Femoral artery Femoral nerve FemoralVein NAVEL
- 17. Post-Catheter PlacementPost-Catheter Placement Aspirateblood 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
- 18. Procedure NoteProcedure Note Nameof 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
- 19. TipsTips After 3-4tries, 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
- 20. Ultrasound-Guided CentralUltrasound-Guided Central VenousAccessVenous 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
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Editor's Notes
- #3 Basic materials section involves going through an actual catheter kit with them and demonstrating technique
- #4 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
- #5 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
- #7 Seldinger originally described this technique in 1953 for percutaneous arteriography.
- #10 UNC preferred site – in the hospital manual
- #11 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.
- #13 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
- #16 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.
- #17 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
- #20 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
- #24 Go over kits and demonstrate procedure with students