CENTRAL VENOUS LINE PRACTICAL APPROACH

Objectives Indications and Contraindications Complications Technique Basic principles Specifics by Site Tips Basic materials Basic materials section involves going through an actual catheter kit with them and demonstrating technique

Central venous catheter In medicine, a central venous catheter ("central line", "CVC", "central venous line" or "central venous access catheter") is a catheter placed into a large vein in the neck (internal jugular vein), chest (subclavian vein or axillary vein) or groin (femoral vein). It is used to administer medication or fluids, obtain blood tests (specifically the "central venous oxygen saturation"), and measure central venous pressure

CENTRAL VENOUS LINE Indications 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 Contraindications Uncooperative patient Uncorrected bleeding diathesis Skin infection over the puncture site Distortion of anatomic landmarks from any reason Pneumothorax or hemothorax on the contralateral side Relative contraindications Positive end-expiratory pressure (PEEP) mechanical ventilation Only one functioning lung

Complications 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

Technique: Seldinger technique The desired vessel or cavity is punctured with a trocar. A round-tipped guidewire is then advanced through the lumen of the trocar. A "sheath" or blunt cannula can now be passed over the guidewire into the cavity or vessel. Drainage tubes are passed over the guidewire e.g chest drains/ nephrostomies). After passing a sheath or tube, the guidewire is withdrawn A sheath can be used to introduce catheters or other devices for endoluminal procedures - angioplasty. Fluoroscopy may be used to confirm the position of the catheter and move it to the desired location. Injection of radiocontrast may be used to visualize organs. Interventional procedures, such as thermoablation, angioplasty, embolisation or biopsy, may be performed

Step I Step II Step III Step IV Step V Step VI

Types Of Central Venous Catheters Nontunneled central catheters Tunneled central catheters Peripherally inserted central catheters (PICC) Implantable ports

Central line equipment

This is a photo of a dialysis two-lumen catheter inserted on the patient's left side. Scars at the base of the neck indicate the insertion point into the left jugular vein.

CENTRAL VENOUS LINE Chest x-ray with catheter in the right subclavian vein Triple lumen in jugular vein

There are several types of central venous catheters Implanted port CVC with three lumens

NON-TUNNELED EXTERNAL CATHETERS Non-tunneled catheters are fixed in place at the site of insertion, with the catheter and attachments protruding directly. Commonly used non-tunneled catheters include Quinton catheters. 1. Polyurethane 2. Single or multiple lumens 3. Flow varies depending on size and ID 4. Temporary - requires frequent exchanges 5. Easier placement, removal and replacement

Non-tunneled Central Venous Catheters Used for short-term therapy Inserted percutaneously Subclavian vein Internal jugular vein Femoral vein Has from 1 to 4 lumens or ports Usually from 6 to 8 inches in length

Tunneled Central Venous Catheters Tunneled catheters are passed under the skin from the insertion site to a separate exit site, where the catheter and its attachments emerge from underneath the skin Used for long term therapy Inserted surgically Small Dacron cuff sits in subcutaneous tunnel No dressing is required after cuff heals unless the patient is immunocompromised Initially sutured but removed in 7 to 10 days External portion of the cath can be repaired Commonly used tunneled catheters include Hickman catheters and Groshong catheters.

Tunneled catheter with cuffs

Tunneled catheter

Peripherally Inserted Central Catheters (PICC) A peripherally inserted central catheter, or PICC line (pronounced "pick"), is a central venous catheter inserted into a vein in the arm rather than a vein in the neck or chest with the tip positioned in the superior vena cava Used for intermediate to long term therapy May be single or double lumen Inserted percutaneously Basalic vein Cephalic vein Threaded into the superior vena cava

Basic 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

Internal Jugular Femoral Subclavian Location Advantage Disadvantage 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 UNC preferred site – in the hospital manual

Subclavian Approach Positioning Right side preferred Supine position, head neutral, arm abducted Trendelenburg (10-15 degrees) Shoulders neutral with mild retraction 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 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.

Internal 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 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

                                                                                              

Internal Jugular Central Approach

Femoral 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 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.

Femoral Vein Femoral nerve Femoral artery 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

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 Write a procedure note

Procedure 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

Tips 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 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

Ultrasound-Guided Central Venous 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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