1. Central Lines Dr. Peter Jones Emergency Medicine Specialist

2. Indications Multiple Access Inotropes Toxic medication Volume CVP / PA pressures Dialysis Pacing wire TPN

3. Contraindications Patient needs to get to definitive treatment NOW Distorted anatomy Chest wall, vessel injury, radiation Coagulopathy Uncooperative patient Inexperienced operator

4. Preparation & Position Consent Universal precautions Sterile technique Local anaesthetic

5. Preparation & Position Head down (IJ) Head away (debated) Pillow between scapulae (debated) Injured side in chest trauma Avoid bilateral pneumothoraces

6. Site SCV (1952) Left theoretically better IJV (1963) Right theoretically better EJV Femoral

7. Anatomy SCV

10. Anatomy IJV

12. EJV Wired

13. Technique Put a big line through a little hole Seldinger 1953 (interventional radiology) Needle and syringe (small hole) Guidewire through needle (smooth and easy) Cut skin Introducer (big hole) Catheter over guidewire Flush and Secure Check patient & position (CxR)

14. Seldinger Equipment

15. Seldinger Technique

19. Complications Infection Malposition Arterial puncture Pneumothorax Haemothorax VTE

20. Complications IJV Needle SCM ICA Catheter Haematoma

21. Complications Hydrothorax Air embolus Osteomyelitis clavicle Catheter embolus Lost guidewire RA perforation ETT cuff puncture

22. IJ vs SC Crit. Care Med 2002 Feb;30(2):486-7 Malposition IJ 5.3%vs 9.3% SC Infection IJ 8.6% vs 4% SC Arterial Puncture IJ 3% vs 0.5% SC VTE IJ 0% vs 1.2% SC

23. IJ vs SC Crit Care Med 2002 Feb;30(2):486-7 No difference Haemopneumothorax 1.5% VTE 1% (trend to SCV)

24. CVP Zero pt = RA MAL 4th CC Junction (mark) 20-25cm fluid in manometer

25. CVP Patient Supine Level Breathing normally 0 of manometer = 0 on patient Open to patient New fluid level = CVP

26. CVP Rough idea of RV filling But EDV determines preload Ventricular compliance varies from patient to patient and with time in the same patient Multiple influences

27. CVP Affected by Circulating volume RV function Intrathoracic pressure Systemic vascular resistance Therefore dynamic change most useful

28. CVP Low <5cm H 2 0 Volume deplete SVR low Zero point too high Patient sitting up

29. CVP High >12cm H 2 0 CHF PPV

30. CVP High Cardiac tamponade Tension pneumothorax PE SVR high SVC obstruction Head down Kinked line Occluded line

31. CVL Summary Know why Know what Know where Prepare, Prepare, Prepare Know the complications Know how to check for them

32. References Clinical Procedures in Emergency Medicine Roberts and Hedges 2nd Edition 1991 Complications of CVC: IJ Vs SC access a systematic review Ruesch S et al Crit Care Med 2002 30:486-7