Download central venous line

PRACTICAL APPROACH
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Indications and Contraindications
Complications
Technique
Basic principles
Specifics by Site
Tips
Basic materials
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
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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
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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
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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withdrawn
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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
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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
CVC with three lumens
Implanted port
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
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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
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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
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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
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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
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
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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
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Positioning
◦ Right side preferred
◦ Trendelenburg position
◦ Head turned slightly away from side of venipuncture
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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
Internal Jugular Central Approach
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Positioning
◦ Supine
Needle placement
◦ Medial to femoral artery
◦ Needle held at 45 degree angle
◦ Skin insertion 2 cm below inguinal ligament
◦ Aim toward umbilicus
Femoral nerve
Femoral Vein
Femoral artery
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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
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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
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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
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Becoming standard of care
Vein is compressible
Vein is not always larger
Vein is accessed under
direct visualization
Helpful in patients with
difficult anatomy