Download Anatomy 14- Central Lines What is a Central Line? Central line: A

Anatomy 14- Central Lines
•
•
•
•
•
•
•
What is a Central Line?
Central line: A catheter that is passed through a vein whose tip projects into the central venous system
Central venous system:
– superior vena cava
– inferior vena cava
– brachiocephalic veins
– internal jugular veins
– subclavian veins
– iliac veins
– common femoral veins
Indications
– Emergency access
– Inability to obtain peripheral access
– Administer concentrated fluids/vasoactive drugs
– Transvenous pacer or pulmonary catheter
– Temporary hemodialysis catheter
– Monitoring of central venous pressure
Longer the catheter, the more resistance you have
Larger the catheter, the less resistance you have
Use a short Large bore IV if you want to give large amounts of fluid!!!– not a central line
Contraindications
– NO ABSOLUTE CONTRAINDICATIONS
– Relative:
• Coagulopathy
• Trauma, prior surgery, radiation
• Uncooperative pt
• Overlying infection
• Marked obesity
• Vasculitis
• Sclerotherapy
• Multiple previous catheterizations at site
Subclavian Vein Cannulation
Pros
•
•
•
Lowest infection rate
Anatomic landmarks are the most consistent  preferred in trauma pts
Cannulae are easier to secure  reduces subsequent movement and dislodgement
Cons
•
•
•
Avoid in pts with bleeding coagulopathies
Risk of pneumothorax
Difficult to apply pressure to inadvertent subclavian artery puncture
External Landmarks
• Junction between the medial and middle thirds of the clavicle
• The lateral edge of the sternocleidomastoid muscle where it inserts into the clavicle
Anatomy 14- Central Lines
Percutaneous (Seldinger) Technique
1. Infiltration of local anesthetic
2. Trendelenburg (head down) position
3. Advance needle just beneath the clavicle toward suprasternal notch
4. Keep needle parallel to the floor to avoid pneumothorax
5. Return of free-flowing venous blood confirms venipuncture
6. Pass guide wire through needle without undue resistance
7. Enlarge skin exit site with scalpel
8. Dilate skin/subcutaneous tract (exercise caution!)
9. Thread catheter over guide wire maintaining control of guide wire
10. Remove guide wire
11. Situate catheter tip at the atrial-caval junction
12. Secure catheter and place sterile dressing
13. Obtain radiographic confirmation
•
•
Steps 1-2, 5-13 are applied to placement of IJ catheter
Steps 1, 5-10, 12-13 are applied to placement of a femoral catheter
Internal Jugular Vein Cannulation
Pros
•
•
•
•
Lowest risk of thrombosis
Decreased risk of pneumothorax
Straight shot to the right atrium (right IJ)
Compressibility of vascular extravasation
Cons
•
•
•
•
More uncomfortable for pt
Risk of carotid artery puncture
Higher risk of infection than subclavian (proximity to aerodigestive secretions)
Anatomic variability
External Landmarks
• Identify sternal and clavicular heads of the sternocleidomastoid
• Visualize triangle formed by the muscle bellies
• Palpate carotid pulse (usually medial border of medial head of SCM)
• * In obese pts where landmarks are not discernible, a reasonable rule of thumb is 3 finger breadths lateral from
the tracheal midline and 3 finger breadths up from the clavicle
Ultrasound Guidance:
• In numerous studies, ultrasound guidance has been shown to increase the success of first-time catheter
placement and to decrease the risk of complications.
• Significant reduction in arterial sticks, posterior wall puncture, pneumothorax.
• Pneumothorax; multiple studies show reduction of risk to 0-1% compared to historical controls of 5-6%
• Improved function of lines (days of use), and greater success at placement with first attempt
• The vein and artery appear circular and black on the ultrasound image; the vein is much more compressible
when gentle pressure is applied to the skin via the probe. The needle appears echogenic and can be followed
into the image of the vein.
Anatomy 14- Central Lines
Femoral Vein Cannulation
Pros
•
•
•
Can be accessed quickly and expediently
Avoids disturbing superior central venous system for future dialysis pts
Fairly consistent anatomy
Cons
•
•
•
Highest rate of infection
Highest rate of thrombosis
High rate of kinking with flexion of the hip
Anatomic Considerations
• Femoral vein medial and just deep to femoral artery
• Deep femoral vein and saphenous veins join at deep surface and anteromedial surface respectively
• NAVEL
Complications of Central Venous Access
Other Complications:
Pseudoaneurysm: not all walls of the blood vessel—generally from puncturing an artery wall
Line migration
Arrhythmias
Air embolism: this is why you place the pt head down (reduces risk)
** Don’t remember numbers, remember the highest/lowest rates of complications
Pneumothorax: has JVD
Malposition: must reposition the line—wire going up to the neck versus to the heart where it needs to be
Pseudoaneurysm: ballooning of wall of artery, will only get bigger until it gets fixed
http://www.youtube.com/watch?v=HE5QhsPRaPU – helpful video
Questions
External anatomy slides are important: know the anatomy around the vessels
Look at the Xray with the KEY—on my ppt
Highest/lowest rates of: infection, thrombosis, etc
Remember the concepts: infuse large volumes through peripheral vs central
Anatomy 14- Central Lines