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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