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Central Venous Access
Module
Approach
• Two approaches are commonly used and
will be described:
1.Right internal jugular vein
2.Right sublclavian vein
Indications
• Measurement of central venous pressure (CVP)
insertion of a pulmonary artery catheter or
transvenous pacemaker
administration of fluids and medications, e.g.,if
there is no peripheral access
administration of hyperalimentation solutions or
other fluids that are hypertonic and damage
peripheral veins (such as Amphotericin B)
CONTRAINDICATIONS
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Coagulopathy
Infection over site of insertion
Distortion of landmarks
SVC syndrome
Patients unable to cooperate or tolerate
Trendelenberg positioning
• Pneumothorax on opposite side
• Patients with high end-expiratory pressures on
mech. ventilation
EQUIPMENT NEEDED
• Commercially available set containing
needles, wires, sheaths, dilators, etc
Needles, syringes, local anesthetic, 0.9%
saline (may be heparinized with 1ml 1 in
100 heparin in 10ml 0.9% saline)
Sterile gown, mask, gloves
RIGHT INTERNAL
JUGULAR VEIN APPROACH
• Three sites are described:
1. anterior - medial to the sternocleiodomastoid
muscle
2. middle - between the two heads of
sternocleidomastoid
3. posterior - lateral to the sternocleidomastoid
• The middle is the commonest and is the one
described here. Patient discomfort when turning
the head is the disadvantage of this technique
Jugular Approach
Procedure
1.Sterilize the site and drape with sterile
towels
2.Administer the local anesthetic
Procedure
1.Whilst this is working flush all the ports of
the catheter with sterile 0.9% saline
2.Put the patient in the Trendelenburg
position (i.E.Head down)
Procedure
1.Use a 21 gauge needle attached to a syringe
containing 0.9% saline to locate the position
of the internal jugular vein. Put your left
hand fingers on the carotid artery and pull it
medially and then introduce the needle at
the apex of the triangle formed by the two
heads of the sternocleidomastoid muscle
and the clavicle
Procedure
• The needle should enter at about 45 o to the
skin and be directed slightly laterally
towards the ipsilateral nipple (often a
shallow notch can be felt in the posterior
aspect of the clavicle which can help in
locating the vein in the lateral/medial plane)
• Puncture of the vein is apparent by sudden
aspiration of non-pulsatile venous blood
Procedure
• If the artery is punctured remove the needle
and apply pressure for 10 minutes
• Insert the introducer needle along the same
track as the first needle, which can be used
as a guide or can be removed with you
remembering the direction and depth it was
inserted
Procedure
• When this needle has been inserted into the
vein the introducer should be removed and
the guidewire introduced down it (leave
enough wire outside the patient to
accommodate the length of the intravascular
catheter
Procedure
• Nick the skin with a number 11 scalpel
blade
• Thread the dilator over the guidewire then
remove it keeping the wire in situ at the
same depth
Procedure
• Thread the catheter over the guidewire keeping
hold of the wire so it does not disappear into the
patient (it is helpful to estimate the length of the
catheter needed to reach the right atrium before
placement)
• When the catheter is in place there should be free
flow of venous blood (if there is no flow the
catheter is not correctly placed or is kinked)
Procedure
• Remove the guidewire and attach fluids
• Suture the catheter in place with 2/0 silk,
spray with povidone iodine and apply an
occlusive dressing
• Observe and listen to the chest to exclude a
pneumothorax
• Obtain a chest radiograph to confirm its
position and exclude a pneumothorax
Subclavian Approach
• The left subclavian route has the lowest
infection rate of all central line routes.
Procedure
1.Place a liter bag of fluid between the
shoulder blades
2.Sterilize a wide area and drape with a sterile
towel
Subclavian Approach
Subclavian Approach
1.Identify the area two fingerbreadths lateral
and inferior to the point where the clavicle
and first rib cross ( about the distal third of
the clavicle) and administer the local
anesthetic
2.Whilst this is working flush all the ports of
the catheter with sterile 0.9% saline
Subclavian Approach
• Place the patient in the Trendelenburg position
• Locate the vein using a 21 gauge needle keeping
the needle parallel to the skin and advancing it just
underneath the clavicle to a point halfway between
the sternal notch and the thyroid cartilage
• Apply back pressure on the syringe until venous
blood is aspirated
Subclavian Approach
• Remove the syringe and insert the guidewire into
the vein (if there is resistance to the guidewire
reposition the needle and replace the guidewire - if
the wire is going into the head the patient may
complain of pain in the ipsilateral ear. If the wire
still encounters resistance withdraw it and ask the
patient to turn their head towards you, then replace
the guidewire)
• Remove the needle and nick the skin with a
number 11 scalpel
Subclavian Approach
• Dilate the track
• Thread the dilator over the guidewire then remove
it keeping the wire in situ at the same depth
• Thread the catheter over the guidewire keeping
hold of the wire so it does not disappear into the
patient (it is helpful to estimate the length of the
catheter needed to reach the right atrium before
placement)
Subclavian Approach
• When the catheter is in place there should
be free flow of venous blood (if there is no
flow the catheter is not correctly placed or
is kinked)
• Remove the guidewire and attach fluids
• Suture the catheter in place with 2/0 silk,
spray with povidone iodine and apply an
occlusive dressing
Subclavian Approach
• Observe and listen to the chest to exclude a
pneumothorax
• Obtain a chest radiograph to confirm its
position and exclude a pneumothorax
Complications
• Generally safe if a small needle is used to identify
the vein first
1. Pneumothorax - suspect if air aspirated. Always
rule out with a CXR. Requires a chest tube. More
likely on left because of higher dome of left
pleura.
2. Hemothorax from vascular injury
3. Hydrothorax from IV fluid administration into the
pleural space
Complications
1.Catheter tip embolus - NEVER withdraw
the catheter over the needle
2.Perforation of endotracheal tube cuff.
Complications
1.Air embolus - always cover the open end of
a central line with a finger. 50-100ml air
can be fatal. If suspected tip the patient head
down and onto their left side so the air stays
in the right atrium and get an urgent chest
radiograph to see if there is air in the heart.
2.Line sepsis.
Documentation in Medical
Record
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Consent
Indications
Lack of contraindications
Procedure including prep, anesthesia,
technique
• Complications?
• Who was notified of complication (family,
attending).