central venous access-1

7/27/2019 Central Venous Access-1

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Central Venous Access

Module

Vic V. Vernenkar, D.O.

Dept. of SurgerySt. Barnabas Hospital


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Approach

Two approaches are commonly used and

will be described:

1.Right internal jugular vein

2.Right sublclavian vein


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Indications

Measurement of central venous pressure (CVP)

insertion of a pulmonary artery catheter or

transvenous pacemakeradministration of fluids and medications, e.g.,if

there is no peripheral access

administration of hyperalimentation solutions or

other fluids that are hypertonic and damageperipheral veins (such as Amphotericin B)


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CONTRAINDICATIONS

Coagulopathy

Infection over site of insertion

Distortion of landmarks

SVC syndrome

Patients unable to cooperate or tolerateTrendelenberg positioning

Pneumothorax on opposite side

Patients with high end-expiratory pressures on

mech. ventilation


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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


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RIGHT INTERNAL

JUGULAR VEIN APPROACH

Three sites are described:

1. anterior - medial to the sternocleiodomastoidmuscle

2. middle - between the two heads ofsternocleidomastoid

3. posterior - lateral to the sternocleidomastoid The middle is the commonest and is the one

described here. Patient discomfort when turningthe head is the disadvantage of this technique


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Jugular Approach


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Procedure

1.Sterilize the site and drape with sterile

towels

2.Administer the local anesthetic


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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)


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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 lefthand fingers on the carotid artery and pull it

medially and then introduce the needle at

the apex of the triangle formed by the twoheads of the sternocleidomastoid muscle

and the clavicle


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Procedure

The needle should enter at about 45 o to the

skin and be directed slightly laterally

towards the ipsilateral nipple (often ashallow 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


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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 wasinserted


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Procedure

When this needle has been inserted into the

vein the introducer should be removed and

the guidewire introduced down it (leaveenough wire outside the patient to

accommodate the length of the intravascular

catheter


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Procedure

Nick the skin with a number 11 scalpel

blade

Thread the dilator over the guidewire thenremove it keeping the wire in situ at the

same depth


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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 thecatheter 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 thecatheter is not correctly placed or is kinked)


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Procedure

Remove the guidewire and attach fluids

Suture the catheter in place with 2/0 silk,

spray with povidone iodine and apply anocclusive dressing

Observe and listen to the chest to exclude a

pneumothorax Obtain a chest radiograph to confirm its

position and exclude a pneumothorax


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Subclavian Approach

The left subclavian route has the lowestinfection rate of all central line routes.

Procedure

1.Place a liter bag of fluid between theshoulder blades

2.Sterilize a wide area and drape with a steriletowel


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Subclavian Approach


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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 ofthe clavicle) and administer the local

anesthetic

2.Whilst this is working flush all the ports ofthe catheter with sterile 0.9% saline


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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 justunderneath 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


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Subclavian Approach

Remove the syringe and insert the guidewire intothe vein (if there is resistance to the guidewirereposition the needle and replace the guidewire - ifthe wire is going into the head the patient maycomplain of pain in the ipsilateral ear. If the wirestill 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


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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)


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Subclavian Approach

When the catheter is in place there shouldbe free flow of venous blood (if there is no

flow the catheter is not correctly placed oris kinked)

Remove the guidewire and attach fluids

Suture the catheter in place with 2/0 silk,spray with povidone iodine and apply anocclusive dressing


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Subclavian Approach

Observe and listen to the chest to exclude a

pneumothorax

Obtain a chest radiograph to confirm itsposition and exclude a pneumothorax


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Complications

Generally safe if a small needle is used to identifythe vein first

1. Pneumothorax - suspect if air aspirated. Alwaysrule out with a CXR. Requires a chest tube. Morelikely on left because of higher dome of left

pleura.

2. Hemothorax from vascular injury3. Hydrothorax from IV fluid administration into thepleural space


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Complications

1.Catheter tip embolus - NEVER withdraw

the catheter over the needle

2.Perforation of endotracheal tube cuff.


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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 headdown 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.


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Documentation in Medical

Record Consent

Indications

Lack of contraindications Procedure including prep, anesthesia,

technique

Complications? Who was notified of complication (family,

attending).

central venous access-1

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