Central Venous Access Module

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Central Venous AccessModule

• Vic V. Vernenkar, D.O.
• Dept. of Surgery
• St. Barnabas Hospital

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Approach

• Two approaches are commonly used and will be
  described
• Right internal jugular vein
• 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
  accessadministration of hyperalimentation
  solutions or other fluids that are hypertonic and
  damage peripheral 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 tolerate
  Trendelenberg 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
• anterior - medial to the sternocleiodomastoid
  muscle
• middle - between the two heads of
  sternocleidomastoid
• 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

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Jugular Approach
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Procedure

• Sterilize the site and drape with sterile towels
• Administer the local anesthetic

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Procedure

• Whilst this is working flush all the ports of the
  catheter with sterile 0.9 saline
• Put the patient in the Trendelenburg position
  (i.E.Head down)

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Procedure

• 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

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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 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

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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 was inserted

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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 (leave enough 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 then remove
  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 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)

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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 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

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Subclavian Approach

• The left subclavian route has the lowest
  infection rate of all central line routes.
  Procedure
• Place a liter bag of fluid between the shoulder
  blades
• Sterilize a wide area and drape with a sterile
  towel

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Subclavian Approach
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Subclavian Approach

• 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
• Whilst this is working flush all the ports of the
  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
  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

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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

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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 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

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Subclavian Approach

• 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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Complications

• Generally safe if a small needle is used to
  identify the vein first
• 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.
• Hemothorax from vascular injury
• Hydrothorax from IV fluid administration into the
  pleural space

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Complications

• Catheter tip embolus - NEVER withdraw the
  catheter over the needle
• Perforation of endotracheal tube cuff.

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Complications

• 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.
• 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).