Central Venous Catheter Insertion (Perform)
PREREQUISITE NURSING KNOWLEDGE
• Knowledge of the normal anatomy and physiology of the cardiovascular system is needed.
• Clinical and technical competence in central line insertion and suturing is important.
• Knowledge of the principles of sterile technique is essential.
• Knowledge of the anatomy and physiology of the vasculature and adjacent structures of the neck, groin, and arm is needed.
• Competence in chest radiographic interpretation is necessary.
• Advanced cardiac life support knowledge and skills are needed.
• Indications for a central venous catheter (CVC) include the following4,7:
Hypotension after major surgery
Right ventricular ischemia or infarction
Administration of total parenteral nutrition
Lack of peripheral venous access
Assessment of hypovolemia or hypervolemia
Long-term infusions of medications
• Placement of a CVC can guide treatment after major surgery and during active bleeding.
• The central venous pressure (CVP) can be helpful in the differentiation of right ventricular failure from left ventricular failure.
• The CVP is commonly elevated during or after right ventricular failure, ischemia, or infarction because of decreased compliance of the right ventricle while the pulmonary artery occlusion pressure is normal.
• The CVP can be helpful in the determination of hypovolemia. The CVP value is low if the patient is hypovolemic. Venodilation also decreases CVP.
• Relative contraindications of CVC insertion include the following4,7:
• The CVP provides information regarding right heart filling pressures and right ventricular function and volume.
• The CVP historically was measured with a water manometer system but is now measured with a single-pressure transducer system (see Procedures 70 and 76).
• The CVP waveform is identical to the right atrial pressure (RAP) waveform.
• The normal CVP value is 2 to 6 mm Hg.
• Electrocardiographic (ECG) monitoring is essential in the accurate interpretation of the CVP value.
• Understanding is needed of a, c, and v waves. The a wave reflects right atrial contraction; the c wave reflects closure of the tricuspid valve; and the v wave reflects right atrial filling during ventricular systole (see Figs. 70-1 and 73-7).
• Dysrhythmias may alter CVP or RAP waveforms.
• The risk for a pneumothorax is minimized with use of an internal jugular vein. The preferred site for catheter insertion is the right internal jugular vein. The right internal jugular vein is a “straight shot” to the right atrium.
• The right or left subclavian veins are also sites for central catheter placement. Placement of a CVC through the right subclavian vein is a shorter and more direct route than the left subclavian vein because it does not cross the midline of the thorax.4,7
• Femoral veins may be accessed but have the disadvantages of limiting the patient to bed rest with immobilization of the leg and increasing the patient’s risk of infection.
• The presence of a pacemaker may alter the choice of placement of a CVC because of a risk for dislodging pacemaker leads with insertion of a CVC.
• Complications may occur during or after insertion of a central venous catheter (see Table 81-1).
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