Central Venous Catheterization

Published on 22/03/2015 by admin

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Last modified 22/04/2025

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W3 Central Venous Catheterization

Judith L. Pepe

image Before Procedure

Indications

• Cannot achieve goal with peripheral intravenous catheterization:

• Rapid, massive intravascular volume resuscitation:

image 2-inch, 16-gauge peripheral catheter has faster flow rate than 16-gauge centrally inserted triple lumen catheter:

• Peripheral catheter difficult to place in shock states

image 3.5-inch, 8.5F introducer catheter has fastest flow rate

• Cardiopulmonary resuscitation:

image Drug administration more effective centrally

• Administration of agents irritating to peripheral veins:

image Concentrated potassium chloride solutions
image Total parenteral nutrition solutions
image Chemotherapy agents
image Vasopressors, inotropes

• Central venous pressure monitoring
• Pulmonary artery pressure monitoring
• Transvenous pacemaker insertion
• Hemodialysis
• Plasmapheresis
• Access for frequent blood sampling

Contraindications

• No absolute contraindications if experienced or supervised operator
• Relative contraindications:

• Severe coagulopathy and/or thrombocytopenia:

image Consider femoral vein, peripherally inserted central catheter (PICC)

• Local skin infection
• Ipsilateral arteriovenous fistula
• Ipsilateral venous thrombosis
• Inferior vena cava filter:

image Avoid wire passage past 20 cm to avoid entanglement

Equipment

• Catheter appropriate for indication (single lumen, multilumen, 8.5F introducer)
• Insertion kit including 10-mL syringes, needles, guidewire, suture, local anesthetic
• Sterile saline flush solution
• Sterile fenestrated barrier drape for head-to-toe coverage of patient
• Four sterile towels
• 2% Chlorhexidine gluconate sterile prep stick
• Sterile gown and gloves for operator and assistant(s)
• Cap and mask with face shield or protective glasses for operator and assistant(s)
• Sterile central line dressing kit
• Shoulder roll (for subclavian vein catheterization)
• Ultrasound (for internal jugular catheterization)
• Sterile sheath, gel, and needle guide for ultrasound

image Anatomy

Pertinent anatomy varies depending upon the chosen site of central venous catheterization. All relevant landmarks should be included in the sterile field. For internal jugular venous catheterization, identification of the triangle formed by the two heads of the ipsilateral sternocleidomastoid (SCM) muscle is imperative. It is also important to note the location of the angle of the mandible, the clavicle, and the sternal notch located between the heads of the right and left clavicles. The carotid artery pulse should be located and protected during placement of the needle into the internal jugular vein. For subclavian vein catheterization, identification of the middle portion of the clavicle and the insertion point of the clavicular head of the ipsilateral SCM muscle and sternal notch are important. Femoral vein catheterization requires identification of the junction of the middle and distal third of an imaginary line drawn from the pubic tubercle to the anterior superior iliac spine. The ipsilateral femoral arterial pulse should be located as well.

Procedure

• Internal jugular vein (middle approach):

• Obtain informed consent from patient or surrogate decision maker.
• Gather necessary equipment.
• Place patient in supine position.
• Position bed at comfortable height with 15% to 30% Trendelenburg.
• Rotate head away from side of insertion.
• Perform nonsterile ultrasound to confirm patency and depth of internal jugular vein and location of surrounding structures.
• Open equipment using sterile technique.
• Wash hands and don cap, face shield mask, sterile gown, and gloves.
• Use 2% chlorhexidine prep stick to prep area bounded by ear lobe, mandible, chin, neck, and sternal notch past midline, 2 cm inferior to clavicle and 2 cm posterior to sternal head of SCM muscle.

image Wide prep preferred to be prepared for change to ipsilateral subclavian approach if internal jugular approach unsuccessful

• Square off sterile area with 4 sterile towels.
• Place head-to-toe fenestrated sterile drape.
• Place ultrasound probe in sterile sheath with gel, and position proper needle guide on probe.
• Find anatomic landmarks: apex of triangle formed by two heads of SCM muscle, sternal notch, clavicle, carotid pulse.
• Locate internal jugular vein with ultrasound probe, and confirm that it collapses easily with compression and is nonpulsatile.
• Inject local anesthetic into skin and surrounding region of proposed insertion site.
• Ensure all materials needed for placement of catheter are within easy reach on sterile field.

image Flush all catheter lumens and place caps on all but distal port.

• Place access needle with attached syringe onto needle guide of ultrasound probe.
• Advance needle into internal jugular vein under direct vision of ultrasound, aspirating syringe gently during advancement.
• Confirm presence of needle within vein lumen on ultrasound and by free-flowing aspiration of nonpulsatile venous blood.
• Remove needle from needle guide on ultrasound probe.
• If ultrasound is unavailable, insert needle at apex of SCM triangle and advance toward ipsilateral nipple at 30- to 45-degree angle while continually aspirating syringe.
• Place curved end of guidewire through syringe and/or needle into vein. Never lose control of the end of the guidewire.
• Confirm presence of guidewire in vein with ultrasound.
• Remove syringe and needle over the guidewire.
• Make nick in skin with scalpel at wire insertion site.
• Place dilator over wire and advance into soft tissues to establish tract.
• Remove dilator, leaving wire in place.
• Place catheter (single or multilumen) over wire into vein:

image 16 cm for right internal jugular
image 19 cm for left internal jugular

• Remove wire and place cap on distal port.
• Aspirate blood via all lumens, and flush each with sterile saline.
• Secure catheter to skin with suture.
• Place sterile dressing.
• Clean up and safely discard sharps.
• Order chest x-ray.

• Subclavian vein (infraclavicular approach):

• Obtain informed consent from patient or surrogate decision maker.
• Gather necessary equipment.
• Place patient in supine position with ipsilateral arm adducted.
• Place shoulder roll under patient vertically between scapulae.
• Position bed at comfortable height with 15% to 30% Trendelenburg.
• Rotate head away from side of insertion.
• Open equipment using sterile technique.
• Wash hands and don cap, face shield mask, sterile gown and gloves.
• Use 2% chlorhexidine prep stick to prep area bounded by ear lobe, mandible, chin, neck, and sternal notch past midline, 2 cm inferior to clavicle and 2 cm posterior to sternal head of SCM muscle.

image Wide prep preferred to be prepared for change to ipsilateral internal jugular approach if subclavian approach unsuccessful

• Square off sterile area with 4 sterile towels.
• Place head-to-toe fenestrated sterile drape.
• Find anatomic landmarks: midportion of ipsilateral clavicle, sternal notch.
• Inject local anesthetic into skin and surrounding region of proposed insertion site
• Ensure all materials needed for placement of catheter are within easy reach on sterile field.

image Flush all catheter lumens and place caps on all but distal port.

• Insert needle with attached syringe into skin 2 cm inferior to midportion of clavicle, directing needle slightly cephalad toward clavicle in direction of sternal notch.
• “Walk” down clavicle with needle until it advances just deep to inferior surface of clavicle.
• Continue to advance needle in direction of sternal notch until vein is entered and free aspiration of nonpulsatile venous blood occurs.
• Place curved end of guidewire through syringe and/or needle into vein. Never lose control of the end of the guidewire.
• Remove syringe and needle over the guidewire.
• Make nick in skin with scalpel at wire insertion site.
• Place dilator over wire and advance into soft tissues to establish tract.
• Remove dilator, leaving wire in place.
• Place catheter (single or multilumen) over wire into vein.

image 18 cm for right subclavian
image 20 cm for left subclavian

• Remove wire and place cap on distal port.
• Aspirate blood via all lumens, and flush each with sterile saline.
• Secure catheter to skin with suture.
• Place sterile dressing.
• Clean up and safely discard sharps.
• Order chest x-ray.

• Femoral vein:

• Obtain informed consent from patient or surrogate decision maker.
• Gather necessary equipment.
• Place patient in supine position with ipsilateral thigh in slight abduction.
• Open equipment using sterile technique.
• Wash hands and don cap, face shield mask, sterile gown, and gloves.
• Use 2% chlorhexidine prep stick to prep area bounded by 2 cm superior to pubis and anterior superior iliac spine, lateral mid thigh, medial mid thigh, and pubis to midline.
• Square off sterile area with 4 sterile towels.
• Place head-to-toe fenestrated sterile drape.
• Find anatomic landmarks: pubic tubercle, anterior superior iliac spine, femoral artery pulse.
• Inject local anesthetic into skin and surrounding region of proposed insertion site.
• Ensure all materials needed for placement of catheter are within easy reach on sterile field.

image Flush all catheter lumens and place caps on all but distal port.

• Insert needle at 90-degree angle while aspirating attached syringe into skin medial to femoral artery pulse at junction of middle and medial third of imaginary line drawn from pubic tubercle to anterior superior iliac spine.
• Continue to advance needle until vein is entered and free aspiration of nonpulsatile venous blood occurs.
• Place curved end of guidewire through syringe and/or needle into vein. Never lose control of the end of the guidewire.
• Remove syringe and needle over the guidewire.
• Make nick in skin with scalpel at wire insertion site.
• Place dilator over wire and advance into soft tissues to establish tract.
• Remove dilator, leaving wire in place.
• Place catheter (single or multilumen) over wire into vein.
• Remove wire and place cap on distal port.
• Aspirate blood via all lumens and flush each with sterile saline.
• Secure catheter to skin with suture.
• Place sterile dressing.
• Clean up and safely discard sharps.

image After Procedure

Postprocedure Care

• Chest x-ray:

• Confirm location of internal jugular and subclavian venous catheter tip at atriocaval junction.
• Rule out hemothorax, pneumothorax, and apical cap.

• Daily inspection of insertion site for development of infection
• Monitor for arrhythmias, as catheter migration may occur.
• Proper local care and dressing imperative to minimizing complications
• Sterile access of all ports at all times

Complications

• Common:

• Cardiac arrhythmias
• Arterial puncture
• Hematoma
• Catheter malposition
• Venous thrombosis:

• More frequent with femoral vein catheters
• Catheter-related bloodstream infection

• Infrequent:

• Pneumothorax
• Hemothorax
• Chylothorax (thoracic duct injury):

• More common with left internal jugular or subclavian vein catheterization

• Local nerve injury
• Entanglement with vena cava filters
• Tracheal perforation
• Endotracheal tube cuff rupture

• Serious rare complications:

• Air embolus
• Cardiac tamponade

image Outcomes and Evidence

• Femoral vein catheters have a higher incidence of infectious and thrombotic complications compared to subclavian vein catheters.
• Lowest infection rates are associated with subclavian vein catheters.
• Infection of central venous catheters is diminished by judicious attention to sterile insertion technique.
• Antibiotic-treated, noncuffed central venous catheters have a lower rate of device-related bloodstream infection than nontreated catheters, but higher rate compared to PICCs.
• Use of ultrasound to guide insertion is beneficial in improving mechanical complications and rates of successful cannulation, particularly when accessing the internal jugular vein or when operators are inexperienced.
• PICCs may be more cost-effective and have lower complication rates than centrally inserted venous catheters.
• Deep venous thrombosis due to PICCs may be related to catheter size.

Suggested Reading

McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. 2003;348:1123-1133.

Farkas JC, Liu N, Bleriot JP, et al. Single- versus triple-lumen central catheter-related sepsis: a prospective randomized study in a critically ill population. Am J Med. 1992;93:277-282.

Smith JR, Friedell ML, Cheatham ML, et al. Peripherally inserted central catheters revisited. Am J Surg. 1998;176:208-211.

Merrer J, DeJonghe B, Golliot F, et al. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA. 2001;286:700-707.

Randolph AG, Cook DJ, Gonzales CA, et al. Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature. Crit Care Med. 1996;24:2053-2058.

RaadII, Hohn DC, Gilbreth BJ, et al. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiol. 1994;15:231-238.

O’Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the prevention of intravascular catheter-related infections. MMWR Morb Mortal Wkly Rep. 2002;51:1-29.

Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc. 2006;81:1159-1171.

Karakitsos D, Labropoulos N, DeGroot E, et al. Real time ultrasound-guided catheterization of the internal jugular vein: a prospective comparison with the landmark technique in critical care patients. Crit Care. 2006;10:R162-R169.

Byrnes MC, Coopersmith CM. Prevention of catheter-related blood stream infection. Curr Opin Crit Care. 2007;13:411-415.

Evans RS, Sharp JH, Linford LH, et al. Risk of symptomatic DVT associated with peripherally inserted central catheters. Chest. 2010;138:803-810.

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