Central Venous Catheterization

Published on 22/03/2015 by admin

Filed under Critical Care Medicine

Last modified 22/03/2015

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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.
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