Central Venous Catheterization

BACKGROUND

Central venous catheters (CVCs) are an enormously important tool in clinical medicine; more than 5 million are placed annually in the United States. Notwithstanding, CVCs are associated with a number of complications, including several that are potentially fatal (e.g., pneumothorax and catheter-associated sepsis). Appropriate patient selection and safe insertion techniques are critical in minimizing the risks associated with this common procedure, and they are the focus of this chapter.

Many catheter types are commonly in use. Multilumen catheters allow for concomitant venous pressure monitoring and infusions, or the infusion of multiple products. Larger-lumen catheters (e.g., Cordis, Miami Lakes, FL) allow for more rapid infusion and are, therefore, useful in the resuscitative setting. Moreover, such catheters can serve as conduits for the insertion of multilumen catheters or pulmonary artery catheters. Catheters designed for long-term access, such as Hickman (Fig. 3-1A) and Broviac catheters, are tunneled under the skin of the chest wall and are equipped with a cuff around which scar tissue forms, holding the catheter in position. Implantable ports facilitate long-term, intermittent access (e.g., weekly chemotherapy). These devices have a reservoir that is implanted in a subcutaneous pocket and can be intermittently accessed by needle puncture through the skin (Fig. 3-1B).

Figure 3-1 Hickman catheter (A) and accessed implantable port (B).

(A, From Marx J, Hockberger R, Walls R: Rosen’s Emergency Medicine: Concepts and Clinical Practice, 6th ed. Philadelphia, Mosby, 2006; B, From Hoffman R, Benz E, Shattil S, et al: Hematology: Basic Principles and Practice, 4th ed. Philadelphia, Churchill Livingstone, 2005.)

In most cases, CVCs are inserted using the Seldinger technique, which involves the placement of a wire into the central vein and insertion of a catheter over the wire. Alternatively, a cut-down approach may be used, as is commonly the case when inserting an implantable port. Percutaneous approaches to the internal jugular vein (IJ), the subclavian (SC) vein, and the femoral vein; the Seldinger technique; and the cut-down approach to port placement are all discussed in this chapter.

INDICATIONS FOR CENTRAL LINE PLACEMENT

PREPROCEDURE EVALUATION

COMPONENTS OF THE PROCEDURE AND APPLIED ANATOMY

Internal Jugular Vein Approach

I. The patient’s head is rotated 45 degrees away from the planned insertion site (Fig. 3-2).

II. The carotid pulse is palpated and displaced medially with the nondominant hand. A small-gauge finder needle is inserted lateral to the carotid pulse at the apex of the triangle formed by the two heads of the sternocleidomastoid muscle and the clavicle, and is advanced toward the ipsilateral nipple. After localization of the IJ with the finder needle (as evidenced by blood return), an introducer needle is inserted along an immediately adjacent path, into the vein.

III. Venous (rather than arterial) catheterization can be confirmed by attaching intravenous extension tubing to the introducer needle and drawing blood into the tubing with a syringe. A column of venous blood readily descends down the intravenous tubing. On the other hand, if the needle is in the carotid artery, the column of blood will continue to ascend through the tubing. In the event that the artery is inadvertently cannulated, the needle should be removed immediately and firm pressure applied at the site.

Figure 3-2 Internal jugular venous anatomy and access. The internal jugular vein is located at the apex of the triangle formed by the two heads of the sternocleidomastoid muscle and the clavicle. The dashed lines demarcate the midline.

(From Roberts JR, Hedges JR: Clinical Procedures in Emergency Medicine, 4th ed. Philadelphia, Saunders, 2004.)

THE COLOR OF THE BLOOD RETURN IS AN UNRELIABLE MARKER FOR VENOUS CATHETER PLACEMENT.

Subclavian Vein Approach

A rolled towel is placed under the scapulae. Local anesthetic is delivered to the subcutaneous tissues and the periosteum of the clavicle. The introducer needle (i.e., a large-gauge, hollow-bore needle) is attached to a syringe and is inserted 2 to 3 cm inferior to the midpoint of the clavicle. The needle is advanced under the clavicle toward the sternal notch until blood return is visualized in the syringe (Fig. 3-3).

Figure 3-3 Subclavian venous anatomy and access. The subclavian vein lies directly beneath the clavicle. The vein is separated from the subclavian artery by the anterior scalene muscle (top). The subclavian artery is cannulated beneath the midportion of the clavicle. On insertion, the needle is directed toward the suprasternal notch (bottom).

(From Salm TJV, Cutler BS, Wheeler HB [eds]: Atlas of Bedside Procedures. Boston, Little, Brown, 1979.)

Femoral Vein Approach

I. The femoral artery is palpated below the inguinal ligament. If the femoral artery is not palpable, the point one third of the distance between the pubic tubercle and the anterior superior iliac crest may serve as a landmark for its location (Fig. 3-4).

II. An introducer needle is inserted 2 cm below the inguinal ligament and medial to the femoral artery at a 45-degree angle with the skin. The needle is advanced until blood return is visualized in the syringe.

Figure 3-4 Femoral artery and vein anatomy.

(From Dieckmann R, Selbst S: Pediatric Emergency and Critical Care Procedures. St. Louis, Mosby, 1997.)

The anatomy of the femoral triangle is summarized by the mnemonic NAVEL: from lateral to medial, the femoral nerve, artery, vein, empty space, and lymphatics pass under the inguinal ligament.

Implantable Port Placement

I. An incision is made over the groove between the deltoid and the pectoralis major muscle (the deltopectoral groove) to expose the cephalic vein. The proximal end of the vein is encircled with a suture and the distal end is ligated.

II. A transverse venotomy is made and a plastic vein pick (Fig. 3-5) is inserted into the lumen of the vessel to open the venotomy. The catheter is inserted into the vein through the venotomy and advanced to the cavoatrial junction. Fluoroscopy is used to confirm appropriate location of the catheter tip. The proximal suture is then tied around the cephalic vein firmly enough to secure the catheter in position without occluding it.

III. A subcutaneous pocket large enough to accommodate the port is made in the infraclavicular fossa using blunt dissection.

IV. A noncoring needle (i.e., a Huber needle) is inserted through the skin and the membrane of the port. Any air is withdrawn and the port is flushed with heparinized saline. The skin incision is closed.

Figure 3-5 Typical implantable port system, including a stainless steel port, catheter, Huber needle, and plastic vein pick.

Additional Operative Considerations

Ultrasound-Guided Placement: Increasingly, bedside sonography is used to guide IJ catheter placement. In the Trendelenburg position, the IJ is compressible and larger than the carotid artery (Fig. 3-6).

Figure 3-6 Ultrasonography of the right internal jugular vein (V) and right carotid artery (A).

POSTPROCEDURE CONSIDERATIONS

After any attempted SC or IJ CVC insertion, a chest radiograph is obtained to confirm position and identify complications (i.e., pneumothorax).

COMPLICATIONS