Chapter 8 Central Vein Catheterization
INTRODUCTION
In the United States, more than 5 million central vein catheters are inserted every year, making it one of the most commonly performed bedside procedures.1
INDICATIONS
Central vein access can be obtained via the jugular, subclavian, or femoral vein, and site selection will vary depending on why access is being obtained, ease of placement, and associated risks. As with any invasive procedure, risks are associated with central vein catheterization that are both hazardous to patients and costly to treat.2–4 The overall complication rate for central vein catheterization is approximately 15%,5 and as with other technical tasks, this risk tends to decrease with operator experience.6 Mechanical complications have been reported to occur in 5% to 19% of patients, infectious complications in 5% to 26%, and thrombotic complications in 2% to 26%.5–9 The objective of this chapter is to discuss, in detail, the complications associated with central vein access in the hope that a thorough knowledge of the potential problems will result in a decrease in the actual occurrences.
OPERATIVE STEPS
CENTRAL VEIN ACCESS: SETUP
Prior to the procedure, a number of “checks” should be performed to ensure that the procedure is completed in the safest and most efficient way. At our institution, a Central Line Checklist has been created to ensure that the appropriate measures for the procedure are considered (Fig. 8-1). This checklist accounts for preprocedure, procedure, and postprocedure issues and serves as a performance improvement tool as well. The first step in central line placement is to assemble all of the necessary materials needed to perform the procedure and complete the tasks outlined in the preprocedure portion of the checklist.
Subclavian Vein Catheterization
When utilizing the infraclavicular approach for SV catheterization, note that the SV arises from the axillary vein at the point where it crosses the lateral border of the first rib. The SV is usually 1 to 2 cm in diameter and fixed in position directly beneath the clavicle. It is separated from the subclavian artery by the anterior scalene muscle. For catheterization, the patient is placed in 15° to 30° Trendelenburg position, and the shoulders are maintained in neutral or slightly extended position by a small towel roll placed between the shoulder blades. After identification of the landmarks (sternal notch, clavicle, deltopectoral groove), sterile preparation (chlorhexidine or povidine-iodine), and administration of local anesthesia (1% lidocaine), the skin is punctured 2 to 3 cm caudal to the midpoint of the clavicle just lateral to the deltopectoral groove with an 18-gauge, 2.5-inch introducer needle. A guide to the puncture site can be created by having the operator place her or his index finger in the sternal notch and the thumb of the same hand at the junction of the medial and middle third of the clavicle, which is typically in the deltopectoral groove. The needle can be inserted just lateral and caudal to the operator’s thumb. The needle should not be bent and should be advanced parallel to the clavicle, aiming toward the sternal notch until the tip of the needle abuts the clavicle at the junction of its medial and middle thirds. The needle is then passed beneath the clavicle, with the needle hugging the inferior surface of the clavicle. During insertion of the needle, slight negative pressure should be held on the syringe until a flash of blood is seen. If no blood returns with passage of the needle, the needle is withdrawn past the clavicle while gentle suction is applied. Blood return may be achieved during withdrawal of the needle. If the first pass is unsuccessful, the needle should be angled in a slightly more cephalad direction on the next attempt.
Seldinger Technique
Once the vein has been accessed, the Seldinger technique should be utilized to place the catheter. This technique involves the passage of a soft-tipped guidewire through the needle and subsequent removal of the needle. After making a small nick in the skin with a no. 11 scalpel blade, a dilator is passed over the guidewire, the dilator is removed, the catheter is passed over the wire, and the wire is removed. During the passing of the guidewire, the operator should have the monitor facing him or her. A common mistake is to pass the wire too far, into the atrium or ventricle, resulting in arrhythmia.11 Close attention to patient hemodynamics and oxygen saturation during the procedure is mandatory.
If the vein cannot be accessed after multiple attempts, stop, reassess, and consult with an experienced operator. When attempting an internal jugular or subclavian approach, prior to moving to the contralateral side, a chest x-ray should be performed to ensure that there is no evidence of injury, that is, pneumo/hemothorax. One of the more common complications is failure to cannulate the central vein. This tends to be a more frequent occurrence in the internal jugular and subclavian routes. This is due, in part, to the fact that central access is “blind” and guided by the use of anatomic landmarks, which may not correlate with vessel location.12 It has been argued that ultrasound guidance may be useful in situations in which difficult access is anticipated. Such situations would include obese patients or those with swollen neck/upper extremity that would make landmarks difficult to identify, those who have had multiple central venous catheters placed and had distorted or thrombosed veins, those requiring repeated access via the central vein, and those with coagulopathy.13
Ultrasound Guidance Techniques
Traditionally, the site of initial needle insertion during central line placement is determined by using palpable or visible anatomic structures with known relationships to the desired vein as landmarks.13 However, ultrasound is increasingly being used to identify vessels and guide needle insertion when placing central lines. The first reported use of Doppler ultrasound to assist with catheter placement was by Legler and Nugent in 1984.14 Since then, multiple studies have reported on this technique.12,15–20 Several meta-analyses that reviewed landmark versus ultrasound-guided IJV central line placement demonstrated significant relative risk reductions in complications, mean insertion attempts, and failed catheter insertions when ultrasound was employed.21–23 The results of ultrasound-guided SV central line placement are not as uniform in documenting an advantage over landmark techniques. However, most randomized studies suggest that there is benefit in utilization of ultrasound guidance for the placement of SV catheters.7,12,15–20,23
It should be emphasized that this technique is operator-dependent, and it is recommended that prior to utilizing this technique, operators undergo both didactic and “hands-on” training. During the technique, the ultrasound transducer is the component of the ultrasound system that contacts the patient and is held by the sonographer. To ensure appropriate imaging and ultrasound resolution, the highest frequency should be selected to maximize definition of the vessel image while maintaining adequate depth of penetration of the ultrasound signal (typically 7.5 MHz). Moreover, the ultrasound beam should be directed essentially perpendicular to the vessel. In order to cannulate, the vein must first be visualized appropriately. With the transducer centered over the vein, the midpoint should be used for introduction of the access needle. The needle will appear hyperechoic (white) when viewed sonographically. Once the vessel has been accessed, the central line is placed as described previously. For IJV access, the transducer should be placed just cephalad to the clavicle at the insertion of the two heads of the sternocleidomastoid muscle. For femoral vein access, the transducer is placed a few centimeters distal to the inguinal ligament; for SV access, holding the transducer below the clavicle allows for adequate visualization.
PATIENT CHARACTERISTICS
There are multiple approaches for obtaining central venous access; however, successful catheterization by any approach is dependent on a thorough understanding of the anatomy (Figs. 8-2 to 8-4). Whenever the landmarks cannot be identified for one route of access, another route should be considered. If central access is needed for resuscitation from shock, the femoral approach should be considered because of the speed and safety with which it can be performed, particularly if the neck landmarks are difficult to identify or if access to the neck is precluded by other care providers during the resuscitation.1 Subsequent to the resuscitation, consideration should be given to changing the line site because femoral cannulation has been associated with greater risk of infectious and thrombotic complications.1,5–8
Obtaining a past medical history is very important prior to line insertion. Patients who have had multiple access procedures performed in the past (e.g., chronic renal failure, chemotherapy, intravenous antibiotics), a history of failed catheterization attempts, the need for catheterization at a site of previous surgery, skeletal deformity, or scarring secondary to radiation therapy pose a greater challenge and patient safety dictates that the procedure be performed or supervised by an experienced physician.1,7 In addition, multiple catheterizations can lead to venous stenosis/thrombosis, resulting in difficulty accessing the vein and placing the catheter successfully.24 When such a situation is encountered, the physician should consider using fluoroscopy and/or ultrasound to aid in the central line insertion.
Special consideration should be given to patients who have undergone previous thoracic surgery (e.g., lobectomy) because compromise of the good lung (e.g., pneumo/hemothorax) may have devastating consequences, whereas placement of a chest tube (if needed secondary to iatrogenic pneumo/hemothorax) on the side of previous thoracic surgery can be difficult owing to the presence of intrathoracic adhesions. Patients who have indwelling central venous devices (e.g., pacemaker, defibrillator) are unique in that placement of a central line could disrupt the device and thereby jeopardize the function. It is imperative that an ample history be taken prior to performing a central line insertion.
Like prior catheterization attempts and prior surgery/scarring, patients with low or high body mass index pose a significant challenge to central line insertion.24–26 Excessive soft tissue, particularly in the supine position, distorts the usual landmarks and spatial relationships in the neck. This is most marked when trying to approach the SV because breast tissue frequently falls toward the clavicle and should prompt one to consider an alternative approach or utilize ultrasound for vessel identification.27 In such cases, it may be necessary to align the puncture site closer to the sternal notch and more inferior to the clavicle. This medial approach shortens the distance to the vein and allows one to ensure that the tip of the needle runs on the underside of the clavicle. Manual downward traction on the breast or taping the breasts out of the field should also be considered because this will allow for better identification of landmarks.
A lack of soft tissue such as that seen in cachectic patients may also contribute to higher morbidity. In these patients, there tends to be a decreased amount of space between the clavicle and the first rib, thus increasing the risk of pneumothorax.28 Care must be taken during needle insertion, staying directly on the clavicle, aiming toward the sternal notch without directing the needle downward toward the cupula of the lung. The contracted patient poses a similar challenge when obtaining central venous access, and it is vitally important to attempt to get the patient’s shoulders into a neutral position. If this cannot be achieved, an alternative site should be considered. A good technique is to always keep the needle and syringe parallel to the clavicle and remember that a failed catheter placement attempt is one of the strongest predictors of subsequent complication.7
Another alternative for SV cannulation is the supraclavicular approach,26,28 but this should be performed only by an experienced operator familiar with the anatomy and the technique. Briefly, the needle is introduced above the clavicle at the midpoint of the triangle formed by the sternal and clavicular heads of the sternocleidomastoid muscle. The needle should be advanced at a 30° angle slowly aiming toward the sternum until a flash of venous blood is obtained. The Seldinger technique is used to complete the procedure. This approach has been reported to be safe, with a low complication rate.29
In emergent situations, our personal preference is to utilize the femoral (first choice) or internal jugular approach in anticoagulated patients. Both of these sites allow for better external compression should bleeding or inadvertent arterial puncture occur. It is important to realize that there is no uniform agreement on site selection in these cases; however, it is also important to understand the problems that may occur when one does not have access for compression should bleeding occur.30 Coagulopathy is not an absolute contraindication to SV catheterization; experience and adherence to safe technical principles are key.
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