Central Venous Catheter Insertion

CHAPTER 211 Central Venous Catheter Insertion

Over the past several decades, the use of central venous catheters has increased to keep pace with other medical and technological advances. Emergency resuscitation protocols, specialized cardiovascular monitoring techniques, transvenous pacer insertion, and total parenteral nutrition protocols all demand access to a large central vein.

Expeditious placement of a large central venous catheter presents a challenge to the clinician, because the central veins are neither readily visible to the eye nor distinctly palpable. If the patient is critically ill or hypovolemic, the challenge is magnified. Fortunately, the larger central veins have predictable and constant relationships to readily identifiable anatomic landmarks.

In recent years, increasing emphasis has been placed on using ultrasound to guide placement of central venous catheters (see Chapter 225, Emergency Department, Hospitalist, and Office Ultrasonography [Clinical Ultrasonography]). Although ultrasonic guidance was not considered the standard of care in a recent informal survey of hospitalists, recent Medicare guidelines suggest monitoring very closely for iatrogenic puncture wounds of vital organs in hospitalized patients.

NOTE: Remember that a short, large-diameter IV catheter (e.g., 14-, 16-, or 18-gauge peripheral catheter) has less resistance to flow than a long, skinny central catheter! Rapid, large-volume infusion is faster with a peripheral, large-bore catheter and is preferred in an emergent situation. Depending on local availability and expertise, newer kits are available to rapidly and dependably obtain intraosseous vascular access (IOVA; see Chapter 198, Intraosseous Vascular Access). In some facilities, this has become the preferred temporary backup or alternative to obtaining central or peripheral venous access, especially in children (see Chapter 182, Pediatric Arterial Puncture and Venous Minicutdown).

Indications

• Venous access in those patients who are either so obese or so debilitated that their peripheral veins are not accessible for intravenous (IV) cannulation

• Emergency venous access after a cardiac arrest

• Administration of cardiac medications during cardiopulmonary resuscitation (CPR)

• Large-volume parenteral fluid administration when peripheral IV cannulation is not readily obtainable

• Central venous pressure monitoring

• Administration of certain chemotherapeutic agents

• Administration of vasopressor medications

• Administration of hyperosmolar or other irritating solutions (e.g., total parenteral nutrition) that have the potential to cause thrombophlebitis or to cause soft tissue necrosis if extravasation occurs

• Patients with significant burns on peripheral areas that may prevent placement of a peripheral catheter

• Placement of a pulmonary artery (Swan-Ganz) catheter (see Chapter 215, Swan Ganz [Pulmonary Artery] Catheterization)

• Placement of a temporary transvenous pacemaker wire (see Chapter 216, Temporary Pacing)

• Performance of right cardiac catheterization and pulmonary angiography

• Performance of hemodialysis or plasmapheresis

Contraindications

Absolute

• Patient refusal

• Combative or agitated patient (may require procedural sedation, see Chapter 2, Procedural Sedation and Analgesia)

• Distortion of local anatomy or landmarks (e.g., prior surgery, trauma, radiation therapy, generalized obesity, orthopedic conditions, masses)

• Superior vena cava syndrome

• Bleeding diathesis or excessive anticoagulation and a noncompressible vessel

• Full-thickness burn or cellulitis over the proposed insertion site

• Pneumothorax or hemothorax on the contralateral side, or inability to tolerate a pneumothorax on the ipsilateral side (for subclavian and internal jugular locations)

• Prior injection of a sclerosing agent into the proposed vein

• Trauma to the proposed insertion site

• Venous thrombosis of the proposed vein

• Avoid internal jugular location if cervical spine fracture or penetrating neck injury

• Allergy to any component of the catheter such as latex

• Cardiac-paced patient (for Seldinger wire technique, whether pacer temporary, internal, or permanent)

• Highly unstable arrhythmias (for Seldinger wire technique, especially ventricular arrhythmias)

• Right-sided endocarditis or mural thrombus

Relative

• Suspected injury to proposed vein (may then use vein on contralateral side, if no associated hemothorax or pneumothorax, when using subclavian or internal jugular)

• Morbid obesity

• Marked cachexia

• Vasculitis that predisposes to sclerosis or thrombosis of veins

• Previous long-term central catheterization or recently discontinued central catheter in proposed vein

• Proposed mastectomy on same side of subclavian vein access

• Patients receiving ventilatory support with high end-expiratory pressures (if possible, for suclavian or internal jugular, ventilation should be briefly interrupted while central vein is cannulated with needle)

• Patients undergoing CPR (should use femoral or internal jugular vein locations)

• Children younger than 2 years old (for whom the internal jugular vein is preferred location)

• Severe hypovolemia (try large bore peripheral IV or IOVA first)

• Prosthetic right heart valve (Seldinger wire technique contraindicated)

• Avoid internal jugular or subclavian vein locations if patient unable to lie in the Trendelenburg position

• Left bundle branch block (use of Seldinger wire can cause complete heart block)

• Avoid internal jugular location if known severe carotid artery stenosis or atherosclerosis on the desired side (accidental artery puncture may result in plaque rupture and stroke)

• Personnel capable of handling complications not immediately available

Equipment

Many commercially prepared central venous catheter kits are available. Most institutions have a relationship with a hospital supplier that provides a catheter kit. These kits, often from a company such as Baxter or Cook, have all the components needed to insert a central venous catheter. These kits often utilize a Seldinger wire technique to place the catheter: a needle enters the vein, a guidewire is threaded through the needle into the vein lumen, and the cannulating needle is removed. A larger, flexible catheter is then passed over the guidewire into the vein, and the guidewire is removed.

• IV solution and connector tubing, flushed and ready

• Pressure transducer and monitor, if monitoring central venous pressure

• Supplemental oxygen

• Continuous pulse oximetry and cardiac and blood pressure monitoring

• Fully stocked code cart and defibrillator nearby

• Surgeon’s cap

• Sterile gloves and gown

• Sterile drapes

• Bio-occlusive dressing (e.g., Tegaderm, Opsite) to cover insertion site, especially useful if clear so the wound can be more easily inspected

• Goggles or eye protection

If a commercially prepared kit is unavailable, the following equipment list will supply what is needed:

• Sterile prep solution (chlorhexidine antisepsis preferred over povidone–iodine solution) and swabs

• Sterile 4 × 4 inch gauze pads

• Lidocaine 1% to 2% with or without epinephrine for local anesthesia

• 3-mL syringe with 25-gauge needle for anesthetic injection

• 5-mL syringe with 22-gauge

-inch seeker needle to find the vein

• 10-mL syringe with

-inch 18-gauge needle to introduce guidewire

• No. 11 scalpel blade and holder

• Guidewire or J-wire (flexible wire 45 cm long, 0.089 cm diameter, 3 mm radius of curvature)

• Central venous catheter

• 3-0 silk suture on straight needle to suture catheter into place

• Suture scissors

• Topical antimicrobial ointment

• Saline flushes

Preprocedure Patient Education

If the clinical situation permits, informed consent must be obtained prior to the procedure. Inform the patient (or family) of potential major complications and their management, which could require chest tube insertion, surgery, or cardioversion. To minimize patient anxiety during procedure, explain the major steps of the procedure, the possible necessity of remaining in a head down (Trendelenburg) position during placement, and the near impossibility of a completely painless procedure.

Techniques

Several distinct approaches are discussed for placement of a central venous catheter. These approaches include cannulation of the subclavian vein (using both the supra- and infraclavicular routes), the internal jugular vein, and the femoral vein.

Generally, the preferred veins are on the right side of the patient. This preference is because the right-sided veins have a more direct course to the right atrium, and thus can be utilized for placement of a pacemaker wire or Swan-Ganz catheter with greater ease than the left-sided veins. The left-sided veins tend to have a more tortuous course and are in closer proximity to the thoracic duct and dome of the lung pleura.

The internal jugular vein is accessible without terminating CPR, although chest compressions and the lack of a carotid pulse may make access more difficult. However, having an internal jugular line requires limited patient neck mobility, which can be uncomfortable, so the subclavian route may be preferable for long-term lines. Likewise, a femoral line limits ambulation, so the subclavian route may be preferable. Ongoing or impending thrombolytic or fibrinolytic therapy is a contraindication to internal jugular puncture. Femoral vein access may be the easiest to obtain and may be preferable in emergencies or during CPR. It may also be preferred for patients with respiratory distress and pulmonary edema because the patient should not be placed in the Trendelenburg position. Supplemental oxygen should be provided and the patient monitored continuously during this procedure. Passage of a guidewire into the right side of the heart can induce arrhythmias and complete heart block; the clinician should be prepared to treat these problems accordingly.

Subclavian Venipuncture

The subclavian vein begins as a continuation of the axillary vein at the lateral border of the first rib, and it joins the internal jugular vein to form the innominate vein (Fig. 211-1). As it crosses behind the first rib, the subclavian vein lies posterior to the medial third of the clavicle. It is only in this “middle region” that an intimate relationship exists between the subclavian vein and the clavicle. The subclavian vein contains no valves and is between 1 and 2 cm in diameter for most people. The subclavian artery is superior and posterior to the vein, and is separated from the vein by the anterior scalene muscle. Other important structures nearby include the phrenic nerve; the thoracic duct (left side); lymphatic duct (on the right side, it joins the subclavian vein near its merger with the internal jugular vein); and the dome of the pleura of the lung. The dome of the pleura may extend above the first rib on the left side but is rarely found this far cephalad on the right.

Figure 211-1 Relationship of great vessels in and about the right neck.

Patient Position

Proper positioning of the patient increases chances of a successful cannulation and reduces risk of complications of this procedure. Place the patient in Trendelenburg position at an angle of 15 to 20 degrees (Fig. 211-2). This position fills these low-pressure great veins by gravity, thus making them swell in diameter and increasing your chances of finding them. It also reduces the risk of air embolism.

• Have the patient turn his or her head contralaterally. (Have an assistant turn the head if the patient is unable to do so.) This gives a wider field of operation.

• Consider placing a rolled-up towel vertically between the patient’s shoulder blades. This may cause the shoulders to fall back from the clavicles, which could help to define the relevant anatomy and improve access the subclavian vein. However, it should be noted that certain experts avoid placing a towel between the shoulder blades because it can decrease the distance between the clavicle and first rib, thereby compressing the subclavian vein and making it more difficult to cannulate.

Figure 211-2 Moderate Trendelenburg position for subclavian central vein catheter insertion.

Supraclavicular Approach to the Subclavian Vein

This approach may sound complicated, but the author believes it to be the least complicated and most efficient technique. It is rapid, stays away from other vital structures, and is easily performed in patients undergoing CPR. Additionally, it is easily and reliably performed in an obese patient.

1 With the patient in the previously described position, locate the insertion area: a spot 1 cm lateral to the lateral head of the sternocleidomastoid muscle and 1 cm superior to the clavicular border (Fig. 211-3).

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May 14, 2017 | Posted by admin in GENERAL & FAMILY MEDICINE | Comments Off

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