Central Venous Catheterization

CHAPTER 3 Central Venous Catheterization



Ronald F. Parsons, Kristoffel R. Dumon




Case Study


A 68-year-old male undergoes an emergent left hemicolectomy for colonic ischemia. His postoperative course is complicated by a persistent ileus and supplemental oxygen requirement. On the seventh postoperative day, he is transferred to the intensive care unit after he has progressive hypotension, oliguria, and respiratory distress, necessitating intubation. The attending surgeon requests that a triple-lumen central venous catheter be placed to monitor central venous pressures and administer total parenteral nutrition.




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).


image image

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



I. Vascular Access: CVCs provide durable venous access in patients who have limited peripheral options. The anticipated length of time during which access is required plays a role in the selection of the type of catheter and the insertion site. For example, femoral access is often an appropriate option for short-term emergent access; however, associated risks preclude long-term maintenance. Many vasoactive and chemotherapeutic agents require central administration because peripheral extravasation of pressors or vesicants can result in significant tissue damage. Additionally, peripheral administration of high-osmolarity total parenteral nutrition is associated with complications, including thrombophlebitis and extravasation, and therefore must be administered centrally.

II. Hemodynamic Monitoring: Transduction of central venous pressure waveforms through a CVC allows for continuous monitoring of volume status and right heart function.

III. Plasmapheresis, Hemodialysis, or Continuous Renal Replacement Therapy: Exchange of blood components requires central venous access in the form of a large-bore catheter.


PREPROCEDURE EVALUATION



I. History: A history of deep venous thrombosis, coagulopathy, previous or unsuccessful CVC placement, and previous surgery should be elicited.

II. Physical Examination: The patient is examined for evidence of previous CVC placement and signs of central venous occlusion (e.g., upper extremity swelling and superficial venous collaterals).

III. Laboratory Evaluation: Thrombocytopenia and coagulopathy are relative contraindications to CVC placement. Optimally, the platelet count and international normalized ratio should be corrected to more than 50,000 and less than 1.5, respectively. In certain circumstances, CVC placement may be necessary with a less optimal coagulation profile.



What is your patient’s platelet count and international normalized ratio?



COMPONENTS OF THE PROCEDURE AND APPLIED ANATOMY



Preprocedure Evaluation


Site selection should be given careful consideration before CVC placement. SC access is associated with low rates of catheter-associated bloodstream infections, but relatively high rates of placement-related complications (e.g., pneumothorax). IJ access is associated with a lower rate of pneumothorax, but a higher rate of infection compared with SC access. Femoral venous catheters are relatively easy to place; however, they are associated with higher rates of thrombosis and infection and should generally be used only for short-term or emergent access.

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May 26, 2018 | Posted by in GENERAL SURGERY | Comments Off on Central Venous Catheterization

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