Central  lines  in  anesthesia:  choices,  techniques  &  pi4alls  IAN  HEWER,  MA,  MSN,  CRNA  

ASSISTANT  Director,  WCU  NURSE  ANESTHESIA  PROGRAM  

OBJECTIVES  

•  IDENTIFY  REASONS  FOR  CENTRAL  LINE  ACCESS  •  IDENTIFY  COMMON  SITES  &  MAJOR  LANDMARKS  FOR  CENTRAL  LINE  PLACEMENT  

•  LIST  FREQUENT  COMPLICATIONS  OF  CENTRAL  VENOUS  ACCESS  &  WAYS  TO  AVOID  THEM  

HISTORY  

• 1656-­‐  original  infusions  of  wine,  ale,  &  opiuminto  dog

• 1680s-­‐  animal  blood  into  humans-­‐  results  ledto  unpopularity!

HISTORY  

• 1700-­‐1800s-­‐  various  experiments  to  measurearterial,  venous  &  cardiac  pressures

• First  experiments  in  early  20th  century  inGermany

• Wanted  a  way  to  introduce  emergency  drugsclose  to  the  heart  (Forssmann,  1929)

HISTORY  

• 1940s-­‐  introducbon  of  PVC  catheters  for  IVsrevolubonizes  field

• 1956-­‐  Cournand,  Forssman    &  Richards  wonNobel  Prize  for  Medicine

Further  development  

• Locabons:  – Infraclavicular  subclavian-­‐  1952  Aubaniac  – Internal  jugular  approach-­‐  1968  English  

• Why?  – Nutribon  – Chemotherapy  – Direct  access  for  drugs  

CVCs  today  

• >  5  million  placed/year  in  the  US  alone  (McGee  &  Gould,  2003)  

• >  15%  have  complicabons  

–Mechanical-­‐  5-­‐19%  

– Infecbous-­‐  5-­‐26%  

– Thrombobc-­‐  2-­‐26%  

implicabons  

• Significant  morbidity-­‐  potenbally  >750,000  have  complicabons  

• Significant  cost-­‐  $16,550/  infecbon  (CDC,  2011)  

• Reducbon  in  CLABSI  2001-­‐2009-­‐  save  $2  billion  in  excess  costs  &  6000  lives  

Major  uses  

• Access  – Poor  peripheral  – Need  for  volume..?  

Side  note:  Fr  vs  gauge  

• French  relates  to  external  diameter,  &  is  a  mulbple  of  3  – 1  Fr  =  .33mm  OD,  3  Fr  =1  mm  OD,  6  Fr  =  2  mm  OD  etc  

– DOES  NOT  INDICATE  INTERNAL  DIAMETER!!  

• Gauge  refers  to  internal  &  external  diameter..kind-­‐of..  – E.g.  14  G  =  2.1mm  OD  &  1.6mm  ID.  Similar  to  6  Fr  OD  

Major  uses  

• Determinabon  of  CV  funcbon  

– CVP  measurement  

– PA  catheter  placement  

• Nutribon  

Not  much  of  a  decision  

• Ultrasound  vs  Landmark  

• Less  arterial  punctures  

• Less  overall  sbcks  

• Beoer  first  aoempt  success  

• Quicker  

Remember..  

• There  is  a  learning  curve!  

Classic  “central”  approach  • Idenbfy  the  triangle  formed  by  clavicular  head/ sternal  head  of  the  sternocleidomastoid  Vein  is  typically  anterior  &  lateral  to  artery  at  the   level  of  cricoid  carblage    

• Lower  down  the  neck,  the  vein  becomes  relabvely  medial,  &  risk  of  pneumothorax

 increases-­‐  stay  away!  

• Higher  up  the  neck,  the  risk  of  brachial  plexus   or  phrenic nerve injury increases-stay away!  

phrenic  nerve  injury  increases-­‐  stay  away!  

Clavicle

Jugular vein

Carotid artery

_,,___Sternal notch

A Sternocleidomastoid muscle

Who  needs  to  see?!  

Mechanical  complicabons  

• Arterial  cannulabon/  injury  – Puncture:  6.3-­‐  9.4%  (McGee  &  Gould,  2003)  – Cannulabon:  most  recent  work,  incidence  of  1%,  but  range  from  .07-­‐1%  (Bowdle)  

– Closed  claims  data  not  encouraging!  • 5/14  died  

– Other  risks  include  stroke  &  addibonal  surgery,  LOS  

5353

Absent internal jugular vein: Another case for ultrasound guided vascular access

Sir,We describe a case of absence of right internal jugular

vein (IJV), which is a rare form of anatomical variation of the IJV. A 65-year-old male patient was admitted to the intensive care unit (ICU) with the complaints of fever and hypotension. The ICU resident placed a central venous catheter (CVC) in left IJV as he was unable to visualize the right IJV on ultrasound. On the 10th ICU day, the CVC insertion site was found to be inflamed, and it was decided to resite the catheter on the right side.

The right side of the neck was examined carefully, and no evidence of scarring suggesting previous surgery or cannulation was seen. The ICU consultant scanned the right side of the neck carefully using a portable ultrasound (US) machine (IMAGIC Agile, Kontron Medical, WA, USA) with a linear, high frequency transducer (7.5–12 MHz). Care was taken to apply minimal pressure on the probe to prevent collapse of the IJV. Imaging showed a single pulsatile vessel, which was non compressible suggestive of the carotid artery with

no evidence of the IJV [Figure 1]. Doppler confi rmed thecharacteristic pulsatile blood flow in the carotid artery. The 2D US imaging on the left side showed normal anatomy with good size IJV [Figure 2]. Subsequently, the CVC was placed in the right axillary vein under real-time US guidance in a single attempt.

Landmark guided central venous cannulation is based on the premise of normal anatomy of the vein and its adjoining structures. In a study on long-term hemodialysis patients, the incidence of signifi cant US findings such as total occlusion, nonocclusive thrombus and stenosis was seen to be as high as 35%.[1] Agenesis or hypoplasia of the central veins though rare is another probable cause of failed cannulation in patients where US guidance is not used. In our patient, the possible absence of the vein can be explained by IJV agenesis, which represents a form of truncular venous malformation due to a developmental arrest during the later stages of embryonic development, which could lead to either aplasia or hypoplasia of the vein.[2] Denys and Uretsky studied 200 patients undergoing IJV cannulation under US guidance and found that in 2.5% of the patients, the IJV was not visualized.[3] Absence of the right sided IJV has also been reported in a 12-year-old boy during US evaluation prior to attempted cannulation.[4] In another report, IJV agenesis was discovered during neck dissection. Patients who require removal of IJV due to disease infiltration may have potentially life-threatening complication of cerebral edema if the other IJV is aplastic.[5]

Letters to the Editor

Figure 1: Ultrasound image of the right side of the neck showing absence of internal jugular vein. CA: Carotid artery

Figure 2: Ultrasound image of the left side of the neck showing normal anatomy. CA: Carotid artery; IJV: Internal jugular vein

Next  step  

• Scan  neck  up  &  down  above  “standard”  entry  site  to  visualize  course  of  vein  &  artery  

• Local  anesthebc?  • As  early  as  possible  

   

Next  step  

 • Center  vein,  enter  at  30-­‐45  degree  angle  about  1cm  away  from  probe  

• Enter  medial  to  guide  line,  aim  slightly  lateral  

• Ideally,  follow  needle  bp  “down”  to  vein  

• Watch  screen,  but  aspirate  as  you  advance  

   

A  word  about  sedabon..  

• Less  is  more  

• With  good  LA,  should  not  be  painful  

Next  step  

• Enter  vein  using  either  “big”  needle  or  some  prefer  18G  catheter;  advantages  to  both    – Catheter-­‐  less  prone  to  pop  out  of  vein,  but  can  be  more  difficult  to  advance  

– Needle-­‐  good  flow,  easy  to  advance  wire  BUT  must  keep  very  sbll  

• Advance  wire-­‐  MUST  THREAD  EASILY  

• Need  to  check  for  venous  placement  

Placing  the  line  

• Triple  lumen  – Scalpel/dilator/line  – Secure  around  15cm  

• Introducer/Swan  – Line  is  on  dilator  – Remember  the  dilator  is  rigid  &  pointy!  – Line  goes  to  hub    

• Both-­‐  ensure  wire  is  free  as  you  advance  line  

Leu  IJ  lines  

• Increased  risk,  but  beoer  choice  in  some   people  -Shorter  length  to  subclavian-­‐  extra  care  with   dilator,  &  may  need  to  pull  back  introducer  for   Swan  -Increased  risk  of  lung  injury  

• Risk  of  thoracic  duct  injury    

More  bad  things  about  the  leu  

• Vein  crosses  over  artery  more  easily  with  turning  head  

• Unfamiliarity  

Subclavian  lines  • Small  roll  between  shoulders-­‐  improves  access  

• Midpoint  of  clavicle,  2-­‐3  cm  back  – Aim:  to  avoid  poinbng  needle  down  – Some  clinicians  bend  needle  for  same  effect  

• Point  needle  towards  sternal  notch

 – Some  hold  leu  hand  on  notch  to  keep  “target”

 • Advance  needle  with  negabve  pressure  • unbl in vein  

 in  vein  

Subclavian  bps  

• Must  use  needle-­‐  catheter  may  kink  

• If  unsuccessful,  point  needle  more  cephalad  

• Keep  passes  to  minimum;  avoid  bilateral  aoempts  

More  subclavian  bps  

• If  line  is  for  thoracic  surgery,  on  same  side  

• If  pt  has  pathology  in  one  lung  (e.g.  pneumothorax),  line  on  same  side  

• Wire  may  not  go  where  you  want  it  

– If  pt  is  awake,  ear/  neck  pain  may  indicate  wire  in  IJ  

– If  pt  is  asleep,  look  for  ectopy  – Always  X  Ray  

Subclavian  &  U/s  

• Not  typically  recommended  

• Can  be  useful  to  idenbfy  normal  anatomy  prior  to  starbng  procedure  

No  complicabons  with  u/s..?  

Accidental Carotid Artery Catheterization

During Attempted Central Venous Catheter

Placement: A Case Report

Pauline Marie Maietta, CRNA, MS

More than 2.1 million central venous catheters are

placed annually. While carotid artery cannulation is

rare, its effects can be devastating. Anesthesia provid-

ers frequently work i/v/frt central venous catheters in

the perioperative setting. Therefore, it is imperative

that they be able to identify and react appropriately to

carotid artery injury both in preexisting central lines

and those that they have placed.

This case report details a case of accidental carotid

artery catheterization during attempted right internal

jugular vein catheterization and the steps taken to

treat the patient following its recognition. A discus-

sion of technique for central venous catheterization,

indications for suspicion of arterial puncture, methods

for confirming venous or arterial placement, appro-

priate methods for management of carotid artery

cannulation, and the benefit of ultrasound in central

venous cannulation follow. Through the appropriate

use of equipment, early detection and management

of carotid artery injury, and proper training, patient

outcomes may be improved.

Keywords: Carotid artery catheterization, central

venous catheter, complication, ultrasound.

Anesthesia professionals commonly work

with and place central venous catheters

(CVCs). Although carotid artery cannula-

tion is a rare complication associated with

central line placement, its occurrence can

be devastating to the patient. It is therefore important for

anesthesia providers to appropriately identify and manage

complications associated with an improperly placed cath-

eter and to be knowledgeable of tools and techniques that

can help prevent future carotid artery catheterizations.

CVCs are commonly placed for: central venous pressure

monitoring; infusion of ñuids, medication, and nutrition:

aspiration of air emboli; insertion of transcutaneous pac-

ing leads; insertion of pulmonary artery catheters; and

temporary hemodialysis (Table 1).

The right internal jugular (RIJ) vein has been the pre-

ferred site for central venous access'" since the central

landmark technique was first described in 1969.^ This

site is often chosen over other central line insertion

sites because of its readily identifiable landmarks, short

direct route to the junction of the superior vena cava

and right atrium, distance from the thoraeic duct, and

its ease of access for the anesthesia provider.' Although

CVCs placed in the internal jugular vein are assoeiated

with a high suecess rate, catheterization of the internal

jugular vein is also associated with various technique-

related complications.'^ Complications of internal jugular

cannulation include infection, embolism, dysrhythmia,

hematoma, pneumothorax, eardiac perforation, cardiae

tamponade, trauma to nearby nerves or arteries, throm-

bosis, and fistula formation (Table 2).'-^ According to

Tom Richardson, Northeast regional district representa-

tive of CVC manufacturer, Arrow International, Boston,

Massachusetts, via a phone conversation, more than 2.1

million CVCs are placed annually. While carotid artery

complieations are 1 of the 3 most common complieations

assoeiated with central venous eatheterization,^ eannula-

tion of the earotid artery by a large bore catheter is less

frequent, occurring in 0.1% to 0.5% of cases.**

Case Summary

A 77-year-old male presented to the emergency depart-

ment (ED) following progressive shortness of breath for

several days and chest pain upon exertion. His medical

history included diabetes mellitus, coronary artery

disease, atrial fibrillation, chronie obstructive pulmonary

disease, and ehronic bronchitis. He had an 80 pack year

smoking history and had been receiving 2.5 L of oxygen

via nasal eannula at home for 6 months before presenta-

Venous access in patients with poor or no previous access

Rapid fluid resuscitation (as in hypovolemia or shock)

Monitoring of central venous pressure and or puimonary artery

catheterization for comprehensive cardiac monitoring

Infusion of caustic drugs, vasoactive drugs, or total parenteral

nutrition

Temporary hemodialysis access

Aspiration of air emboli ¡n the event of venous air embolism

Insertion of transcutaneous pacing leads

Table 1. Indications for Central Venous

www.aarna.com/aanajournalonline

AANA Journal m August 2012 • Vol. 80, No. 4251

(Maieoa,  2012

)  

U/s  examined  • Operator  error  could  be  an  issue  

• We  cannot  see  whole  length  of  wire  • Pressure  transducbon  could  prevent  arterial

 cannulabons  not  detected  by  other  means-­‐  approx  0.8%  of  all  aoempted  (Ezaru,  2009)  – That’s  potenbally  40,000  cases/yr!!  

• Should  we  use  pressure  measurement  for  all?

 

residents placing the CVC in each of the six cases were credentialed by their hospital in emergencyultrasound based on American College of Emergency Physicians ultrasound criteria. All residentsreceived a 2-day introductory ultrasound course, which included 3 hours of didactic and hands-oneducation in ultrasound-guided vascular access. Table 3 summarizes each of the six cases, including asanalysis of the error based on a video review of the ultrasound-guided arterial cannulation.

Age Mechanism of injury Outcome 67 Needle went through IJ into Carotid artery Patient Died 75 Needle went though femoral vein into

femoral artery Vascular surgery for AV fistula

48 Needle went though IJ and entered carotid artery sitting underneath the IJ

Surgery for tear and focal dissection of carotid artery

67 Guidewire traveled through IJ and its posterior wall and into carotid artery

Hematoma with respiratory distress requiring emergent intubation.

69 Needle penetrated the carotid artery which was very close to the IJ

Emergency carotid artery repair; Patient died of complications

14 Needle penetrated rear wall of IJ and entered carotid artery

Central line removed and bleeding eventually stopped

Table 3: Analysis of six accidental arterial cannulations with dynamic ultrasound guidance

The mechanism of injury in 5 of the 6 cases involved passage of the needle through the vein, out itsposterior wall, and into the artery. This highlights the importance of confirming the location of the tip ofthe needle prior to inserting the guidewire. The author concluded, “In summary, the short-axis approach,as seen in this series, can provide a false sense of security to the practitioner and allows for potentiallydangerous accidental arterial cannulation…it may be prudent to not only visualize the entire path of theneedle with the long-axis approach but also confirm correct cannulation by tracing the guidewire in the long axis before line placement.” However, it is important to realize that even with multiple ultrasoundviews of needles or wires, misdiagnosis remains a possibility. For example, as noted in the case below (see Figure 6), it is possible for a needle and wire to pass through the internal jugular vein and into thesubclavian artery, which may not be possible to visualize with ultrasound because of interference fromthe clavicle.

Parsons and Alfa reported a case of inadvertent arterial cannulation despite the use of ultrasoundguidance in a 34-year old with chronic renal failure undergoing renal transplantation29. The arterialcannulation was eventually discovered by transducing the pressure in the lumen of a 7 Fr catheter. Theauthors proposed that the introducer needle was correctly placed in the internal jugular vein underultrasound guidance, but later shifted during guidewire insertion, at which point ultrasound had beendiscontinued (Figure 2). The authors noted, “Movement may still occur with migration of the needleoutside the vein during the Seldinger technique, resulting in wire malposition. We suggest that re-imagingthe vein and confirming the presence of the guidewire in the internal jugular vein prior to dilation mightprevent catheter placement into the carotid artery. We should be aware that US techniques do notremove all risks associated with CVC insertion.” Other case reports of arterial cannulation duringattempted cannulation of the internal jugular vein under ultrasound guidance have described similarerrors (passage of the introducer needle though a vein and into the underlying artery) and reached similarconclusions (confirm that the needle tip and/or guidewire are in a vein prior to placing the catheter)30,31.

Source:  Bowdle,  nd  

Some  general  comments  About  complicabons  

• Site  dependent  

• Provider  dependent-­‐  VOLUME  OF  PROCEDURES  

• Procedure  dependent  

Our  study  

• Wanted  to  examine  complicabon  rates  in  CVCs  placed  by  CRNAs  vs  MDs  

• Easy  access  to  QI  database  

• Problem  – Polibcal  – Numbers-­‐  a  vicbm  of  our  own  success  

Major  complicabons  

 • Mechanical  – Vessel  or  nerve  injury  – Pneumothorax/  hemothorax  

• Infecbous  

• Thrombobc  

Mechanical  complicabons  

• Vein  injury  – Vein  is  thin  walled  relabve  to  artery-­‐  more  prone  to  damage  

– Can  be  acute  during  line  placement  – Or  later  as  result  of  erosion  

What  we  found  

• Hematoma-­‐  1/359  (.003%)  

• Cannulabon-­‐  0  

Pneumothorax  

• Incidence  varies  according  to  site  (duh!)  

• Commonest  with  subclavian  (1.5-­‐3.1%)  

• Rare  but  seen  with  IJ  (.2%)  

What  we  found  

• 9/359  pts  =  2.5%  

• Typical  incidence  =  0.1-­‐0.2%  

• BUT  rate  of  ptx  in  cardiac  surgery  =  0.7-­‐5.3%  (higher  with  IMA  harvest)  (Weissman,  2004)  

hemothorax  

• Result  of  vessel  injury,  typically  venous  

• Rare,  but  significant  mortality  (92%  in  Closed  Claims)  

• Remember:  veins  are  fragile  

Thrombobc  complicabons  

• Significant  issue  outside  of  the  OR  

• Incidence  cited  varies  e.g  1.9%  of  subclavian  lines  (McGee,  2003)  

• With  thrombosis  comes  risk  of  embolizabon  

• Probably  related  to  durabon  

Thrombosis:more  

• Contact  with  vein  wall  is  probably  a  big  risk  for  thrombosis  (Fletcher  &  Bodenham,  2000)  

• Therefore  posiboning  is  key  

• Think  post-­‐op  CXR  

Infecbous  complicabons:  background  

• Interest  in  Healthcare  Acquired  Infecbons  (HAI)  has  increased  dramabcally-­‐  in  response  to  the  problem  

• Priority  of  WHO,  IOM,  CDC,  TJC,  &  a  hospital  near  you..  

• 1.7  million  infecbons  &  99,000  deaths  in  the  US  from  HAI  (TJC,  2012)  

Infecbon:  cvcs  

• CLABSI:  Central  Line-­‐  Associated  Blood  Stream  Infecbon  

• Est  80,000  CLABSI/  year  in  ICU  alone  

• Mortality:  difficult,  but  maybe  10,000  yr  

• Cost  significant:  >$16,000  per  case  

• Source  TJC,  2012  

More  specifics  

• Most  risk  =  femoral  line  

• Next,  Internal  Jugular-­‐  ?  Due  to  proximity  to  mouth  

• Least  risk  =  subclavian  

What  we  found  

• 2  infecbons  (.006%)  

• Preliminary:  no  associabon  with  “difficult  inserbon”,  second  line(31  pabents),  diabetes  or  line  durabon  

• ..but  average  line  durabon  3.03  days  

Chapter 1: Types of Central Venous Catheters and Risk Factors for and Pathogenesis of CLABSIs

5

● Heavy microbial colonization at insertion site, whichis closely related to the site chosen for insertion; den-sity of skin flora is higher at the base of the neck,where internal jugular CVCs are inserted, than at theupper chest, where subclavian CVCs areinserted.24,33,34

● Multilumen CVCs7,24

● Lack of maximal sterile barriers (cap, mask, sterilegown, sterile gloves, and a sterile full body drape) forthe insertion of CVCs or guidewire exchange35,36

● CVC insertion in an ICU or emergency depart-ment23,25,37,38

Also, as will be described in Chapter 2, staff who insert andmaintain CVCs must receive education and training to ensurecompetence and minimize the risk of CLABSI in theirpatients; a sufficient nurse-to-patient ratio is also important tominimize risks for patients with CVCs. A more in-depth dis-cussion regarding education and training and their roles inpatient safety initiatives can be found in Chapter 4.

Chapter 3 contains a comprehensive review of the recom-mended strategies and techniques for preventing CLABSIs.

Pathogenesis of CLABSIsCVCs can become contaminated with microorganisms viatwo major routes7,39–42 (also see Figure 1-1 below):1. Extraluminally:

● The patient’s skin organisms at the insertion site canmigrate along the surface of the catheter into the cuta-neous catheter tract surrounding the catheter, resultingin colonization at the catheter tip. For short-termcatheters (nontunneled CVCs in place less than 10days), this is the most common source of infection.

2. Intraluminally● Most commonly, direct contamination of the

catheter or at any point along the fluid pathwaywhen the IV system is manipulated (as might occurwhen health care personnel have hand contact withIV solution connection sites, access hubs, needlelessconnectors, or tubing junctions, or contaminationwith the patient’s own body fluids or skin). Thisroute has been associated with more prolonged CVCdwell time (for example, in place for more than 10days), including tunneled CVCs such as Hickman-and Broviac-type catheters and PICCs.

Figure 1-1. Routes for Central Venous Catheter Contamination withMicroorganismsPotential sources of infection of a percutaneous intravascular device (IVD): the contiguous skin flora, contamination of thecatheter hub and lumen, contamination of infusate, and hematogenous colonization of the IVD from distant, unrelated sites ofinfection. HCW: health care worker.

Source: Crnich CJ, Maki DG. The promise of novel technology for the prevention of intravascular device-related bloodstream infection. I.Pathogenesis and short-term devices. Clin Infect Dis. 2002 May 1;34(9):1232–1242. Used with permission.

Source:  TJC,  2012  

What  can  we  do?  • Is  the  line  really  needed?

– Minimum  number  of  lumens

• Hand  hygiene

• Asepbc  techniqueo Maximal barrier techniqueo Right prepo Antibiotic impregnated line/dsg

 

–    

• Ultrasound-­‐  diminished  #  of  aoempts  

A  word  about  scrub  the  hub!  

• Focus  of  TJC  in  recent  years  

• Anesthesia  compliance…sub-­‐opbmal!!  

• 15  second  scrub  with  alcohol  

• ..or  the  “orange  cap”  

Miscellaneous  issues  

• Experience  – Like  surgical  cases,  experience  counts  – Sznajder  et  al  (1986)-­‐  Experience  with  >  50  CVCs  =  ½  rate  of  complicabon  compared  with  <  50  CVCs  

– >  3  aoempts  =  8  x  mechanical  complicabon  rate  

• Quesbon:  should  everybody  put  in  lines?  

In  closing  

• U/S  may  not  be  essenbal,  but  does  offer  benefits  

• Consider  using  manometry  to  check  placement  even  with  U/S  

• HAND  HYGIENE!!  (Scrub  the  hub  too)  

references  • Aljure,O.,  Casbll-­‐Pedraza,  C.,  Mitzova-­‐Vladinov,  G.,  Maraeta,  E.  (2015).  Right  internal  jugular  cross-­‐secbonal  area:  is  there  an  

opbmal  area  for  cannulabon?  Jnl  of  the  Associa1on  for  Vascular  Access  20(1):  22-­‐25.  • Bowdle,  TA.  Arterial  cannula1on  during  central  line  placement:  mechanisms  of  injury,  preven1on  &  treatment.• Ezaru  et  al.  (2009).  Eliminabng  arterial  injury  during  central  venous  catheterizabon  using  manometry.  Anesth  Analg  109:

130-­‐4.  • Fletcher  &  Bodenham.  (2000).  Safe  placement  of  central  venous  catheters:  where  should  the  bp  lie?  Brit  Jnl  Anaes  85:  

188-­‐91.  • Hamilton  &  Bodenham  (eds).  (2009).  Central  venous  catheters.  Chichester:  Wiley  Blackwell.• Maieoa.  (2012).Accidental  carobd  artery  catheterizabon  during  aoempted  central  venous  catheter  placement:  a  case  

report.AANA  Jnl  80(4):  251-­‐  255.  • McGee  &  Gould.  (2003).  Prevenbng  complicabons  of  central  venus  catheterizabon.  NEJM  348:  1123-­‐33  • Seo  et  al.  (2008).  Perforabon  of  the  superior  vena  cava  during  liver  transplantabon:  a  case  report.  Korean  Jnl  Anesth  55(4):  

506-­‐10  • Sznajder  et  al.  (1986).  Central  vein  catheterizabon:  failure  &  complicabon  rates  by  3  percutaneous  approaches.  Arch  Int  Med

146:  259-­‐61.  • The  Joint  Commission.  (2012).  Preven1ng  central-­‐line  associated  bloodstream  infec1ons:  a  global  perspec1ve.  OakBrook,  Il:  

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