Central Venous Access

Slides Courtesy of : Joan Hoch Kinniry ACNP-BC

Lead Practitioner , Critical Care Medicine, Procedure and Resuscitation Service

Office of Graduate Medical EducationPerelman School of Medicine

University of Pennsylvania

Central Venous Line Placement Goals

Reduce anxiety about procedures Review basics

Indications Complications Mechanics

Improve familiarity with various catheter types Establish good habits and solid foundation Improve confidence and competency Ensure safe and sterile catheter placement

Central Venous Line Placement Indications

Hemodynamic monitoring CVP / Scv02 PA-Catheters (Swan-Ganz, RHC)

Administration of hyperosmolar agents, vasopressors and other medications

Temporary transvenous cardiac pacing Hemodialysis and plasmapheresis Lack of peripheral access

Central Venous Line Placement Absolute contraindications

None

Relative contraindications Coagulopathy / thrombocytopenia Anatomic abnormalities Thrombus / stenosis Localized infection over insertion site Recent pacemaker insertion

Approach Advantages DisadvantagesInternal

Jugular

Control of bleeding

PTX uncommon

Lower infection rate (vs. femoral)

PA-Cath (R) IJ

Carotid artery injury

Uncomfortable for Pt.

Maintenance of dressings

Tracheostomies

IJ vein prone to collapse

Subclavian Maintenance of dressings

More comfortable

Clearer landmarks

SC vein less collapsible

Lowest infection rate PA-Cath (L) SC

Risk of PTX

SC artery difficult to compress

(typically, SC vein is compressible)

Should be avoided in CKD/ESRD

Femoral No interference with CPR

No risk of PTX

Highest infection rate

Difficulty for PA-Cath

Femoral artery injury

DVT

NEJM 356;21 2007

Central Venous Line Placement

Complications-Immediate Failure to cannulate Pseudoaneurysm Catheter malposition Arteriovenous fistula Vessel laceration Hematoma Arrhythmia (wire or

catheter) Air embolism Pneumo / Hemo thorax

Complications-Distant Pneumo / Hemo thorax Air embolism Arrhythmia (catheter) Skin infection or bacteremia Stenosis or thrombosis of

vessel Thoracic duct injury-

chylothorax Nerve injury (brachial plexus,

sympathetic chain, phrenic) Cardiac tamponade

IJ SC Fem

Pneumothorax (%) <0.1 -0.2 1.5 - 3.1 n/a

Hemothorax (%) n/a 0.4 – 0.6 n/a

Infection (rate per 1000 catheter days) 8.6 4 15.3

Thrombus (rate per 1000 catheter days) 1.2 – 3 0 – 13 8 – 34

Arterial Puncture (%) 3 0.5 6.25

Malposition low high low

Complication Rate / Site Comparison

NEJM 356;21 2007

Central Venous Line Placement

Preprocedure Prep Informed consent process – use procedure specific consents Review procedure, indications and alternatives

Risks / Benefits Obtain written consent

Coordinate procedure timing with bedside RN Enter Bedside Procedure Order in SCM Review equipment check list for needed supplies Review Preprocedure Checklist

Procedure sign posted Procedure cart at bedside

Central Venous Line Placement Preprocedure Prep

Perform Time out at bedside with RN – document in SCM Sterile Technique

Chlorhexidine 30 second friction scrub with 60 second dry time for dry site 30 second friction scrub with 2 minute “soak” time for moist site

Maximum Barrier Precautions Sterile Gloves Long-sleeved gowns Full field drape Masks/Caps for all participants & observers

Sterilize from chin to nipple to shoulder to ear (allows both IJ and SC to be accessed on the same side)

Central Venous Line Placement

PROCEDURE All IJ lines must be done with US guidance All lines must be transduced before dilation (verified by

performing MD and RN)

DOCUMENTATION Consent Bedside Procedure Order in (SCM) Time Out (SCM) US vessel evaluation note Procedure Note

IJ Anatomical Landmarks

Sternal Notch

Posterior belly of Sternocleidomastoid

Anterior belly of Sternocleidomastoid

Clavicle

Subclavian Anatomical Landmarks

ClavicleTurn

Sternal Notch

Insertion Point and Trajectory

Femoral Anatomy Landmarks

Catheter type Description Advantages Disadvantages

Standard Triple Lumen (TLC)

7 Fr, 15 cm

• 18 gauge x 2• 16 gauge

Multiple access points Not optimal resuscitation line for hemorrhagic shock

Multi-Access Catheter (MAC)

9 Fr, 11.5 cm

•Introducer (PA-Cath, TVP, “buddy catheter”)• 12 gauge• 9 Fr.• 18 gauge x 2 (optional)

•Multiple access points•Hemorrhagic Shock Resuscitation Line•When used w/o “Buddy catheter”

•More difficult to insert•Sharper tip on dilator increases risk of misplacement•Shorter length with left sided placement

Percutaneous Introducer Sheath (Cordis)

• Introducer (PA-Cath, TVP)

• Usually 8.5 FR

Hemorrhagic Shock Resuscitation Line

Limited access points unless PA-Cath inserted

Trauma Line • Single lumen large bore central access• Usually 8.5 FR, 8.89cm

Hemorrhagic Shock Resuscitation line

•Limited access points•No introducer sheath

Hemodialysis Dual Lumen Catheter

Usually 13.5 FR Used for HD and plasmapheresis

•Not to be used except in extreme emergency for general IV access

Infusion Rate Comparison

MACDistal (9fr) 33,000 cc/hrProximal (12g) 13,000 cc/hrDistal w/ 8fr catheter 10,500 cc/hr

TLCDistal (16g) 3,400 cc/hrMedial (18g) 1,800 cc/hrProximal (18g) 1,900 cc/hr

Choosing the Catheter SizePt. Height RIGHT

SubclavianLEFT

SubclavianRIGHT Internal

JugularLEFT Internal

Jugular

4'6" - 4'9" inches 12 16 13 17

4'10"- 5'1" inches 13 17 14 18

5'2" - 5'4" inches 14 18 15 19

5'5" - 5'8" inches 15 19 16 20

5'9" - 6'0" inches 16 20 17 21

6'1" - 6'4" inches 17 21 18 22

HD Catheters: 15 cm Right IJ, 20 cm Left IJ, 24 cm FemoralCan adjust for particularly small or large patients

Choosing the Catheter Size

• When deciding which site to use, consider if the patient is a potential dialysis candidate.• Avoid SC catheter placement

• Left sided hemodialysis catheters have a greater chance of being malpositioned.• For HD catheters risk of atrial perforation

• Always use the longest catheter available for groin lines: 25” Cook CVC and 24” dual lumen HDC.

Proper Use of Adjustable Suture Wing

• Used to secure catheter when not inserted to manifold (“hub” aka - full catheter length)

• Must apply both white rubber clamp and red rigid fastener to avoid catheter migration

• secure with 4 sutures: adjustable suture wing and catheter manifold (hub)

• Do not bend catheter in excess in order to suture at catheter hub, keep straight as possible

•Dressing placed over adjustable suture wing only, manifold sutures open to air

• Provider procedure note documentation and daily RN documentations MUST include catheter depth

•catheter depth or securement concerns

Centimeter markings on catheter are used to determine catheter depth

Catheter length is printed on manifold (hub) Double hash mark equals full catheter length as indicated on

manifold Single hash marks indicate one centimeter increment Document catheter depth where catheter exits the skin in daily

access assessment

Documenting Catheter Depth

Catheter length printed on manifold

Single hash mark = one centimeter increments

5 cm increment numerical marking

Double hash mark = full catheter length

measure catheter depth at skin exit

Post-Line Insertion Chest X-ray

Delayed PTX is not unusal – have low threshold to obtain repeat CXR if clinical s/s PTX

Single plane view of ICU CXR is suboptimal to evaluate catheter malposition Transduce waveform via monitor --(can be done without

CXR, will demonstrate intravascular placement and arterial vs venous vessel or extravascular placement)

Blood gas if intravascular may be useful but clinical conditions can confound interpretation

If extravascular catheter is suspected t/c Chest CT w/ contrast

Coagulopathic Patients

Caution with INR > 2.5, PT or PTT > 2x normal, Plt < 50k, or untreated uremia (not on HD). The more parameters fulfilled, increases the cumulative effect on hemostasis.

Consider correction (FFP, platelets, ddavp, HD)

Consider IJ placement under US over SC

Coagulopathic state and /or thrombocytopenia are RELATIVE CONTRAINDICATIONS and warrant a risk/benefit discussion with attending

Helpful Reminders Recommend restraining all patients during central line placement.

(even awake or intact) Keep everything within reach (needles, wire, catheter, flush) Always place patient in trendelenberg (>15 degrees) For SC catheters, placing a rolled towel/sheet in between the

scapulae can help “open” the clavicular angle & allow easier passage of the needle underneath the clavicle

If wire does not pass: Re-attach syringe and aspirate (see if still in vessel) Lower angle of needle (and aspirate) If wire “clears” the tip of the needle, then consider structural

reason (thrombus, anatomic abnormality, ect.) If the wire does not come out easily, give GENTLE traction and try

rotating the wire. DO NOT pull firmly on the wire! Remove catheter and wire together if able If unable to remove wire call vascular

Ultrasound Guided Vascular Access

Transducer Transmits and receives the ultrasound beam Contacts the patient’s skin Takes thin slices of object being imaged Rotated or angled to change views Beam Profile

Width of the beam (1mm) Length of beam 38mm

38mm

1 mm

Ultrasound Basics

Fluid (i.e. blood) is black b/c near complete transmission of U/S waves occurs

Bone and air cause marked reflection and appear white (in B – mode)

Strong reflection creates an acoustic shadow obscuring distal imaging (bone shadow)

Ultrasound Basics

Most large vessels are easily visualized with U/S probes Arteries are pulsatile, difficult to compress and

thick walled Veins are non-pulsatile, easily compressible,

engorge w/ Trendelenburg or Valsalva and thin walled

Transverse Orientation – IJ

Longitudinal Orientation – IJ

Transverse Orientation – Subclavian

Longitudinal Orientation: Subclavian

Guide wire in Longitudinal View

Jugular Vein Thrombosis

Acute thrombus can appear “black” or “cloudy” on US exam

Always evaluate the whole neck ensuring IJ is fully compressible along the entire length

Presence of small caliber anomalous vessels can be indicative of past or present clot or stenosis

Jugular Vein Thrombosis