Central Venous Access
Mazen Kherallah, MD, FCCP
Indications
Need for IV access and failure of peripheral access Peripheral access too painful or tenuous Long term IV access anticipated Medications indicated that are toxic to peripheral
veins Hemodynamic monitoring Volume resuscitation with large bore central lines Special procedure: Swan Ganz, dialysis,
plasmapheresis
04/18/23
Site Selection
Site Pro’s Con’s Subclavian Large vessel
Can tolerate high flow
Dressing easy to maintain
Less restrictive for patient
Lowest sepsis rate
Close to lung apex, risk of pneumothorax
Close to subclavian artery
Hard to control bleeding
04/18/23
Site Selection
Site Pro’s Con’s Internal Jugular
Large vessel Easily located Easy access Short, straight
path to superior vena cava
Decreased risk of pneumothorax
Uncomfortable for patient
Difficult to maintain dressing
Close to carotid artery
Easily contaminated
Difficult maintenance with trach or neck injury
04/18/23
Site Selection
Site Pro’s Con’sFemoral Easy access
Large vessel Good access
duringresuscitation
Decreasedmobility
Increased riskof thrombosis,phlebitis &infection
Easilycontaminated
Close tofemoral artery
Dressingdifficult tomaintain
Choice of Site
Subclavian IJ FemoralSuccess Rate 90-95% 90-99% 90-95%
Arterial puncture 0.5-1% 10% 5-10%
Pneumothorax 1-5% 0-0.2% 0
Infectious rate Lowest Intermediate Highest
Access during cardiac arrest
2nd 3th 1st
Side of body preference
Left: angle of subclavian vein
Right: avoid thoracic duct
None
Coagulopathy present 3th 2nd 1st
Hypovolemia present 1st: vein supported by fibrous sheath
3th: vein collapses 2nd
Pacemaker 2nd 1st 3th
Anatomy of Great Vessels
Anatomy of Great Vessels
Anatomy of Great Vessels
Seldinger Technique
The Procedure
Patient position: Patient is moved to the side of the bed so
physician would not lean over The bed is high enough so physician would
not have to stoop over Patient should be flat without a pillow,
Trendelenburg position if patient is hypovolemic
The head is turned away from the side of the procedure
Wrist restraints if necessary
The Procedure
Skin preparation: Prepare before putting sterile gloves Start at the center and work outward the
edges Allow time for the sterilizing agent to dry Disposable drape under the patient Betadine or Chlorhexidine are acceptable
solution and have activity against gram positive organisms
The Procedure
Drape: Large enough Handed sterilely by the assistant Hole in the area of placement
Prepare the tray: Handed sterilely by the assistant Prepare the equipment before starting
Anesthesia Use local anesthesia with lidocaine
YOUR ROLE AFTER THE INSERTION
Dispose all sharps Place an occlusive sterile dressing Flush lumens to maintain patency Obtain a chest x-ray (ask for order if physician doesn’t
mention it) Monitor site for bleeding Assess breath sounds Assess circulation Assess for hematoma Document insertion, site, dressing and flushing
USING THE CENTRAL LINE
Flush q shift, before and after use with NS. Some places also require heparin flush
Close clamps when not is use Check P&P of facility, but usually fluids are changed
every 24 hours, tubing changed every 48-72 hours Dressing is usually changed every 3 days Line can be used for blood drawing - withdraw and
waste 10 cc, then withdraw blood for samples If port becomes clotted, do not use - sometimes ports
can be opened up with urokinase (requires a doctor’s order)
Complications
Immediate Hemothorax Pneumothorax Arterial puncture Vessel erosion Nerve Injury Dysrhythmias Catheter malplacement Embolus Cardiac tamponade
Complications
Delayed Dysrhythmias Catheter malplacement Vessel erosion Embolus Cardiac tamponade Catheter related infection Thrombosis
Vascular Erosion/Cardiac Tamponade
Large vessel perforation is uncommon Vessel erosion more common with stiff
catheters, like dialysis catheters Cardiac tomponade occur mainly if the tip is
located in the RA Complication is fatal in 2/3 of cases
Air Embolism
Air is sucked in through the catheter due to negative intrathoracic pressure during inspiration
Air can be pushed with flushing the catheter if it was not pulled back before flushing
Complication is uncommon but can be fatal Manifests with hypoxemia, cardiovascular collapse,
mental status changes and livedo reticularis Place patient to left lateral position if suspected
Bleeding
More common in patients with coagulopathy Easily controlled with femoral or IJ sites Place local pressure and correct
coagulopathy
Arterial Puncture and Cannulation
If the artery is puncture local pressure is applied for 3-5 minutes, observe for hematoma formation
If the artery is cannulated, pulsatile reflux of blood can be noticed, blood gas analysis reveals arterial.
The catheter should not be used, and remove it after coagulopathy is corrected if present
Thrombosis
Sleeve fibrin surrounding the catheter (occurs on the majority of catheters)
Mural thrombus on the wall of the vein (10-30% of catheters)
Occlusive thrombus (1-10%)
Pneumothorax
Most likely, pneumothorax is noticed after CXR is seen, unless patient developed tension pneumothorax with hypoxemia, cardiopulmonary collapse and absent breath sound
Small pneumothorax may be watched closely without chest tube placement in the spontaneously breathing patients
Large pneumothorax requires chest tube placement Even small pneumothorax in patients on positive
pressure ventilation requires chest tube placement
Catheter-Related Sepsis
Late complications Femoral > IJ > subclavian Triple lumen > single lumen Large bore > smaller catheter Sterility of procedure Number of hub manibulations
Basic Pressure Measurements from Swan Ganz Catheter
Measurement Normal range
Central venous pressure <10 mm Hg
Right atrial pressure <10 mmHg
Right ventricular pressure, systolic 15-30 mm Hg
Right ventricular pressure, diastolic 0-8 mm Hg
Pulmonary artery pressure, systolic 15-30 mm Hg
Pulmonary artery pressure, diastolic 5-16 mm Hg
Pulmonary artery pressure, mean 10-22
Pulmonary artery wedge pressure, mean 8-12
Hemodynamic MonitoringPosition of Transducer
Components of the Atrial Waves
Differences in CVP and PCWP EKG correlation
Wave EKG correlate Description
A In the P-R interval RA contraction
C End of QRS Closure of the tricuspid valve
V Near end of T wave Filling of the RA
X descent Downward slope of a wave
Y descent Downward slope of v wave
CVP Correlation with EKGNormal CVP Tracing
Reading the mean of an A wave
22+10/2=16
Spontaneous BreathingReading CVP
Spontaneous BreathingInsp./Exp. Ratio in Rapid Breathing
Spontaneous BreathingInsp./Exp. Ratio in Rapid Breathing
Hemodynamic MonitoringCentral Venous Pressure: normal 4-10
Increased CVP: Right heart failure Right myocardial infarction Cardiac tomponade Tricuspid insufficiency Left to right shunt Pulmonary emboli COPD and cor pulmonale ARDS Excess fluid Tricuspid stenosis
Decreased CVP hypovolumia Decreased venous return Excessive veno or
vasodilation Shock
Central Venous Pressure Tracings
Normal EKG tracing and right atrial pressure waveform
Atrial fibrillation
Atrioventricular dissociation
Central Venous Pressure Tracings
Normal EKG and right atrial waveforms
Tricuspid stenosis
Mild to moderate tricuspid insufficiency
Severe tricuspid insufficiency
Constrictive pericarditis
Large A wave Secondary to Loss of Atrioventricular Synchrony Simultaneous Atrial and Ventricular Contraction
Loss of A WaveAtrial Fibrillation
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