The LSUHSC New Orleans Emergency Medicine Interest Group Presents The Student Procedure Manual

Central Venous Line

by Mark Wegmann, Aruna Akundi,
and Scott Branting with
Wayne Berkowitz

Indications for Central Venous Access
Contraindications
Equipment
Anatomy and Approaches
-Middle or Central Jugular Approach (IJ)
-Posterior Jugular Approach (IJ)
-Infraclavicular Subclavian (SC) Approach
-Supraclavicular(SC) Approach
-Femoral Approach
Procedure For All Central Venous Access
Seldinger Technique
Complications
References

Indications for Central Venous Access

• Rapid fluid replacement especially during external cardiac compressions. The femoral and internal jugular sites can be accessed without discontinuing CPR if necessary.
  
• Central Venous Pressure (CVP) monitoring
  
• Passage of transvenous pacemakers.
  
• Pressure measurement via a pulmonary artery (Swan-Ganz) catheter in critically ill patients.
  
• Clinical contraindications for use of upper extremities or lack of peripheral venous access.
  
• When intravenous access can not be obtained elsewhere.
  
• Emergency cardiopulmonary bypass for resuscitation.
  
• Charcoal hemoperfusion for severe drug overdose
  
• Parenteral nutrition
  
• Drug Administration - irritant medications, vasoactive agents, concentrated solutions
  
• Aspiration for venous air embolism
  
• Emergency dialysis - acute hemodialysis, plasmapheresis
  
• Pulmonary artery catheterization

Contraindications

• Distortion of the local anatomy or the skin at the site.
  
• Extremes of weight that interfere with access to the site.
  
• Evidence of vasculitis; this is a relative contraindication.
  
• Evidence of cellulitis or infection of desired area
  
• Prior long-term cannulation of the site.
  
• Previous injection of sclerosing agents at the site.
  
• Suspected great vessel injury.
  
• Previous radiation therapy administered to the area.
  
• Ambulatory patients requiring central lines should not have femoral lines; these patients are more likely to kink the catheter and ultimately dislodge the device during ambulation.
  
• Significant trauma to the site.
  
• Patients with coagulopathies; this is a relative contraindication to all central venous access.
  
• Patients who are uncooperative and/or combative.
  
• Infants and small children

Equipment (Usually all found in the central line kit).

• Size and length of catheter are determined by the application. Measure the depth of catheter placement from the insertion site to the sternal notch plus approximately 5 centimeters.
  
• Catheter device
  Types:
  • Single lumen- standard adult size: 5F (F=French); length: 15-25cm
    
  • Double lumen- standard adult size: 7F; length: 20cm
    
  • Triple lumen- standard adult size: 7F; length: 30cm
    
  • Double lumen dialysis: standard adult size: I IF;
    length: 15cm
• Introducers: standard adult size: IOF/7F; length 10/20cm
  
• "J" wire(guidewire that is flexible at one end)
  
• Iodine solution and sterile cleaning sponges.
  
• Lidocaine, 1% or 2%, solution and small syringe for topical anesthesia.
  
• 22 or 25 gauge finder needle and 10 or 15 cc syringe.
  
• 16 or 18 gauge introducer needle and a 10 or 15 cc syringe. #1 I Scalpel.
  
• Dilator: some kits may come with more than one size.
  
• Luer lock caps for the distal catheter ports.
  
• Heparin or saline flush.
  
• Extra 4x4 gauze sponges.
  
• Swabs, prep solution, sterile gloves, drapes
  
• IV tubing and solution
  
• Needle holder
  
• 4-0 silk sutures, suture scissors
  
• Antibiotic ointment, gauze pads, tincture of benzoin
  
• Cloth tape

Anatomy and Approaches

• Middle or Central Jugular Approach (IJ)

  The landmark for this access is the triangle formed by the two heads of the sternocleidomastoid muscle and the clavicle.
  

  • The carotid artery runs just beneath the belly of the stemocleidomastoid. The internal jugular vein runs just laterally and slightly anterior to the carotid artery in the carotid sheath and emerges in the triangle just before merging with the subclavian vein.
    
  • The carotid pulse can be palpated in the triangle if the patient is not in cardiac arrest. It can also be felt higher in the neck medially to the belly of the stemocleidomastoid.
    
  • The Middle or Central approach involves accessing the vein in the triangle. After palpating the carotid pulse, the needle will be introduced at the apex of the triangle directed at just lateral to the carotid pulse. The needle should also be directed towards the ipsilateral nipple with 45 degrees of angulation to the frontal plane.
• Posterior Jugular Approach (IJ)
  
  • The Posterior approach involves accessing the vein from behind the clavicular belly of the stemocleidomastoid. The needle is inserted at the junction of the middle and lower thirds of the lateral belly just above the point where the external jugular vein crosses the muscle. The needle is aimed at the suprastemal notch as the landmark of reference with 45 degrees angulation to the sagittal and horizontal planes and 15 degrees to the frontal plane.
• Infraclavicular Subclavian (SC) Approach
  • Introduce the needle lcm belo the junction of the middle and medial thirds of the clavicle.
    
  • Press your fingertip against the suprastemal notch as a point of reference.
    
  • Direct the needletip to a point above and behind the fingertip while keeping the syringe and needle parallel to the frontal plane. Needle bevel should be oriented caudally.
    
  • Vessel punctures at about 3 to 4 cm in depth. If no puncture by 5 cm, withdraw needle to just under skin surface while keeping negative pressure on the syringe and redirect.
• Supraclavicular (SC) Approach
  • Find the junction of the clavicle with the clavicular head of the stemocleidomastoid muscle.
    
  • Introduce the needle lcm lateral to the lateral border of the clavicular head and lcm posterior to the clavicle.
    
  • Orient the syringe so that its axis bisects the angle made by the clavicular head of the stemocleidomastoid muscle and the clavicle. The needletip should be about I 00 above the frontal plane, directed cephalad to the contralateral nipple, with bevel facing medially.
    
  • Vessel punctures at about 1 to 2 cm in depth. If no puncture by 3 cm, withdraw needle to just under skin surface while keeping negative pressure on the syringe and redirect.
• Femoral Approach
  • Place the patient in a supine position, flex the knee and laterally rotate the hip (frog leg like position). This is ideal, but remember that this may not be possible with every patient in every situation.
  • Palpate the femoral pulse and locate femoral vein lcm medial to femoral artery, if pulse is not palpable, the vein may be located blindly at a point one third the distance from pubic tubercle to anterior superior iliac spine just below inguinal ligament. You may mark the area if this will help with your approach. Do not use ink but instead use the tip of the pen to make a small indentation of the skin.

Procedure For All Central Venous Access

1. Place the patient in a supine position, and tilt the patient cephalad at approximately a 10 to 15 degree angle. This Trendelenburg position will distend the jugular and subclavian vein making access easier. This also reduces the chance of air embolism. For the femoral approach leave the patient flat.
   
2. The right side is preferred in subclavian and jugular access because the dome of the pleura is lower on that side thus reducing the chance of pneumothorax. Turn the patients head in the direction opposite to that of the approach.
   
3. It is best to mark the site that is to be used using the end of a pen, but not with the pen's ink. Use the tip of the pen to make a small indentation at the site if time is available.
   
4. Using the sponges and iodine solution, start at the marked spot and circle outward without crossing over previous circles, prepping an area large enough to include IJ and Clavicular approaches. Repeat this three times to sterilize the area.
   
5. Note: It may be a good idea to repeat this sterilization process for the opposite side in case it becomes necessary to go to the other site.
   
6. Apply the sterile drape with the center opening over the marked area.
   
7. Using the lidocaine solution and the small syringe, make a skin wheal ove'r the marked area to anesthetize the site. Then proceed downward at a 45 degree angle, as directed above, toward the head approximately I to 1.5 cm deep to the mark, aspirating as you go. While withdrawing the needle inject more lidocaine to anesthetize the deeper structure. If you accidentally hit the vein at this point, do not inject lidocaine until you have pulled back and aspirated to make sure you have left the vessel.
   
8. Next, use the 25 gauge or 22 gauge finder needle attached to the 10 or 15 cc syringe. Insert the syringe through the skin wheal and through the tract you anesthetized downward aspirating all the way down until the needle enters the vein and venous blood is returned into the syringe. When you have entered the vein, stop and hold the needle very steady.
   
9. Note: some personnel will skip using the finder needle altogether and will use the introducer needle attached to the syringe for this step, thus saving a stick.
   Insert introducer needle at the same angle and beside the finder needle,, aspirating while inserting, until the needle is in the vein and there is good venous return.
   
10. Remove the finder needle but maintain control of the introducer needle. If you only used the introducer needle, then maintain control of the introducer needle. Also, remove the syringe from the introducer needle.

*Remainder of procedure describes the Seldinger Technique

1. Take the guidewire holder into your free hand and retract the wire until only 0.5 cm of the tip is visible. You will notice that the tip of the guide wire is curved; this is to help the guide wire pass once it has entered the vein. It is also very flexible which is why it will straighten when pulled back into the guidewire holder. Do not attempt to insert the guidewire if the curved end is sticking out.
   
2. Insert the guidewire through the introducer needle until you have approximately 20 cm remaining and it has cleared the guidewire holder. Now keep one hand on the introducer needle and the other on the guidewire.
   
3. FROM THIS POINT FORWARD, YOU MUST HAVE AT LEAST
   ONE HAND ON THE GUIDEWIRE AT ALLTIMES.
   
4. Hold the guidewire and remove the introducer needle.
   
5. With the scalpel positioned so that cutting edge is away from guidewire and the back of the blade is running along the guidewire, enlarge the cutaneous puncture site to approximately I cm.
   
6. Take the small dilator, or the only dilator, depending on your kit, and slip it over the guidewire, at no time taking a hand off the guidewire. In other words, hold the wire near the skin site while using your other hand to place the dilator over the wire. Once the dilator is on the wire, then you may place your other hand on the wire at the distal end and use the first hand to guide the dilator. Push the dilator along the wire into the skin site and down to the vein. You will feel some resistance at the venous site as the dilator hits the curve in the guide wire as it enters the vein. Push the dilator only slightly further than this so as not to shear the other side of the vein. Remove the small, or only, dilator and, if necessary, repeat the process with the larger size dilator.
   
7. Before threading the catheter over the guidewire, make sure the most distal port on the catheter is open with its cap off. Hold one hand on the guide wire at the skin site and thread the catheter onto the wire from the opposite end until the wire sticks out of the distal port. If necessary, you may remove a small portion of the guidewire from the site. Once the wire is sticking out of the other side, take control of the guidewire from this end and thread the catheter over the wire advancing the catheter into the vessel so that catheter tip lies parallel to vessel. Make sure to insert the catheter to the appropriate length that will be marked on the catheter itself.
   
8. Remove guide wire making sure to control the catheter with the other hand.
   
9. Check to see if the catheter is in the vessel by using a syringe to aspirate. Make sure the free flow of venous blood is present (if you are not sure that it is venous blood, you can get a blood gas to determine if it is venous or arterial). Once you are certain the catheter is properly placed, flush each port with several milliliters of the heparin/sodium flush.
   Secure the catheter using the suture material provided to the skin. 'rhe catheter has a flange that contains two small holes through which you should thread your suture needle prior to placing it in the skin. It is usually helpful to anesthetize the sites of the suture skin penetration. Apply antibiotic ointment around the site and dress appropriately.
   
10. Order a chest x-ray immediately to confirm catheter placement and to rule out pneumothorax, or a flat plate abdominal film for femoral access confirmation.
    
11. At this point, you may attach your intravenous fluids or give medications.

Complications

• Accidental arterial perforation; if the artery is punctured on the attempt, remove the syringe and apply pressure to the site with sterile dressings for 10 minutes.
  
• Pneumothorax/Hematoma/ Hemothorax formation (IJ/SC) Air embolus
  
• Infection and or thrombophlebitis
  
• Injury to the vagus nerve (IJ/SC)
  
• Perforation of endotracheal tube cuffs (IJ/SC)
  
• Catheter or wire embolus
  
• Loss of guide wire into vein
  
• Tracheal perforation
  
• Pericardial tamponade
  
• SVC obstruction
  
• Thoracic duct laceration
  
• Great vessel laceration
  
• Hematoma
  
• Mural thrombus formation (IJ/SC)
  
• Nerve injury/ cerebral infarct
  
• Dysrhythmias (IJ/SC)
  
• Ascites
  
• Catheter knotting

*Remainder applies only to femoral access

• Perforation of peritoneum
• Perforation of bowel (likely if patient has femoral hemia)
  
• Psoas abscess from penetration of psoas fascia
  
• Puncturing of a distended bladder
  
• Septic arthritis of the hip by puncture of the joint capsule Leg swelling secondary to impeded venous flow or hematoma formation
  
• Retroperitoneal bleeding after external iliac artery puncture

REFERENCES

1. Cummins RO, Bill JE, eds. Advanced Cardiac Life Support. Nashville, TN: American Heart Association;
   1994: 6.3-6.11.
   
2. Dronen SC. Central venous catheterization: subclavian vein approach. In: Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 2n' ed. Philadelphia, Pa: WB Saunders Co; 1991: 325-340.
   
3. Mihm FG, Rosenthal MH.Central venous catheterization: subclavian vein access. In: Benumof JL, ed.Clinical Procedures in Anesthesia and Intensive Care. Philadelphia, Pa: JB Lipincott Co; 1992: 339-370.
   
4. Deneff MG. Central venous catheterization. In: Rippe JM, et al. eds. Procedures and Techniques in Intensive Care Medicine. Philadelphia, Pa:Little, Brown and Co; 1995: 15-30.