0071643192.pdf

VASCULAR ACCESS

Central Venous Catheterization

INDICATIONS

■ Need for CVP monitoring
■ Need for rapid volume resuscitation
■ Need for emergent venous access
■ Need for nonemergent venous access in patients with poor or no peripheral
access
■ Need to infuse hyperalimentation or other concentrated solutions
■ Need for emergent hemodyalisis

CONTRAINDICATIONS

■ Relative:
■ Distorted local anatomy or landmarks or previous radiation therapy
■ Cellulitis, burns, abrasions over insertion site
■ Suspected proximal vascular injury
■ Bleeding disorders or patient on anticoagulants

TECHNIQUE

■ Use strict sterile technique to reduce infectious complications.
■ Seldinger (guidewire) technique: Thin-walled needle is used to introduce
a guidewire into the vessel lumen. A catheter is placed over the guidewire
and once it is in place, the guidewire is removed.
■ Ultrasound guidance is strongly recommended for the IJ approach and
may be useful for femoral approach. It is also useful for obese patients
and patients with a history of multiple access at that site. The use of ultra-
sound has been shown to increase the rate of successful first puncture,
increase patient satisfaction, decrease the number of attempts, decrease
the time to perform the procedure, and lower the complication rate.
■ Subclavian: Patient is placed in Trendelenberg position. Vein lies poste-
rior to the medial third of the clavicle. Aim needle toward suprasternal
notch. Vein is entered at a depth of 3–4 cm (see Figure 19.5).
■ Internal jugular: Patient is placed in Trendelenberg position and head
is turned slightly away from puncture site. The vein usually lies ante-
rior and lateral of the carotid artery just deep to the SCM muscle at
the level of the thyroid cartilage. Vein can be accessed medial to the
SCM aiming toward ipsilateral nipple (anterior approach), lateral to
the SCM aiming towards sternoclavicular notch (posterior approach),
and between the sternal and clavicular heads of the SCM (central
approach) (see Figure 19.5).
■ Femoral: Patient is supine. Vein lies medial to femoral artery below the
inguinal ligament. Palpate femoral pulse and place needle just medial to it
below inguinal ligament.

COMPLICATIONS

■ Pneumothorax, hydrothorax (higher with SC access)
■ Vein or artery laceration, bleeding/hematomas that can compress airway (IJ)
■ Arterial puncture (higher with IJ access)
■ Air embolism
■ Infections (higher with femoral vein access)
■ Dysrhythmias

PROCEDURES AND SKILLS

During IJ central line insertion,

ultrasound helps you find the

internal jugular vein and

avoid the common carotid

artery.

For IJ and subclavian lines,

use Trendelenburg to increase

intrathoracic pressure and

decrease the risk of an air

embolism.