1. CENTRAL VENOUS LINE
PRACTICAL APPROACH

2. Objectives Indications and Contraindications Complications Technique
Basic principles
Specifics by Site
Tips
Basic materials
Basic materials section involves going through an actual catheter kit with them and demonstrating technique

3. Central venous catheter
In medicine, a central venous catheter ("central line", "CVC", "central venous line" or "central venous access catheter") is a catheter placed into a large vein in the neck (internal jugular vein), chest (subclavian vein or axillary vein) or groin (femoral vein). It is used to administer medication or fluids, obtain blood tests (specifically the "central venous oxygen saturation"), and measure central venous pressure

4. CENTRAL VENOUS LINE Indications Central venous pressure monitoring
Volume resuscitation
Cardiac arrest
Lack of peripheral access
Infusion of hyperalimentation
Infusion of concentrated solutions
Placement of transvenous pacemaker
Cardiac catheterization, pulmonary angiography
Hemodialysis
Contraindications
Uncooperative patient
Uncorrected bleeding diathesis
Skin infection over the puncture site
Distortion of anatomic landmarks from any reason
Pneumothorax or hemothorax on the contralateral side
Relative contraindications
Positive end-expiratory pressure (PEEP) mechanical ventilation
Only one functioning lung

5. Complications Vascular Air embolus Arterial puncture
Arteriovenous fistula
Hematoma
Blood clot
Infectious
Sepsis, cellulitis, osteomyelitis, septic arthritis
Miscellaneous
Dysrhythmias
Catheter knotting or malposition
Nerve injury
Pneumothorax, hemothorax, hydrothorax, hemomediastinum
Bowel or bladder perforation

6. Technique: Seldinger technique
The desired vessel or cavity is punctured with a trocar.
A round-tipped guidewire is then advanced through the lumen of the trocar.
A "sheath" or blunt cannula can now be passed over the guidewire into the cavity or vessel.
Drainage tubes are passed over the guidewire e.g chest drains/ nephrostomies).
After passing a sheath or tube, the guidewire is withdrawn
A sheath can be used to introduce catheters or other devices for endoluminal procedures - angioplasty.
Fluoroscopy may be used to confirm the position of the catheter and move it to the desired location.
Injection of radiocontrast may be used to visualize organs.
Interventional procedures, such as thermoablation, angioplasty, embolisation or biopsy, may be performed

7. Step I
Step II
Step III
Step IV
Step V
Step VI

8. Types Of Central Venous Catheters
Nontunneled central catheters
Tunneled central catheters
Peripherally inserted central catheters (PICC)
Implantable ports

9. Central line equipment

10. This is a photo of a dialysis two-lumen catheter inserted on the patient's left side. Scars at the base of the neck indicate the insertion point into the left jugular vein.

11. CENTRAL VENOUS LINE
Chest x-ray with catheter in the right subclavian vein
Triple lumen in jugular vein

12. There are several types of central venous catheters
Implanted port
CVC with three lumens

13. NON-TUNNELED EXTERNAL CATHETERS
Non-tunneled catheters are fixed in place at the site of insertion, with the catheter and attachments protruding directly. Commonly used non-tunneled catheters include Quinton catheters.
1. Polyurethane
2. Single or multiple lumens
3. Flow varies depending on size and ID
4. Temporary - requires frequent exchanges
5. Easier placement, removal and replacement

14. Non-tunneled Central Venous Catheters
Used for short-term therapy
Inserted percutaneously
Subclavian vein
Internal jugular vein
Femoral vein
Has from 1 to 4 lumens or ports
Usually from 6 to 8 inches in length

15. Tunneled Central Venous Catheters
Tunneled catheters are passed under the skin from the insertion site to a separate exit site, where the catheter and its attachments emerge from underneath the skin
Used for long term therapy
Inserted surgically
Small Dacron cuff sits in subcutaneous tunnel
No dressing is required after cuff heals unless the patient is immunocompromised
Initially sutured but removed in 7 to 10 days
External portion of the cath can be repaired
Commonly used tunneled catheters include Hickman catheters and Groshong catheters.

16. Tunneled catheter with cuffs

17. Tunneled catheter

18. Peripherally Inserted Central Catheters (PICC)
A peripherally inserted central catheter, or PICC line (pronounced "pick"), is a central venous catheter inserted into a vein in the arm rather than a vein in the neck or chest with the tip positioned in the superior vena cava
Used for intermediate to long term therapy
May be single or double lumen
Inserted percutaneously
Basalic vein
Cephalic vein
Threaded into the superior vena cava

19. Basic Principles Decide if the line is really necessary
Know your anatomy
Be familiar with your equipment
Obtain optimal patient positioning and cooperation
Take your time
Use sterile technique
Always have a hand on your wire
Ask for help
Always aspirate as you advance as you withdraw the needle slowly
Always withdraw the needle to the level of the skin before redirecting the angle
Obtain chest x-ray post line placement and review it

20. Internal Jugular Femoral Subclavian Location Advantage Disadvantage
Bleeding can be recognized
and controlled
Malposition is rare
Less risk of pneumothorax
Risk of carotid artery puncture
PTX possible
Femoral
Easy to find vein
No risk of pneumothorax
Preferred site for
emergencies and CPR
Fewer bad complications
Highest risk of infection
Risk of DVT
Not good for ambulatory
patients
Subclavian
Most comfortable for
conscious patients
Highest risk of PTX, should not do on intubated pts
Should not be done if < 2 years
Vein is non-compressible
UNC preferred site – in the hospital manual

21. Subclavian Approach Positioning Right side preferred
Supine position, head neutral, arm abducted
Trendelenburg (10-15 degrees)
Shoulders neutral with mild retraction
Needle placement
Junction of middle and medial thirds of clavicle
At the small tubercle in the medial deltopectoral groove
Needle should be parallel to skin
Aim towards the supraclavicular notch and just under the clavicle
Arm abduction flattens the deltoid bulge
Trendelenburg reduces incidence of air embolism
Shoulders – as the shoulder falls backward, the space between the clavicle and first rib narrows, making the subclavian vein less accessible
Right side preferred – lower pleural dome and thoracic duct on left
Junction of the middle and medial thirds of the clavicle – here the vein in just posterior to the clavicle and just above the first rib which acts as a barrier to the pleura.

23. Internal Jugular Approach
Positioning
Right side preferred
Trendelenburg position
Head turned slightly away from side of venipuncture
Needle placement: Central approach
Locate the triangle formed by the clavicle and the sternal and clavicular heads of the SCM muscle
Gently place three fingers of left hand on carotid artery
Place needle at 30 to 40 degrees to the skin, lateral to the carotid artery
Aim toward the ipsilateral nipple under the medial border of the lateral head of the SCM muscle
Vein should be cm deep, avoid deep probing in the neck
Right side preferred – left IJ is more circuitous, thoracic duct on left
Trendelenburg – IJ is distensible
Central approach is most common
Anterior approach has highest risk of puncturing carotid artery

25. Internal Jugular Central Approach

26. Femoral Approach Positioning Supine Needle placement
Medial to femoral artery
Needle held at 45 degree angle
Skin insertion 2 cm below inguinal ligament
Aim toward umbilicus
The more distal you are from the inguinal ligament, the closer the vein is to the artery as the femoral vein begins to dive behind the artery and the saphenous vein comes off the femoral vein.

27. Femoral Vein Femoral nerve Femoral artery
NAVEL – N = nerve, A = artery, V = vein, E = empty space, L = lymphatics
(must be read from right side of body, L is always medial. So it is spelled backwards from the left side approach

28. Post-Catheter Placement
Aspirate blood from each port
Flush with saline or sterile water
Secure catheter with sutures
Cover with sterile dressing (tega-derm)
Obtain chest x-ray for IJ and SC lines
Write a procedure note

29. Procedure Note Name of procedure Indication for procedure
Comment on consent, if applicable
Describe what you did, including prep
Comment on aspiration/flushing of ports
How did patient tolerate procedure
Any complications

30. Tips After 3-4 tries, let someone else try
Get chest x-ray after unsuccessful attempt
If attempt at one site fails, try new site on same side to avoid bilateral complications
Halt positive pressure ventilation as the needle penetrates the chest wall in subclavian approach
If you meet resistance while inserting the guide wire, withdraw slightly and rotate the wire and re-advance
Align the bevel with the syringe markings
Use the vein on the same side as the pneumothorax
Withdraw slowly, you will often hit the vein on the way out
Resistance during wire advancement comes from incorrect placement or from valves and tortuous vessels which can be overcome with GENTLE manipulation of the guide wire

31. Ultrasound-Guided Central Venous Access
                                                                                 
Becoming standard of care
Vein is compressible
Vein is not always larger
Vein is accessed under direct visualization
Helpful in patients with difficult anatomy

32. THANK YOU FOR YOUR
ATTENTION