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KRISTIN WISE, MD, FHM CENTRAL VENOUS CATHETERS. OBJECTIVES Understand the indications & contraindications for Central Venous Catheters (CVCs) Identify.

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Presentation on theme: "KRISTIN WISE, MD, FHM CENTRAL VENOUS CATHETERS. OBJECTIVES Understand the indications & contraindications for Central Venous Catheters (CVCs) Identify."— Presentation transcript:

1 KRISTIN WISE, MD, FHM CENTRAL VENOUS CATHETERS

2 OBJECTIVES Understand the indications & contraindications for Central Venous Catheters (CVCs) Identify factors that influence the selection of appropriate site for CVC insertion Describe the procedural steps for CVC placement Recognize common CVC complications

3 KEY MESSAGES CVC indications include medication administration, hemodynamic monitoring, poor peripheral IV access & venous access to place other devices. There are no absolute contraindications for a CVC. Relative contraindications depend on patient specific factors. While the preferred CVC insertion site varies between patients, subclavian (SC) & internal jugular (IJ) veins have significantly fewer infectious & mechanical complications than femoral veins. AHRQ Safety Practices recommend US guidance and use of maximal sterile barriers when inserting CVCs. The Seldinger technique uses an access needle, guidewire & dilator to introduce CVCs safely into vessels. Common immediate complications include arterial puncture, hematoma & PTX. Common delayed complications include infection & thrombosis.

4 OVERVIEW Described first in 1952 by Dr. Aubaniac Cannulated subclavian vein in battlefield to resuscitate wounded soldiers ACGME, ABIM, SHM recognize CVCs as a competency for internal medicine physicians ~8% hospitalized pts require CVCs >5 mil CVCs inserted annually in US >15% pts have complications

5 INDICATIONS FOR CVC S Administer Meds or Nutrition Infuse meds (ie, vasopressors, chemotherapy) or total parenteral nutrition (TPN) that cause phlebitis/sclerosis when given through peripheral IVs Hemodynamic monitoring Measurement of central venous pressure, venous oxyhemoglobin saturation & cardiac parameters (via pulmonary artery catheter). Poor peripheral venous access Perform ultrafiltration, plasmapheresis/apheresis, HD or other blood filtering process Provide venous sheath access to place other devices IVC filters, venous stents, cardiac pacemakers/defibrillators, etc.

6 CONTRAINDICATIONS No absolute contraindications for CVC placement Important relative contraindications: Coagulopathy target values: INR <1.5, PTT <40 Thrombocytopenia target value: Plts >50K No literature to support correcting these abnormalities Expert opinion recommends most experienced individual available perform procedure Avoid subclavian vein Difficult to monitor bleeding & effectively compress venipuncture site

7 RELATIVE CONTRAINDICATIONS Infected area overlying target vein Anatomic distortion or injury proximal to insertion site Other indwelling intravascular hardware (ie, pacemaker, hemodialysis catheter) Fracture or suspected fracture of clavicle or proximal ribs (for subclavian) Thrombosis of target vein Complications would be life-threatening (ie, PTX in hypoxic pt)

8 SITE SELECTION PROsCONs

9 SITE SELECTION: OTHER CONSIDERATIONS Multiple scars from prior access Unilateral lung disease (ie, PNA, traumatic PTX) Place access ON disease side to minimize resp decompensation from procedure-related PTX Future need for HD Avoid subclavian due to risk of catheter-induced vein stenosis which complicates/eliminates subsequent HD access options Cerebral venous outflow in acute stroke or neuro pts Subclavian site preferred over IJ

10 SITE SELECTION: CONSIDERING COMPLICATIONS Remember these complications to obtain informed consent

11 CATHETER DESCRIPTIONS Types: Central Peripheral (think PICC line) Introducer sheaths (think pul artery catheter) Size: Diameter: 7-French most common 8.5-French common for introducers 11.5-French common for HD Length: 15cm to 30cm for central lines <10cm for introducers

12 CATHETER DESCRIPTIONS Most polyurethane or silicone Specialized catheters exist-–valve mechanisms, power-injectable, antibiotic-impregnated or heparin-coated Lumenssingle, double, triple, quadruple number of lumens means CVC diameter More lumens does NOT mean a better catheter individual lumen diameter thus max infusion rates rate of catheter thrombosis correlates with mechanical complications

13 CATHETER DESCRIPTIONS Lumens infuse fluid through end & holes located on side of catheter end hole more reliable for blood draws (less likely suctioned against vein wall)

14 PREPARATION FOR INSERTION Review labs or imaging Use clinical info to determine best site US site to confirm vessel patency Review allergies to meds & tape Obtain informed consent Position patient for procedure AND your comfort Supine, Trendelenberg Rotate head 45 away from cannulation site Monitor if possible (telemetry, pulsox) O 2 available, consider O 2 use prior to draping patient Universal Time-Out

15 SAFETY PRACTICES AHRQ (2001)Top 11 most highly-rated safety practices List based on strength of evidence to support widespread implementation Use of real-time US guidance during CVC insertion to prevent complications Use of maximum sterile barriers while placing CVCs to prevent infections

16 ULTRASOUND GUIDANCE High frequency probe (5-10MHz) Scan potential insertion sites Evaluate venous patency with compression Facilitate patient positioning to optimize vessel location Identify vein Non-pulsatile, compressible (if hypotensive, artery may compress) Often irregularly shaped compared to artery Thinner vessel wall than artery Often bigger than artery (if volume depleted, may be smaller) time to venous cannulation cannulation attempts, complications

17 STERILE TECHNIQUE Non-sterile mask & cap for everyone present Non-sterile cap on patient Proper hand hygiene Wear sterile gown & gloves Open sterile kit & get organized Prepare/flush all ports of CVC Prep site 30sec continuous scrubbing with Chlorhexidine allow site to fully dry Use wide sterile drape Use sterile US probe cover

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19 IJ vein Landmarks: apex of triangle formed by SCM heads & clavicle lateral to carotid pulse aim for ipsilateral nipple

20 SC vein Landmarks: crosses under clavicle just medial to mid- clavicular point ~2cm lateral, ~2cm caudal to middle third of clavicle

21 PROCEDURE STEPS Re-identify vein on US Use non-dominant hand to hold US probe Anesthetize cannulation site Use 1% lidocaine with 25g needle Aspirate before injecting (lidocaine causes vasospasm & systemic effects!) Only use 1-2 ml to avoid creation of distracting fluid pocket on US

22 SELDINGER TECHNIQUE Dr. Sven-Ivar Seldinger ( ) Swedish radiologist Technique introduced In 1953 to obtain safe access to blood vessels & hollow organs Modified version in use today.

23 SELDINGER TECHNIQUE Cannulate vein with US guidance (preferred) Advance needle at 45 angle Maintain negative pressure (aspirate) on syringe as advance needle until vein punctured Use non-dominant hand (set aside US) to grasp needle Brace hand against pts body to stabilize & maintain needle position Lower angle of needle Disconnect syringe with dominant hand If no blood seen from hub: Reconnect immediately Aspirate to ensure proper needle placement Consider Trendelenburg

24 SELDINGER TECHNIQUE Insert guidewire through needle Should thread easily, w/o resistance, dont force it! Never let go of wire Dont over-insert guidewire End of guidewire remains longer than pts head (IJ) or shoulder (SC) If arrhythmia noted, pull wire back until rhythm normalizes Remove needle while controlling guidewire Never let go of wire Use scalpel to make skin nick adjacent to wire

25 SELDINGER TECHNIQUE Advance dilator over guidewire Dont over-insert dilator Advance it 5cm from skin surface Non-obese, shallow vessel only insert ~2cm Never let go of wire Remove the dilator Never let go of wire

26 SELDINGER TECHNIQUE Thread catheter over guidewire Hold wire taut to make catheter slide on wire easier Dont accidentally pull wire back until catheter in Never let go of wire Catheter indwelling length depends on insertion site & pt size Average guidelines: RIJ 13cm, LIJ 18-20cm RSC 15cm, LSC 18cm Femoral 20cm or longer

27 SELDINGER TECHNIQUE Remove guidewire Now you can safely let go of wire Aspirate blood from all ports & flush with saline Secure catheter with sutures Do not overtighten sutures, can lead to skin necrosis then sutures come out Apply sterile dressing Use Biopatch if available, blue side points up to sky Remove sterile drape carefully Do not dislodge CVC, it can get caught in drape

28 POST-PROCEDURE ETIQUETTE Obtain CXR (IJ, SC) to confirm catheter tip position Tip in right atrium or SVC Malposition of tip increases venous thrombosis risk CXR also allows evaluation for PTX Clarify with RNs whether line ready to use or if CXR required OK to draw urgent/emergent labs from functioning line w/o CXR results Clarify line flushing orderssaline or heparin? Write procedure note

29 PROCEDURE NOTE Name of procedure performed Date & time Indication Clinician(s) involved Refer to Informed Consent & Universal Time-Out Note use of wide sterile barriers & proper hand hygiene Was US used? Vessel(s) cannulated, number of attempts Type catheter, # lumens, insertion length Patient status during & after procedure Whether post-procedure CXR ordered Relevant findings/events during procedure

30 REVIEW OF COMPLICATIONS Most common: Arterial puncture Hematoma PTX Most common: Infection DVT

31 COMPLICATION RATES Incidence rate of complications 6x higher with 3 insertion attempts vs. single attempt US can improve 1 st attempt success Operator experience: Mechanical complications 50% higher with MD who has placed 50 CVCs vs. MD who has placed 50 CVCs Most experienced person available to place CVC on complicated, unstable pts

32 KEY REFERENCES Rosen BT, Wittnebel K. Central line placement. In: McKean SC, Ross JJ, Dressler DD, Brotman DJ, Ginsberg JS, eds. Principles and Practice of Hospital Medicine. 1 st ed. New York, NY: McGraw-Hill; 2012: McGee DC, Gould MK. Preventing complications of central venous catheterization. NEJM. 2003;348(12): McGee DC, Gould MK. Preventing complications of central venous catheterization. NEJM. 2003;348(12): Taylor RW, Palagiri AV. Central venous catheterization. Crit Care Med. 2007;35(5): Web-based resources Heffner AC, Androes MP. (2013). Overview of central venous access. In: Collins KA, ed. UpToDate. Available from Web-based resources: Videos in Clinical Medicine Graham AS, Ozment C, Tegtmeyer K, Lai S, Braner DV. Central venous catherization. NEJM. 2007;356:e21Graham AS, Ozment C, Tegtmeyer K, Lai S, Braner DV. Central venous catherization. NEJM. 2007;356:e21. Braner DAV, Lai S, Eman S, Tegtmeyer K. Central venous catherization Subclavian vein. NEJM. 2007;357:e26.


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