2 ObjectivesUnderstand 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 messagesCVC 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 CVCS Administer Meds or Nutrition Infuse meds (ie, vasopressors, chemotherapy) or total parenteral nutrition (TPN) that cause phlebitis/sclerosis when given through peripheral IVsHemodynamic monitoringMeasurement of central venous pressure, venous oxyhemoglobin saturation & cardiac parameters (via pulmonary artery catheter).Poor peripheral venous accessPerform ultrafiltration, plasmapheresis/apheresis, HD or other blood filtering processProvide venous sheath access to place other devicesIVC filters, venous stents, cardiac pacemakers/defibrillators, etc.
6 contraindications No absolute contraindications for CVC placement Important relative contraindications:Coagulopathytarget values: INR <1.5, PTT <40Thrombocytopeniatarget value: Plts >50KNo literature to support correcting these abnormalitiesExpert opinion recommends most experienced individual available perform procedureAvoid subclavian veinDifficult to monitor bleeding & effectively compress venipuncture site
7 relative contraindications Infected area overlying target veinAnatomic distortion or injury proximal to insertion siteOther indwelling intravascular hardware (ie, pacemaker, hemodialysis catheter)Fracture or suspected fracture of clavicle or proximal ribs(for subclavian)Thrombosis of target veinComplications would be life-threatening(ie, PTX in hypoxic pt)
9 Site selection: other considerations Multiple scars from prior accessUnilateral lung disease (ie, PNA, traumatic PTX)Place access ON disease side to minimize resp decompensation from procedure-related PTXFuture need for HDAvoid subclavian due to risk of catheter-induced vein stenosis which complicates/eliminates subsequent HD access optionsCerebral venous outflow in acute stroke or neuro ptsSubclavian 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 siliconeSpecialized catheters exist-–valve mechanisms, power-injectable, antibiotic-impregnated or heparin-coatedLumens—single, double, triple, quadruple↑ number of lumens means ↑ CVC diameterMore lumens does NOT mean a better catheter↓ individual lumen diameter thus ↓ max infusion rates↑ rate of catheter thrombosiscorrelates 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 imagingUse clinical info to determine best siteUS site to confirm vessel patencyReview allergies to meds & tapeObtain informed consentPosition patient for procedure AND your comfortSupine, Trendelenberg 15-30◦Rotate head 45◦ away from cannulation siteMonitor if possible (telemetry, pulsox)O2 available, consider O2 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 CVCinsertion 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 sitesEvaluate venous patency with compressionFacilitate patient positioning to optimize vessel locationIdentify veinNon-pulsatile, compressible (if hypotensive, artery may compress)Often irregularly shaped compared to arteryThinner vessel wall than arteryOften 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 patientProper hand hygieneWear sterile gown & glovesOpen sterile kit & get organizedPrepare/flush all ports of CVCPrep site30sec continuous scrubbing with Chlorhexidineallow site to fully dryUse wide sterile drapeUse sterile US probe cover
19 IJ vein Landmarks:apex of triangle formed by SCM heads & claviclelateral to carotid pulseaim 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 Anesthetize cannulation site Use non-dominant hand to hold US probeAnesthetize cannulation siteUse 1% lidocaine with 25g needleAspirate before injecting(lidocaine causes vasospasm & systemic effects!)Only use 1-2 ml to avoid creation of distracting fluid pocket on US
22 Seldinger techniqueDr. 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◦ angleMaintain negative pressure (aspirate) on syringe as advance needle until vein puncturedUse non-dominant hand (set aside US) to grasp needleBrace hand against pt’s body to stabilize & maintain needle positionLower angle of needleDisconnect syringe with dominant handIf no blood seen from hub:Reconnect immediatelyAspirate to ensure proper needle placementConsider ↑ Trendelenburg
24 Seldinger technique Insert guidewire through needle Should thread easily, w/o resistance, don’t force it!Never let go of wireDon’t over-insert guidewireEnd of guidewire remains longer than pt’s head (IJ) or shoulder (SC)If arrhythmia noted, pull wire back until rhythm normalizesRemove needle while controlling guidewireUse scalpel to make skin nick adjacent to wire
25 Seldinger technique Advance dilator over guidewire Don’t over-insert dilatorAdvance it ≤ 5cm from skin surfaceNon-obese, shallow vessel only insert ~2cmNever let go of wireRemove the dilator
26 Seldinger technique Thread catheter over guidewire Hold wire taut to make catheter slide on wire easierDon’t accidentally pull wire back until catheter inNever let go of wireCatheter indwelling length depends on insertion site & pt sizeAverage guidelines:RIJ 13cm, LIJ 18-20cmRSC 15cm, LSC 18cmFemoral 20cm or longer
27 Seldinger technique Remove guidewire Now you can safely let go of wireAspirate blood from all ports & flush with salineSecure catheter with suturesDo not overtighten sutures, can lead to skin necrosis then sutures come outApply sterile dressingUse Biopatch if available, “blue” side points up to “sky”Remove sterile drape carefullyDo not dislodge CVC, it can get caught in drape
28 Post-procedure etiquette Obtain CXR (IJ, SC) to confirm catheter tip positionTip in right atrium or SVCMalposition of tip increases venous thrombosis riskCXR also allows evaluation for PTXClarify with RNs whether line ready to use or if CXR requiredOK to draw urgent/emergent labs from functioning line w/o CXR resultsClarify line flushing orders—saline or heparin?Write procedure note
29 Procedure noteName 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 punctureHematomaPTXMost common:InfectionDVT
31 Complication ratesIncidence rate of complications 6x higher with ≥3 insertion attempts vs. single attemptUS can improve 1st attempt successOperator experience: Mechanical complications 50% higher with MD who has placed ≤50 CVCs vs. MD who has placed ≥50 CVCsMost experienced person available to place CVC on complicated, unstable pts
32 Key referencesRosen BT, Wittnebel K. Central line placement. In: McKean SC, Ross JJ, Dressler DD, Brotman DJ, Ginsberg JS, eds. Principles and Practice of Hospital Medicine. 1st ed. New York, NY: McGraw-Hill; 2012: 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:e21. Braner DAV, Lai S, Eman S, Tegtmeyer K. Central venous catherization—Subclavian vein. NEJM. 2007;357:e26.
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