1. Central Venous Access Module

2. Approach Two approaches are commonly used and will be described: 1.Right internal jugular vein 2.Right sublclavian vein

4. Indications Measurement of central venous pressure (CVP) insertion of a pulmonary artery catheter or transvenous pacemaker administration of fluids and medications, e.g.,if there is no peripheral access administration of hyperalimentation solutions or other fluids that are hypertonic and damage peripheral veins (such as Amphotericin B)

5. CONTRAINDICATIONS Coagulopathy Infection over site of insertion Distortion of landmarks SVC syndrome Patients unable to cooperate or tolerate Trendelenberg positioning Pneumothorax on opposite side Patients with high end-expiratory pressures on mech. ventilation

6. EQUIPMENT NEEDED Commercially available set containing needles, wires, sheaths, dilators, etc Needles, syringes, local anesthetic, 0.9% saline (may be heparinized with 1ml 1 in 100 heparin in 10ml 0.9% saline) Sterile gown, mask, gloves

7. RIGHT INTERNAL JUGULAR VEIN APPROACH Three sites are described: 1.anterior - medial to the sternocleiodomastoid muscle 2.middle - between the two heads of sternocleidomastoid 3.posterior - lateral to the sternocleidomastoid The middle is the commonest and is the one described here. Patient discomfort when turning the head is the disadvantage of this technique

8. Jugular Approach

9. Procedure 1.Sterilize the site and drape with sterile towels 2.Administer the local anesthetic

10. Procedure 1.Whilst this is working flush all the ports of the catheter with sterile 0.9% saline 2.Put the patient in the Trendelenburg position (i.E.Head down)

11. Procedure 1.Use a 21 gauge needle attached to a syringe containing 0.9% saline to locate the position of the internal jugular vein. Put your left hand fingers on the carotid artery and pull it medially and then introduce the needle at the apex of the triangle formed by the two heads of the sternocleidomastoid muscle and the clavicle

12. Procedure The needle should enter at about 45 o to the skin and be directed slightly laterally towards the ipsilateral nipple (often a shallow notch can be felt in the posterior aspect of the clavicle which can help in locating the vein in the lateral/medial plane) Puncture of the vein is apparent by sudden aspiration of non-pulsatile venous blood

13. Procedure If the artery is punctured remove the needle and apply pressure for 10 minutes Insert the introducer needle along the same track as the first needle, which can be used as a guide or can be removed with you remembering the direction and depth it was inserted

14. Procedure When this needle has been inserted into the vein the introducer should be removed and the guidewire introduced down it (leave enough wire outside the patient to accommodate the length of the intravascular catheter

15. Procedure Nick the skin with a number 11 scalpel blade Thread the dilator over the guidewire then remove it keeping the wire in situ at the same depth

16. Procedure Thread the catheter over the guidewire keeping hold of the wire so it does not disappear into the patient (it is helpful to estimate the length of the catheter needed to reach the right atrium before placement) When the catheter is in place there should be free flow of venous blood (if there is no flow the catheter is not correctly placed or is kinked)

17. Procedure Remove the guidewire and attach fluids Suture the catheter in place with 2/0 silk, spray with povidone iodine and apply an occlusive dressing Observe and listen to the chest to exclude a pneumothorax Obtain a chest radiograph to confirm its position and exclude a pneumothorax

18. Subclavian Approach The left subclavian route has the lowest infection rate of all central line routes. Procedure 1.Place a liter bag of fluid between the shoulder blades 2.Sterilize a wide area and drape with a sterile towel

19. Subclavian Approach

20. 1.Identify the area two fingerbreadths lateral and inferior to the point where the clavicle and first rib cross ( about the distal third of the clavicle) and administer the local anesthetic 2.Whilst this is working flush all the ports of the catheter with sterile 0.9% saline

21. Subclavian Approach Place the patient in the Trendelenburg position Locate the vein using a 21 gauge needle keeping the needle parallel to the skin and advancing it just underneath the clavicle to a point halfway between the sternal notch and the thyroid cartilage Apply back pressure on the syringe until venous blood is aspirated

22. Subclavian Approach Remove the syringe and insert the guidewire into the vein (if there is resistance to the guidewire reposition the needle and replace the guidewire - if the wire is going into the head the patient may complain of pain in the ipsilateral ear. If the wire still encounters resistance withdraw it and ask the patient to turn their head towards you, then replace the guidewire) Remove the needle and nick the skin with a number 11 scalpel

23. Subclavian Approach Dilate the track Thread the dilator over the guidewire then remove it keeping the wire in situ at the same depth Thread the catheter over the guidewire keeping hold of the wire so it does not disappear into the patient (it is helpful to estimate the length of the catheter needed to reach the right atrium before placement)

24. Subclavian Approach When the catheter is in place there should be free flow of venous blood (if there is no flow the catheter is not correctly placed or is kinked) Remove the guidewire and attach fluids Suture the catheter in place with 2/0 silk, spray with povidone iodine and apply an occlusive dressing

25. Subclavian Approach Observe and listen to the chest to exclude a pneumothorax Obtain a chest radiograph to confirm its position and exclude a pneumothorax

26. Complications Generally safe if a small needle is used to identify the vein first 1.Pneumothorax - suspect if air aspirated. Always rule out with a CXR. Requires a chest tube. More likely on left because of higher dome of left pleura. 2.Hemothorax from vascular injury 3.Hydrothorax from IV fluid administration into the pleural space

27. Complications 1.Catheter tip embolus - NEVER withdraw the catheter over the needle 2.Perforation of endotracheal tube cuff.

28. Complications 1.Air embolus - always cover the open end of a central line with a finger. 50-100ml air can be fatal. If suspected tip the patient head down and onto their left side so the air stays in the right atrium and get an urgent chest radiograph to see if there is air in the heart. 2.Line sepsis.

29. Documentation in Medical Record Consent Indications Lack of contraindications Procedure including prep, anesthesia, technique Complications? Who was notified of complication (family, attending).