1. Central Venous Access Office of Graduate Medical Education
Perelman School of Medicine
University of Pennsylvania
Slides Courtesy of : Joan Hoch Kinniry ACNP-BC
Lead Practitioner , Critical Care Medicine, Procedure and Resuscitation Service

2. Central Venous Line Placement
Goals
Reduce anxiety about procedures
Review basics
Indications
Complications
Mechanics
Improve familiarity with various catheter types
Establish good habits and solid foundation
Improve confidence and competency
Ensure safe and sterile catheter placement

3. Central Venous Line Placement
Indications
Hemodynamic monitoring
CVP / Scv02
PA-Catheters (Swan-Ganz, RHC)
Administration of hyperosmolar agents, vasopressors and other medications
Temporary transvenous cardiac pacing
Hemodialysis and plasmapheresis
Lack of peripheral access

4. Central Venous Line Placement
Absolute contraindications
None
Relative contraindications
Coagulopathy / thrombocytopenia
Anatomic abnormalities
Thrombus / stenosis
Localized infection over insertion site
Recent pacemaker insertion

5. Approach Advantages Disadvantages Internal Jugular Control of bleeding
PTX uncommon
Lower infection rate (vs. femoral)
PA-Cath (R) IJ
Carotid artery injury
Uncomfortable for Pt.
Maintenance of dressings
Tracheostomies
IJ vein prone to collapse
Subclavian
More comfortable
Clearer landmarks
SC vein less collapsible
Lowest infection rate PA-Cath (L) SC
Risk of PTX
SC artery difficult to compress
(typically, SC vein is compressible)
Should be avoided in CKD/ESRD
Femoral
No interference with CPR
No risk of PTX
Highest infection rate
Difficulty for PA-Cath
Femoral artery injury
DVT
NEJM 356;

6. Central Venous Line Placement
Complications-Distant
Pneumo / Hemo thorax
Air embolism
Arrhythmia (catheter)
Skin infection or bacteremia
Stenosis or thrombosis of vessel
Thoracic duct injury-chylothorax
Nerve injury (brachial plexus, sympathetic chain, phrenic)
Cardiac tamponade
Complications-Immediate
Failure to cannulate
Pseudoaneurysm
Catheter malposition
Arteriovenous fistula
Vessel laceration
Hematoma
Arrhythmia (wire or catheter)
Air embolism
Pneumo / Hemo thorax

7. Complication Rate / Site ComparisonIJ SC
Fem
Pneumothorax (%)
<
n/a
Hemothorax (%)
0.4 – 0.6
Infection (rate per 1000 catheter days)
8.6 4
15.3
Thrombus (rate per 1000 catheter days)
1.2 – 3
0 – 13
8 – 34
Arterial Puncture (%) 3
0.5
6.25
Malposition
low
high
NEJM 356;

8. Central Venous Line Placement
Preprocedure Prep
Informed consent process – use procedure specific consents
Review procedure, indications and alternatives
Risks / Benefits
Obtain written consent
Coordinate procedure timing with bedside RN
Enter Bedside Procedure Order in SCM
Review equipment check list for needed supplies
Review Preprocedure Checklist
Procedure sign posted
Procedure cart at bedside

9. Central Venous Line Placement
Preprocedure Prep
Perform Time out at bedside with RN – document in SCM
Sterile Technique
Chlorhexidine
30 second friction scrub with 60 second dry time for dry site
30 second friction scrub with 2 minute “soak” time for moist site
Maximum Barrier Precautions
Sterile Gloves
Long-sleeved gowns
Full field drape
Masks/Caps for all participants & observers
Sterilize from chin to nipple to shoulder to ear (allows both IJ and SC to be accessed on the same side)

10. Central Venous Line Placement
PROCEDURE
All IJ lines must be done with US guidance
All lines must be transduced before dilation (verified by performing MD and RN)
DOCUMENTATION
Consent
Bedside Procedure Order in (SCM)
Time Out (SCM)
US vessel evaluation note
Procedure Note

11. IJ Anatomical Landmarks
Posterior belly of
Sternocleidomastoid
Clavicle
Anterior belly of
Sternocleidomastoid
Sternal Notch

12. Subclavian Anatomical Landmarks
Clavicle
Turn
Insertion Point
and Trajectory
Sternal Notch

13. Femoral Anatomy Landmarks

14. Catheter type Description Advantages Disadvantages
Standard Triple Lumen (TLC)
7 Fr, 15 cm
18 gauge x 2
16 gauge
Multiple access points
Not optimal resuscitation line for hemorrhagic shock
Multi-Access Catheter (MAC)
9 Fr, 11.5 cm
Introducer (PA-Cath, TVP, “buddy catheter”)
12 gauge
9 Fr.
18 gauge x 2 (optional)
Hemorrhagic Shock Resuscitation Line
When used w/o “Buddy catheter”
More difficult to insert
Sharper tip on dilator increases risk of misplacement
Shorter length with left sided placement
Percutaneous Introducer Sheath (Cordis)
Introducer (PA-Cath, TVP)
Usually 8.5 FR
Limited access points unless PA-Cath inserted
Trauma Line
Single lumen large bore central access
Usually 8.5 FR, 8.89cm
Hemorrhagic Shock Resuscitation line
Limited access points
No introducer sheath
Hemodialysis Dual Lumen Catheter
Usually 13.5 FR
Used for HD and plasmapheresis
Not to be used except in extreme emergency for general IV access

15. Infusion Rate Comparison
MAC
Distal (9fr) 33,000 cc/hr
Proximal (12g) 13,000 cc/hr
Distal w/ 8fr catheter 10,500 cc/hr
TLC
Distal (16g) 3,400 cc/hr
Medial (18g) 1,800 cc/hr
Proximal (18g) 1,900 cc/hr
MAC: pt with GIB, pt who needs a TIPS, or banding, RP bleed. Always have a 2nd sterile assistant when doing a MAC line. There is an abrupt transition point where dilator ends and catheter begins, you often need a second set of hands to retract neck tissue. Attach blue cap immediately, once pierced by dilator it could entrain air. Don’t forget the 2 port adapter cuts flow rate from 30L to 10L/hr.

16. Choosing the Catheter Size
Pt. Height
RIGHT Subclavian
LEFT Subclavian
RIGHT Internal Jugular
LEFT Internal Jugular
4'6" - 4'9" inches 12 16 13 17
4'10"- 5'1" inches 14 18
5'2" - 5'4" inches 15 19
5'5" - 5'8" inches 20
5'9" - 6'0" inches 21
6'1" - 6'4" inches 22
These charts can be found on the CVC/HDC equipment checklist and on display in the conference room. When deciding which site to use, please consider if the patient is a potential dialysis candidate. Left sided hemodialysis catheters have a greater chance of being malpositioned. Always use the longest catheter available for groin lines: 25” Cook CVC and 24” Niagra HDC.
HD Catheters: 15 cm Right IJ, 20 cm Left IJ, 24 cm Femoral
Can adjust for particularly small or large patients

17. Choosing the Catheter Size
When deciding which site to use, consider if the patient is a potential dialysis candidate.
Avoid SC catheter placement
Left sided hemodialysis catheters have a greater chance of being malpositioned.
For HD catheters risk of atrial perforation
Always use the longest catheter available for groin lines: 25” Cook CVC and 24” dual lumen HDC.

18. Proper Use of Adjustable Suture Wing
Used to secure catheter when not inserted to manifold (“hub” aka - full catheter length)
Must apply both white rubber clamp and red rigid fastener to avoid catheter migration
secure with 4 sutures: adjustable suture wing and catheter manifold (hub)
Do not bend catheter in excess in order to suture at catheter hub, keep straight as possible
Dressing placed over adjustable suture wing only, manifold sutures open to air
Provider procedure note documentation and daily RN documentations MUST include catheter depth
catheter depth or securement concerns

19. Documenting Catheter Depth
Centimeter markings on catheter are used to determine catheter depth
Catheter length is printed on manifold (hub)
Double hash mark equals full catheter length as indicated on manifold
Single hash marks indicate one centimeter increment
Document catheter depth where catheter exits the skin in daily access assessment
Double hash mark = full catheter length
Single hash mark = one centimeter increments
measure catheter depth at skin exit
5 cm increment numerical marking
Catheter length printed on manifold

20. Post-Line Insertion Chest X-ray
Delayed PTX is not unusal – have low threshold to obtain repeat CXR if clinical s/s PTX
Single plane view of ICU CXR is suboptimal to evaluate catheter malposition
Transduce waveform via monitor --(can be done without CXR, will demonstrate intravascular placement and arterial vs venous vessel or extravascular placement)
Blood gas if intravascular may be useful but clinical conditions can confound interpretation
If extravascular catheter is suspected t/c Chest CT w/ contrast

21. Coagulopathic Patients
Caution with INR > 2.5, PT or PTT > 2x normal, Plt < 50k, or untreated uremia (not on HD). The more parameters fulfilled, increases the cumulative effect on hemostasis.
Consider correction (FFP, platelets, ddavp, HD)
Consider IJ placement under US over SC
Coagulopathic state and /or thrombocytopenia are RELATIVE CONTRAINDICATIONS and warrant a risk/benefit discussion with attending

22. Helpful Reminders
Recommend restraining all patients during central line placement. (even awake or intact)
Keep everything within reach (needles, wire, catheter, flush)
Always place patient in trendelenberg (>15 degrees)
For SC catheters, placing a rolled towel/sheet in between the scapulae can help “open” the clavicular angle & allow easier passage of the needle underneath the clavicle
If wire does not pass:
Re-attach syringe and aspirate (see if still in vessel)
Lower angle of needle (and aspirate)
If wire “clears” the tip of the needle, then consider structural reason (thrombus, anatomic abnormality, ect.)
If the wire does not come out easily, give GENTLE traction and try rotating the wire. DO NOT pull firmly on the wire!
Remove catheter and wire together if able
If unable to remove wire call vascular

23. Ultrasound Guided Vascular Access

24. Transducer Transmits and receives the ultrasound beam
Contacts the patient’s skin
Takes thin slices of object being imaged
Rotated or angled to change views
Beam Profile
Width of the beam (1mm)
Length of beam 38mm
38mm
1 mm

25. Ultrasound Basics
Fluid (i.e. blood) is black b/c near complete transmission of U/S waves occurs
Bone and air cause marked reflection and appear white (in B – mode)
Strong reflection creates an acoustic shadow obscuring distal imaging (bone shadow)

26. Ultrasound Basics
Most large vessels are easily visualized with U/S probes
Arteries are pulsatile, difficult to compress and thick walled
Veins are non-pulsatile, easily compressible, engorge w/ Trendelenburg or Valsalva and thin walled

27. Transverse Orientation – IJ

28. Longitudinal Orientation – IJ

29. Transverse Orientation – Subclavian

30. Longitudinal Orientation: Subclavian

31. Guide wire in Longitudinal View

32. Jugular Vein Thrombosis

33. Jugular Vein Thrombosis
Acute thrombus can appear “black” or “cloudy” on US exam
Always evaluate the whole neck ensuring IJ is fully compressible along the entire length
Presence of small caliber anomalous vessels can be indicative of past or present clot or stenosis
There is no real definition of “acute” (thrombus) in hours, days, etc. This is why we need to ensure the compressibility.