C.V.C 99 .pptx central venous access lecture

Central venous access
Dr. Hanan Beshr

• Definition
 Central venous line (CVL): a vascular catheter
that is inserted into a large central vein, e.g.,
subclavian, femoral, or internal jugular
vein (IJV), usually under ultrasound guidance.

Properties of CVLs
• Slower flow rates than peripheral venous
catheters of the same diameter because they are longer
• High flow rate can be achieved with large-gauge
central venous catheters (e.g., dialysis catheters).

CVL insertion site :
Anatomic location
Internal jugular line (IJ line)
 Enters the neck via the left or
right IJV
 Terminates at the SVC-
RA junction
Subclavian line
 Enters below the left or
right clavicle via
the subclavian vein
 Terminates at the SVC-
RA junction
Femoral line
 Enters the femoral vein at the
groin
 Terminates in the
iliac vein or IVC

Internal jugular line (IJ line)
Advantages Disadvantages
 Good insertion landmarks
 Lower risk
of pneumothorax than su
bclavian line insertion
 Can compress bleeding
vessels
 Uncomfortable for the
patient
 Higher risk of infection
than subclavian line

Subclavian line
 Lowest infection rate
 Most comfortable for the
patient
 Higher risk
of pneumothorax than IJ
line
 Cannot compress
bleeding vessels
 Ultrasound guidance is
difficult.

Femoral line
 Easier access
during ACLS
 Good insertion
landmarks
 High risk of infection
 High risk of thrombosis

Special catheters :
Hemodialysis catheters
Can be a tunneled CVL (long-term use) or nontunneled CVL (short-term
use)
Usually a large gauge double-lumen CVL
Peripherally inserted central catheter (PICC)
Long catheter that is inserted via a peripheral vein and terminates in a
large central vein.
Advantages: lower procedural risk than other CVLs
Disadvantages: high risk of thrombosis, small gauge limits
administration rate

• Indications
 Large-volume fluid resuscitation
 Anticipated long-term IV therapy
 Poor peripheral IV access
 Administration of vesicants or irritant medications
 Hemodynamic monitoring
 Therapies requiring high-volume extracorporeal
circulation

• Contraindications
 Absolute:
 allergy to an antibiotic impregnated within
 the catheter [1]
 Relative [1]
o Infection or thrombosis at the site of insertion
o Superior vena cava syndrome (for subclavian
and IJV venipuncture)
o Coagulopathy (especially for
subclavian venipuncture)

Equipment checklist
1. Ultrasound machine
2. Sterile gown and gloves
3. Sterile full-body drape
4. Sterile ultrasound probe cover
5. Chlorhexidine skin preparation
6. 1% lidocaine without epinephrine
7. 25-gauge needle and syringe

8. Thin-wall introducer needle (TWN) and
syringe
9. 5 mL syringe
10. Guidewire
11. Scalpel
12. Vascular dilator
13. Central venous catheter
14. Nonabsorbable suture
15. Sterile dressing

Preparation
o Ready the ultrasound machine.
o Apply cardiac monitors to the patient.
o Place the patient in the Trendelenburg position.
o Perform a preprocedure ultrasound examination.
o Perform skin preparation to create a sterile field.
o Apply a sterile full-body drape.
o Prepare the sterile ultrasound transducer cover.
o Administer single-point local anesthesia for conscious
patients.

• Procedure/application
The Seldinger technique:
1.Center the probe above the IJV.
2.Place the needle beneath the center of the
probe at a 45° angle to the skin.
3.Apply negative pressure to the syringe
plunger and advance the needle until blood
flashback occurs.
4.Hold the needle firmly and remove the syringe.
5.Feed 15–20 cm of wire through the needle.

6. Remove the needle while holding the wire
in place.
7.Make a small skin incision over the wire.
8.Advance the vascular dilator 5–7 cm into
the vein.
9.Remove the dilator and advance the catheter ∼
16cm (right IJV) or ∼ 20 cm (left IJV) over the
wire.
10.Remove the wire, aspirate blood from all ports,
and flush each port with saline.
11.Secure the catheter to the skin and apply
a sterile dressing.

Postprocedure checklist
1. Wire removed and inspected
2. All ports aspirated and flushed
3. Sterile dressing applied
4. CXR obtained
5. Correct catheter location confirmed
6. Pneumothorax ruled out
7. Procedure documented
8. Postprocedural CLABSI prevention measures
ordered

• Complications
 Complications of indwelling catheters
o Infection, e.g., CLABSI
o Thrombosis
 Complications of CVC insertion
o Arrhythmia
o Arterial injury
o Venous air embolism
o Pneumothorax
o Hemothorax
o Guidewire embolism
o Incorrect catheter placement

C.V.C 99 .pptx central venous access lecture

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