Central Venous Catheterization(without USG)
Runal Shah3rd year MEM
Kokilaben Dhirubhai Ambani Hospital.
Objectives
• Indications• Contraindications• Anatomy• Complications• Videos
Central Venous Catheterization
• Indications1) CVP monitoring2) High-volume/flow resuscitation3) Emergency venous access4) Inability to obtain peripheral venous access5) Repetitive blood sampling6) Administering hyperalimentation, caustic agents, or other
concentrated fluids7) Insertion of transvenous pacemakers8) Hemodialysis or plasmapheresis9) Insertion of PA cath
Central Venous Catheterization
• Contra-indications1) Infection over the placement site2) Distortion of landmarks by trauma or congenital anomalies3) Coagulopathies, including anticoagulation and thrombolytic
therapy4) Pathologic conditions, including superior vena cava
syndrome5) Current venous thrombosis in the target vessel6) Prior vessel injury or procedures7) Morbid obesity8) Uncooperative patients
Anatomy
Internal Jugular Vein cannulationPros:
• Good external landmarks• Improved success with USG• Less risk for pneumothorax
than with SV access• Can recognize and control
bleeding• Malposition of the catheter is
rare• Almost a straight course to
the SVC on the right side• Carotid artery easily
identified
Cons:
• More difficult and inconvenient to secure
• Possibly higher infectious risk than with SV access
• Possibly higher risk for thrombosis than with SV access
Right IJV cannulation
Right IJV cannulation
Right IJV cannulation
Anatomy
Subclavian venous cannulation
• Pros:– Good external
landmarks
• Cons:– “Blind” procedure– Unable to compress
bleeding vessels
Anatomy
Femoral Venous Cannulation• Pros:– Good external landmarks– Useful alternative with
coagulopathy
• Cons:– Difficult to secure in
ambulatory patients– Not reliable for CVP
measurement– Highest risk for infection– Higher risk for thrombus
Complications
Complications
Caveats & Helpful hints
• If there is a concern about possibility of bleeding – avoid Subclavian approach, as direct compression is difficult and surgical exploration is required.
• If anticipating Transvenous Pacemaker or PA catheter insertion, use either Right IJV or Left Subclavian approach, as this aligns catheter trajectory with SVC and RA.
• The catheter tip should be positioned in the SVC and not the right atrium. In most adults, the right atrium is 10–15 cm from the subclavian vein. Be sure that the catheter is not inserted deeper than this.
Caveats & Helpful hints
• If pneumothorax occurs and central access remains a priority, subsequent attempts should be made on the same side of the thorax as the pneumothorax to prevent the development of bilateral pneumothorax.
• If the pulse cannot be palpated (e.g., cardiac arrest), divide the distance from the anterior superior iliac spine to the symphysis pubis into thirds. The artery typically lies at the junction of the medial and the middle thirds and the vein is 1 cm medial to this location.
• Excessive contralateral head rotation increases overlap of the carotid by the internal jugular and may increase the risk for arterial injury.
Reference:
Roberts and Hedges’ Clinical Procedures in Emergency Medicine Expert Consult – 5th & 6th Edition