Central Venous Central Venous CatheterizationCatheterization

by, Dr G.RAJASEKHAR MBBS,DCH MODERATORS Dr SREEDEVI MD Dr PADMAJA MD

Central venous catheterCentral venous catheterCentral venous access is the placement

of a venous catheter in a vein that leads directly to the heart.

ObjectivesObjectivesTypes of cathetersIndications and ContraindicationsTechniqueBasic principlesSpecifics by SitecomplicatonsTips

TYPE OF CENTRAL VENOUS TYPE OF CENTRAL VENOUS CATHETERCATHETERPatient’s conditionAnticipated length of therapy

Types Of Central Venous CathetersTypes Of Central Venous Catheters

Nontunneled central cathetersTunneled central cathetersPeripherally inserted central catheters

(PICC)Implantable ports

NONTUNNELED CENTRAL NONTUNNELED CENTRAL CATHETERTSCATHETERTS

NONTUNNELED CENTRAL NONTUNNELED CENTRAL CATHETERTSCATHETERTS

POLYURETHANESINGLE OR MULTIPLE LUMENSUSED FOR SHORT TERM THEARAPYEASIER PLACEMENT,REMOVAL AND

REPLACEMENTUSUALLY 6to8 INCHES IN LENGTHCAN BE QUICKLY INSERTED

Dislodged more easily

Has the highest infection rate

Dressing changes required using aseptic technique

Unused ports must be routinely flushed with heparin solution and clamped

NOT FLEXIBLE AND MAY BREAKNOT FLEXIBLE AND MAY BREAK

TUNNELED CENTRAL VENOUS TUNNELED CENTRAL VENOUS CATHETERSCATHETERS

Single or multiple lumensFlow variableLog termInserted surgicallyCuff –dacron, vitaNo dressing is required after cuff heals

unless the patient isimmunocompromised

Tunneled catheter

Peripherally Inserted Central Peripherally Inserted Central Catheters (PICC)Catheters (PICC)

Used for intermediate to long term therapy

May be single or double lumenInserted percutaneously◦ Basalic vein◦ Cephalic vein

Threaded into the superior vena cava

PICCPICCSILASTIC OR POLYURETHANE

SINGLE OR DOUBLE LUMEN

LOW FLOW

SHORT-LONGTERM

EASY ACCESS

SUBCUTANEOUS PORTSSUBCUTANEOUS PORTSSINGLE OR DOUBLELUMENFLOW-MOST COMMONLY SLOWLONG TERMACCESS REQUIRES NEEDLE PUNCTURE

LESS MAINTENANCEACTIVITY IS UNLIMETED AFTER SITE HEALSCOSMETICALLY MORE APPEALINGCONCEALED PACKET RETARDS

INFECTION

Minimizes infectionHuber needle must be used to access portMust always confirm needle placement before

med administrationUnused port is flushed every 28 days with

Heparin solution

IndicationsIndicationsCentral venous pressure monitoringVolume resuscitationInfusion of hyperalimentationInfusion of concentrated solutionsPlacement of transvenous pacemakerCardiac catheterization & pulmonary angiographyTemporary Hemodialysis Lack of peripheral access

Relative Contraindications Relative Contraindications Bleeding disordersAnticoagulation or thrombolytic therapyDistorted local anatomyCellulitis, burns, severe dermatitis at siteVasculitis

Technique Technique Seldinger technique◦ Use introducing needle to locate vein◦ Wire is threaded through the needle◦ Needle is removed◦ Skin and vessel are dilated◦ Catheter is placed over the wire◦ Wire is removed◦ Catheter is secured in place

Basic PrinciplesBasic PrinciplesDecide if the line is really necessaryKnow your anatomyBe familiar with your equipmentObtain optimal patient positioning and cooperationTake your timeUse sterile techniqueAlways have a hand on your wireAsk for helpAlways aspirate as you advance as you withdraw the needle

slowlyAlways withdraw the needle to the level of the skin before

redirecting the angleObtain chest x-ray post line placement and review it

Location Advantage Disadvantage

Internal Jugular

• Bleeding can be recognized and controlled• Malposition is rare• Less risk of pneumothorax

• Risk of carotid artery puncture• PTX possible

Femoral • Easy to find vein• No risk of pneumothorax• Preferred site for emergencies and CPR• Fewer bad complications

• Highest risk of infection• Risk of DVT• Not good for ambulatory patients

Subclavian • Most comfortable for conscious patients

• Highest risk of PTX, should not do on intubated pts• Should not be done if < 2 years• Vein is non-compressible

Subclavian Approach Subclavian Approach Positioning◦ Right side preferred◦ Supine position, head neutral, arm abducted◦ Trendelenburg (10-15 degrees) ◦ Shoulders neutral with mild retraction

Needle placement◦ Junction of middle and medial thirds of clavicle◦ At the small tubercle in the medial deltopectoral groove◦ Needle should be parallel to skin ◦ Aim towards the suprasternal notch and just under the clavicle

Internal Jugular ApproachInternal Jugular ApproachPositioning◦ Right side preferred◦ Trendelenburg position◦ Head turned slightly away from side of venipuncture

Needle placement: Central approach◦ Locate the triangle formed by the clavicle and the sternal and

clavicular heads of the SCM muscle◦ Gently place three fingers of left hand on carotid artery◦ Place needle at 30 to 40 degrees to the skin, lateral to the carotid

artery◦ Aim toward the ipsilateral nipple under the medial border of the

lateral head of the SCM muscle◦ Vein should be 1-1.5 cm deep, avoid deep probing in the neck

Internal Jugular Central Approach

Femoral ApproachFemoral ApproachPositioning◦ Supine

Needle placement◦ Medial to femoral artery ◦ Needle held at 45 degree angle ◦ Skin insertion 2 cm below inguinal ligament◦ Aim toward umbilicus

Femoral artery

Femoral nerve

Femoral Vein

NAVEL

Post-Catheter PlacementPost-Catheter PlacementAspirate blood from each portFlush with saline or sterile water

(heparinised)Secure catheter with suturesCover with sterile dressing (tega-derm)Obtain chest x-ray for IJ and SC linesWrite a procedure note

Complications Complications Vascular◦ Air embolus◦ Arterial puncture◦ Arteriovenous fistula◦ Hematoma◦ Blood clot

Infectious◦ Sepsis, cellulitis, osteomyelitis, septic arthritis

Miscellaneous ◦ Dysrhythmias◦ Catheter knotting or malposition◦ Nerve injury◦ Pneumothorax, hemothorax, hydrothorax,

hemomediastinum◦ Bowel or bladder perforation

Tips Tips After 3-4 tries, let someone else tryGet cheast x-ray after unsuccessful attempt If attempt at one site fails, try new site on same side to

avoid bilateral complicationsHalt positive pressure ventilation as the needle penetrates

the chest wall in subclavian approach If you meet resistance while inserting the guide wire,

withdraw slightly and rotate the wire and re-advanceAlign the bevel with the syringe markingsWithdraw slowly, you will often hit the vein on the way out

Ultrasound-Guided Central Venous Ultrasound-Guided Central Venous AccessAccess

Becoming standard of care

Vein is compressibleVein is not always largerVein is accessed under direct

visualizationHelpful in patients with difficult

anatomy

Needle entering IJ

FemoralVein

Femoral Artery

Compression of veinwith US probe

Catheterization KitsCatheterization Kits