The indications for central venous catheterization are listed in Table 31-4. The indication for direct central venous access in the setting of resuscitation of cardiac arrest is debated.
TABLE 31-4Indications for Central Venous Catheterization |Favorite Table|Download (.pdf) TABLE 31-4 Indications for Central Venous Catheterization
Inability to obtain peripheral access
Access to central circulation needed for procedures (pulmonary artery catheter placement, transvenous pacemaker placement, or urgent hemodialysis)
Measurement of central venous pressure (sepsis, congestive heart failure, pericardial effusion)
Administration of sclerosing medications, continuous vasopressors, concentrated ionic solutions, or cytotoxic chemotherapeutic agents
The most frequent sites used for central venous access are the internal jugular, subclavian, and femoral veins (Figures 31-3 and 31-4). The external jugular vein, a superficial structure, also provides a route to the central circulation but is technically a peripheral site.
Vascular anatomy of the neck.
Vascular anatomy of the torso and lower extremities.
The clavicles, first ribs, sternum, sternocleidomastoid, platysma, and other strap muscles of the neck overlie the internal jugular and subclavian veins (Figure 31-3). The internal jugular vein lies lateral to the internal carotid artery inside the carotid sheath. The internal jugular vein joins the subclavian vein to form the brachiocephalic vein.
The subclavian vein crosses under the clavicle at the medial to proximal third of the clavicle. The subclavian artery lies posterior and superior to the brachiocephalic vein. The thoracic duct joins the left subclavian vein at its junction with the left internal jugular vein. The domes of the pleura lie posterior and inferior to the subclavian veins and medial to the anterior scalene muscles.
The femoral vein is the most accessible central vein below the waist. It travels in the femoral sheath with the femoral artery, nerve, and lymphatics deep to the medial third of the inguinal ligament. A mnemonic for the anatomy of the femoral structures from lateral to medial is NAVEL: nerve, artery, vein, empty space, and lymphatics.
TECHNIQUE FOR CENTRAL VENOUS ACCESS
After gaining consent if possible, identify the access site and approach and position the patient. Prepare all materials before the procedure (Table 31-5). Use a procedure checklist to optimize infection prevention practices.
TABLE 31-5Materials for Central Venous Catheterization |Favorite Table|Download (.pdf) TABLE 31-5 Materials for Central Venous Catheterization
Sterile personal protective gear (gloves, gown, mask, hair cover)
Sterile drape and towels
Sterile prep solution (povidone-iodine or chlorhexidine)
3 × 10-mL syringes containing sterile normal saline flush
Central venous catheter set containing:
1% Lidocaine, small-gauge needle and syringe
18-Gauge introducer needle
#11 Blade scalpel
Single- or multilumen catheter
4 × 4 gauze pads
3-0 or 4-0 silk suture with straight needle or with needle driver
Sterile transparent dressing
The technique for all approaches is summarized in Table 31-6 and depicted in Figure 31-5.
TABLE 31-6Seldinger Technique* for Insertion of Central Venous Line |Favorite Table|Download (.pdf) TABLE 31-6 Seldinger Technique* for Insertion of Central Venous Line
|Step ||Comments |
|1. Gown in sterile fashion. || |
Use sterile gloves and gown.
Wear mask and hair covering.
|2. Identify vessel—US guidance preferred over landmarks. ||— |
|3. Prep and drape patient using standard sterile procedure. || |
Prep a wide area so an alternate site can be used if initial attempts fail.
Prep the entire ipsilateral neck and upper chest when preparing to insert an internal jugular or subclavian catheter.
4. Open the central catheter kit.
Inspect for content in a sterile fashion.
Place kit close to bedside and operator.
Maintain sterile conditions.
|5. Anesthetize area in all conscious patients. || |
Inject area with 1%–2% lidocaine.
Anesthetize the periosteum of the clavicle if using the subclavian approach.
Reorient to landmarks after injection.
|6. Hold the 18-gauge introducer needle on a 10-mL syringe in the dominant hand and align the needle to the target. ||— |
|7. Advance the needle slowly though the skin and subcutaneous tissue until a flash of dark venous blood appears. ||Maintain steady constant aspiration of syringe. |
|8. Stabilize the needle with the nondominant hand. ||— |
|9. Check for continued free venous flow with aspiration. ||If no flow is noted, withdraw the needle slightly, as the needle may have breached the posterior vessel wall. |
|10. Remove the syringe attached to the needle and immediately occlude the catheter with a finger. ||This maneuver helps to prevent introducing air in the catheter and subsequent central system air embolism. |
|11. Insert the guidewire gently through the needle. Always maintain a firm grip on the wire—do not let go of the wire for any reason. || |
The wire should advance with minimal resistance.
Do not force the wire for any reason.
If the wire does not pass easily, reattach the syringe and aspirate to confirm continued venous flow.
Reposition the needle as needed.
Premature ventricular contractions or dysrhythmias during wire advancement may indicate that the wire is in the right atrium or beyond.
|12. Remove the needle over the wire when the guidewire is inserted at least 10 cm into the vessel. ||— |
|13. Incise the skin with a #11 blade scalpel at the entry site to accommodate the venodilator or catheter. ||Do not cut the guidewire. |
|14. Advance the dilator or catheter over the guidewire into the vessel lumen with a gentle twisting motion. ||— |
|15. Remove the dilator (if used), and advance the catheter over the wire until the wire is advanced through the distal port. ||Maintain a grip on the guidewire during this procedure. |
|16. Grab the end of the guidewire. ||— |
|17. Advance the catheter to the appropriate depth. ||— |
|18. Remove the guidewire. ||It is easy to "lose" the wire; if you cannot find it after a procedure, immediately obtain an x-ray to seek retention. |
|19. Aspirate and flush all ports to confirm catheter function. ||— |
|20. Secure catheter with suture and apply a sterile transparent dressing. ||— |
|21. Confirm catheter placement in the superior vena cava with chest x-ray. || |
A catheter tip in the right atrium can perforate the right atrium and cause hemothorax or hemomediastinum with pericardial tamponade.
Examine the chest x-ray for signs of complications.
Seldinger technique. A. Needle is inserted through skin and vessel until venous blood is aspirated. B. Guidewire is inserted gently through the needle and advanced. C. Needle is removed over guidewire. D. The skin is incised. E. Dilator or catheter is inserted over the guidewire. F. The guidewire is removed.
Complications of central venous catheterization are listed in Table 31-7.
TABLE 31-7Complications of Central Venous Catheterization |Favorite Table|Download (.pdf) TABLE 31-7 Complications of Central Venous Catheterization
Chylothorax (injury to the thoracic duct on left-sided attempts)
Hydrothorax/hydromediastinum (infusion into the pleural space)
Great vessel or right atrial perforation (hemothorax, tamponade)
Airway compromise (tracheal injury, hematoma with airway compression)
Complication rates increase with each additional attempt or percutaneous puncture. Accidental arterial puncture during internal jugular cannulation can lead to hematoma formation and airway compromise. Carotid arterial puncture may result in acute plaque rupture and stroke in patients with known carotid artery stenosis or atherosclerosis. Femoral lines often become infected and thrombose (nearly 20% each in some studies) and so are avoided for longer use. Do not use the subclavian approach in patients with coagulopathy because accidental subclavian arterial puncture or injury is not amenable to direct vascular compression.
US-GUIDED CENTRAL VENOUS ACCESS
US-guided central venous access increases first attempt success rates and decreases the number of attempts needed for success when compared to the unassisted standard method. Complication rates are similar in both techniques. The technique of US-guided central venous access is similar to peripheral venous access described previously.
TECHNIQUES OF COMMONLY USED APPROACHES
The external jugular vein is readily available due to its superficial location in the subcutaneous tissue overlying the sternocleidomastoid muscle. Place the patient in the head-down position or use Valsalva maneuvers to distend the vein and improve visualization. Entering a central vein via the external jugular vein is difficult and rarely successful without using a J wire; it is often not required because the site accommodates large-volume flow. Puncture the skin at a 10-degree angle. Placement is aided by tilting the head to the contralateral side, applying skin traction to "straighten" the course of the vein, and by rotating the guidewire 180 degrees before re-advancement if the first pass fails.
Preprocedure Checklist for Central Line Access |Favorite Table|Download (.pdf) Preprocedure Checklist for Central Line Access
Before the procedure, did the provider:
Perform a time out to ensure right patient, right location/side?
Cleanse hands immediately prior?
Sterilize procedure site and allow site to dry?
Drape the patient from head to toe with a large sterile drape?
During the procedure:
Did the provider wear sterile gloves, cap, mask, and gown?
Did assisting physician(s) follow the above precautions?
Did the provider maintain sterility of tray, site, field, and gloves at all times?
Did ALL staff in room wear a mask?
Was unnecessary traffic in and out of the room prevented during the procedure (did the door remain closed)?
After the procedure, did the provider:
The internal jugular vein is easily located with US guidance.
Place the probe on the sternocleidomastoid muscle (Figure 31-6). Identify the thyroid gland and carotid artery in addition to the internal jugular vein. Do not attempt needle insertion before visualizing all three structures.
US-guided localization of the internal jugular vein. US image of the large internal jugular vein and deeper carotid artery. Probe position (A) and corresponding US image (B). CA = carotid artery; IJ = internal jugular vein.
The three traditional approaches to internal jugular vein catheterization are central, posterior, and anterior. The right internal jugular has a shorter, straighter course to the superior vena cava and avoids injury to the thoracic duct on the left; use this site unless contraindications exist.
Place the patient in Trendelenburg position, head slightly tilted to the contralateral side. The landmark for the central approach is the triangle created by the clavicle and the sternal and clavicular heads of the sternocleidomastoid. The internal jugular vein lies just deep to this triangle. Insert the needle at a 30- to 45-degree angle to the skin, 1 cm below the apex of the triangle, parallel to the carotid artery located medially, and directed toward the ipsilateral nipple (Figure 31-7). Successful venous return typically occurs within 1 to 3 cm of needle advancement.
Central approach to the internal jugular vein.
The landmark for the posterior approach is the lateral aspect of the clavicular portion of the sternocleidomastoid, one third of the distance from the clavicle to the mastoid process. The needle is directed toward the sternal notch (Figure 31-8). Successful venous return typically occurs within 3 to 5 cm of needle advancement.
Posterior approach to the internal jugular vein.
Identify the pulse and course of the carotid artery, which lies just medial to the site of entry for the anterior approach. Hold the carotid artery with fingers of the nondominant hand. Hold the needle and syringe in the dominant hand at an angle of 30 to 45 degrees and enter at the midpoint of the medial aspect of the sternal portion of the sternocleidomastoid muscle. Aim the needle toward the ipsilateral nipple (Figure 31-9). Successful venous return typically occurs within 3 to 5 cm of needle advancement.
Anterior approach to the internal jugular vein.
See Table 31-8 for a summary of traditional approaches to internal jugular vein catheterization.
TABLE 31-8Summary of Approaches to Internal Jugular Vein Catheterization |Favorite Table|Download (.pdf) TABLE 31-8 Summary of Approaches to Internal Jugular Vein Catheterization
| ||Landmarks ||Direction of Aim ||Depth of Vein (cm) |
|Central ||Apex of triangle formed by the clavicle and sternal and clavicular components of the sternocleidomastoid muscle ||Ipsilateral nipple ||1–3 |
|Posterior ||Lateral aspect of the clavicular portion of the sternocleidomastoid, one third of the distance from the clavicle to the mastoid process ||Sternal notch ||3–5 |
|Anterior ||Midpoint of the medial aspect of the sternal portion of the sternocleidomastoid, lateral to the carotid artery ||Ipsilateral nipple ||3–5 |
The location of the subclavian vein allows patient mobility and is an excellent choice for longer-term use.
The supraclavicular approach allows good sonographic visualization of the proximal subclavian vein anatomy. The infraclavicular approach to US-guided subclavian vein catheter placement is limited by the large acoustic shadow created by the clavicle (Figure 31-10).
US-guided localization of the subclavian vein. A. Placement of the transducer to facilitate visualization of the internal jugular/subclavian vein junction using a supraclavicular approach. In some patients, a more lateral probe position is required. B. Transverse view of the "venous lake" created by the combined subclavian (SUBCL) vein and internal jugular (IJ) vein.
The two traditional approaches to the catheterization of the subclavian vein are the infraclavicular and supraclavicular (Figure 31-11).
Anatomy of the subclavian vein. A. Anatomy of the subclavian vein. B. Cross-section of the subclavian vein with its relation to the clavicle.
Place the patient head down and in a neutral position with a small towel under the thoracic spine to help identify the clavicle. The landmark for the site of entry is the junction of the middle and medial thirds of the clavicle. Orient the bevel of the needle inferomedially to direct the guidewire to the brachiocephalic trunk rather than the internal jugular vein. Align the numbered markings on the syringe with the bevel of the needle to guide the orientation of the bevel once the needle has breached the skin. Place the index finger of the nondominant hand at the suprasternal notch and the thumb at the midpoint of the clavicle. Direct the needle toward the suprasternal notch at a 10-degree angle parallel to the surface of the chest (Figure 31-12). If the clavicle is encountered, "walk" the needle down the clavicle until the needle is posterior to it. Successful venous return occurs typically at a depth of 3 to 5 cm.
Infraclavicular approach to the subclavian vein.
The supraclavicular approach is often referred to as the "pocket-shot." The supraclavicular approach has fewer failures, fewer catheter malpositions, and less interference with CPR than the infraclavicular approach. It may also be performed in the upright position in patients unable to lay supine in the setting of severe orthopnea.
The landmark for entry is 1 cm lateral to the clavicular head of the sternocleidomastoid and 1 cm posterior to the clavicle. Enter at an angle of 10 degrees above horizontal. Orient the bevel of the needle medially, bisecting the angle formed by the clavicle and sternocleidomastoid toward the contralateral nipple. Successful venous return typically occurs at a depth of 2 to 3 cm (Figure 31-13).
Supraclavicular approach to the subclavian vein.
The risk of pneumothorax is higher when cannulating the subclavian vein. If attempts at subclavian venous access fail on one side, assess for pneumothorax using chest x-ray or US before attempting cannulation on the contralateral side.
The femoral vein is the most accessible central access site during critical illness, notably cardiac arrest.
Place the transducer in a transverse position just below the midportion of the inguinal ligament. Identify the femoral vein just below the inguinal ligament and medial to the femoral arterial pulsation. The vein is more easily compressed than the artery. The relationship among the vessels varies depending on limb position (Figure 31-14).
US-guided localization of the femoral vein. A. Gentle pressure is applied to the transducer to identify venous structures by their easy compressibility. B. Femoral vein (FV) collapses with compression, and the femoral artery (FA) retains its shape even with compression. C. FV position is seen to vary with hip abduction and external rotation. In neutral position (left frame), the vein is closely opposed to the FA; however, when the hip is abducted and rotated, the vein is displaced from the artery (right frame). [Part A used with permission of Michael Blaivas, MD.]
Place the patient supine in reverse Trendelenburg position with the hip slightly abducted and leg slightly externally rotated.7,8 Palpate the femoral artery, if possible. Classically, the femoral vein is just medial to the femoral artery and 1 to 2 cm below the inguinal ligament, although US often demonstrates an anomalous position, which is one reason why landmark-based insertions are less successful (Figure 31-15). Use a 45-degree angle of approach.
Technique for femoral vein access.
In pulseless arrest, locate the femoral vein using the "V" technique. Place the thumb on the pubic tubercle and the index finger on the anterior superior iliac spine. The femoral vein is typically located at the interdigital space (the "V" of the finger and thumb) just inferior to the inguinal ligament.
Always insert the needle below the inguinal ligament, because vascular injury above the inguinal ligament may cause severe hidden hemorrhage into the retroperitoneal space.
Limit femoral vein cannulation because of the higher complication rates (notably infection and thrombosis) and the limits it places on patient mobility.