Percutaneous cannulation of the central veins is an essential technique for both long-term and emergent medical care. Access to the major veins of the torso allows rapid high-volume fluid resuscitation, administration of concentrated ionic and nutritional solutions, and hemodynamic measurements.
Obtaining venous access is an essential skill for the Emergency Physician. Indications for peripheral venous access are broad, ranging from simple fluid and medication administration to delivery of intravenous (IV) contrast for imaging studies. Central venous access is less often compulsory, but still remains an indispensable procedure in the practice of Emergency Medicine. Central venous access allows for multiple critical actions to be performed from the administration of blood products and vasoactive medications to transvenous cardiac pacing. Central venous access is often undertaken in cases where peripheral IV access cannot be obtained.
Even the most experienced provider can have difficulty securing rapid and functional access to the venous system in specific situations such as severe dehydration, cardiac arrest, large body habitus, and injection drug users with sclerosed veins. The classical “blind” technique, based on anatomical and vascular landmarks, has been the most commonly taught method. The growing integration of bedside ultrasound (US) into the practice of Emergency Medicine has slowly changed the way Emergency Physicians are choosing to perform central venous access. US visualization of the patients' vascular anatomy allows the specific advantage of determining the ideal location to access the central venous circulation. A thrombosed femoral vein can be identified, allowing the Emergency Physician to preemptively choose another site. The visualization of the overlap of the right internal jugular vein and the carotid artery may prevent inadvertent arterial puncture and the resultant sequelae in the anticoagulated patient. US guidance for central venous access has altered the clinical algorithm of obtaining vascular access, making the procedure easier for the Emergency Physician and safer for the patient.
Evidence supporting US guidance for central vascular access is fairly robust.1–5 Convincing data from the Critical Care and Emergency Medicine literature indicate an increased success rate and a decrease in the complication rates. Recently, the Agency for Healthcare Research and National Institute for Clinical Excellence both recommended US guidance for central venous access. The availability of small, low cost, and portable US machines has made US guidance for central venous access a requisite skill for all Emergency Physicians. A brief description of US-guided central venous access is discussed in the following sections as appropriate. Refer to Chapter 50 for the complete details.
The tip of the central venous catheter must lie in the superior or inferior vena cava and never in the right atrium. The thin wall of the right atrium may easily be perforated by the catheter tip, resulting in hemorrhage and cardiac tamponade. The central venous anatomy is shown in Figure 49-1. The superior vena cava is accessed through the internal jugular veins, the subclavian veins, and less commonly via the external jugular ...