4. Introduction
⢠Central venous access refers to lines placed
into the large veins of the neck, chest, or groin
and is a frequently performed invasive
procedure which carries a significant risk of
morbidity and even mortality.
5. ⢠This procedure should be carried out in
operating theatre or high-dependency care
areas, always using a fully aseptic technique.
6. Indications
⢠Monitoring of central venous pressure in critically ill
patient and after major surgery
⢠Infusion of irritant drugs that may damage smaller
veins.
⢠Insertion of pacing wires.
⢠Renal replacement therapy.
⢠Emergency venous access.
⢠Parenteral feeding.
⢠Resuscitation of patients who are intravascularly
depleted.
7. Relative Contraindications
⢠Uncorrected coagulopathy
⢠Thrombocytopenia
⢠Skin infection over the site of access
⢠Obscure anatomical landmarks
⢠Haemo or pneumothorax on the contralateral
side
⢠Recent surgery to other structures nearby
such as carotidendartectomy
9. Site Advantage Disadvantage
Subclavian â˘Lower risk of infection
â˘Does not require
movement of patientâs
head and can be
accessed during c-spine
immobilisation
â˘Useful in emergencies
â˘Vein does not collapse
fully in hypovolaemic
states
â˘Highest chance of
pneumothorax
â˘Puncture of
tracheostomy or ET tube
cuff
â˘Cannot apply pressure to
stop bleeding
â˘Can be painful even with
good skin anaesthesia
â˘Less easy to visualise
with USG
10. Site Advantaqge Disadvantage
Internal
jugular
â˘Anatomy readily visible
with ultrasound
â˘Can be adapted to
accommodate patient
size
and position
â˘Easily accessed surface
of patient
â˘Puncture of internal
carotid or misplaced
line in the internal
carotid
â˘Pneumothorax is a
recognised
complication
â˘Difficult to nurse long
term.
11. Site Advantaqge Disadvantage
Femoral â˘Safest vein to place large
lines, for example for
venoâveno
haemofiltration because
there are
fewer important
structures nearby.
â˘Puncture of femoral
artery can usually be
treated
with pressure
â˘Femoral artery
puncture leading to
retroperitoneal
bleed
â˘Femoral nerve
damage
â˘Difficult to nurse
and keep clean
â˘Highest likelihood
of infection
12. Central line kit containing: Additional items:
⢠needle or a cannula over needle
⢠central venous catheter
⢠guidewire
⢠dilator
⢠anchoring clips.
⢠suture
⢠scalpel
⢠appropriate dressing
⢠syringes
⢠blue and green needles
⢠three-way taps, one for each lumen
⢠drapes
⢠cleaning fluid (2% chlorhexidine gluconate in
70% isopropyl alcohol is recommended)
⢠swabs
⢠Gallipot or similar
⢠sterile ultrasound probe sheath
⢠0.9% normal saline
Equipments needed
13.
14. Basic Principles
⢠Must Decide if the line is really necessary
⢠Should know the anatomy
⢠Should be familiar with the equipments
⢠Must obtain optimal patient positioning and cooperation
⢠Should not try to do it fast
⢠Must use sterile technique
⢠Always have a hand on the guide wire
⢠Should ask for help
⢠Always aspirate as you advance as you withdraw the
needle slowly
⢠Always withdraw the needle to the level of the skin before
redirecting the angle
⢠Obtain chest x-ray post line placement and review it
15. Subclavian Approach
⢠Positioning
â Right side preferred
â Supine position, head neutral, arm abducted
â Trendelenburg (10-15 degrees)
â Shoulders neutral with mild retraction
â Right side preferred
⢠Needle placement
â Junction of middle and medial thirds of clavicle
â At the small tubercle in the medial deltopectoral groove
â Needle should be parallel to skin
â Aim towards the supraclavicular notch and just under the
clavicle
16.
17. Internal Jugular Approach
⢠Positioning
â Right side preferred
â Trendelenburg position
â Head turned slightly away from side of venipuncture
⢠Needle placement: Central approach
â the triangle formed by the clavicle and the sternal and
clavicular heads of the SCM muscle is located
â three fingers of left hand are gently palced on carotid
artery
â Needle should be placed at 30 to 40 degrees to the
skin, lateral to the carotid artery
â Aim toward the ipsilateral nipple under the medial
border of the lateral head of the SCM muscle
â Vein should be 1-1.5 cm deep, deep probing in the
neck should be avoided.
22. Post-Catheter Placement
⢠Aspirate blood from each port
⢠Flush with saline or sterile water
⢠Secure catheter with sutures
⢠Cover with sterile dressing (tega-derm)
⢠Obtain chest x-ray for IJ and SC lines
⢠Write a procedure note
23. Procedure Note
⢠Name of procedure
⢠Indication for procedure
⢠Comment on consent, if applicable
⢠Describe what you did, including prep
⢠Comment on aspiration/flushing of ports
⢠How did patient tolerate procedure
⢠Any complications
24. Maintenance of CV line
⢠Hepsol flush 8 hourly
⢠Central Short channel is used for measuring
CVP
⢠Rest two channels are used for medication
and TPN
⢠The dressing should be changed at regular
interval
⢠Catheter should not be kept for more tha 3
weeks
25. Ultrasound-Guided Central Venous
Access
⢠Becoming standard of care
⢠Vein is compressible
⢠Vein is not always larger
⢠Vein is accessed under direct
visualization
⢠Helpful in patients with
difficult anatomy
30. ⢠Venous cutdown is a surgical technique by
which a selected vein is exposed and
mobilised and then cannulated under direct
vision.
⢠It has been largely replaced by central venous
and intraosseous access, but remains a useful
alternative when other methods fail or are not
available.
31. Cutdown sites
⢠Basilic vein (antecubital fossa)
⢠Adult: 2â3 cm lateral to the medial epicondyle
of the humerus.
⢠Child: 1â2 cm lateral to the medial epicondyle
of the humerus.
32. Cutdown sites
Long saphenous vein (groin)
⢠Adult: 4 cm inferior and lateral to the pubic
tubercle.
Long saphenous vein (ankle)
⢠Adult: 2 cm anterior and superior to the
medial malleolus.
⢠Child: 1 cm anterior and superior to the
medial malleolus.
33. Step-by-step cutdown method
⢠Place a venous tourniquet proximal to
intended cutdown site where possible.
⢠Identify cutdown site and inject local
anaesthetic along the intended incision line if
the patient is conscious.
⢠Make a transverse incision through skin being
careful not to damage the underlying vein
⢠Spread the skin and identify the vein lying at
right angles to the line of the incision.
34. ⢠Mobilise a 2-cm length of vein by blunt
dissection using curved forceps
⢠Pull a loop of suture (e.g. 2/0 vicryl) under
vein.
⢠Cut the loop to form proximal and distal
sutures.
35. ⢠Tie off distal suture and transfix vein with a
needle
⢠Make a vertical stab incision down onto the
transfixing needle to produce a hole
(venotomy) in the anterior vein wall
⢠Insert a cannula or the cut end of a sterile
giving set through venotomy into vein
⢠Tie off proximal suture around vein and
inserted cannula.
⢠Suture and dress wound.
36. Complications of venous cutdown
⢠Damage to adjacent structures
⢠Posterior wall perforation
⢠Haematoma
⢠Extravasation of fluid or drugs
⢠Local cellulites
⢠Phlebitis
⢠Venous thrombosis
⢠Scarring