Chapter 38 CENTRAL VENOUS ACCESS

Home , Jugular vein, Subclavian vein, Venous access

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Robert Feldman

INTRODUCTION icular heads of the sternocleidomastoid muscle. The internal jugular vein increases in diameter as it descends. Percutaneous cannulation of the central veins is an es- It is joined by tributary veins in the upper neck, making sential technique for both long-term and emergent med- it easier to cannulate below the level of the cricoid ical care. Access to the major veins of the torso allows cartilage. rapid high-volume fluid resuscitation, administration of The internal jugular vein is collapsible (Figure 38-3). It concentrated ionic and nutritional solutions, and hemo- has a very small diameter in low-flow states, as during dynamic measurements. cardiopulmonary resuscitation (CPR) and when the patient is upright. The vein is easily compressible and will collapse with gentle external pressure from a palpating ANATOMY AND PATHOPHYSIOLOGY finger or a large-diameter needle indenting the skin (Fig- ure 38-3B). Fortunately, the vein is also very distensible. The tip of the central venous catheter must lie in the Placing the patient in the Trendelenburg position or hav- superior or inferior vena cava and never in the right ing the patient perform the Valsalva maneuver will dis- atrium. The thin wall of the right atrium may easily be tend the vein and help to locate the vessel (Figure 38-3C). perforated by the catheter tip, resulting in hemorrhage The common carotid artery travels alongside the in- and cardiac tamponade. The central venous anatomy is ternal jugular vein and is an important anatomic land- shown in Figure 38-1. The superior vena cava is accessed mark for locating the internal jugular vein. The carotid through the internal jugular veins, the subclavian veins, artery runs deep and slightly anterior to the internal and less commonly via the external jugular veins. The jugular vein. The left internal jugular vein usually over- inferior vena cava is accessed through the femoral veins. laps the carotid artery in the lower neck (Figure 38-3A). These access routes are discussed in greater detail in the The right internal jugular vein and the right carotid ar- corresponding sections below. The advantages and dis- tery are usually separated slightly. advantages of each route for central venous access are The right internal jugular vein is generally preferred summarized in Table 38-1. to the left internal jugular vein as the site of central venous cannulation. The right internal jugular vein pro- INTERNAL JUGULAR VEIN vides a nearly direct route to the superior vena cava. The The internal jugular vein is not directly visible from dome of the right lung is somewhat lower than that of the surface of the skin. A thorough knowledge of its the left lung and thus decreases the chance of a pneu- anatomic relationships is essential for successful cannu- mothorax. The thoracic duct is relatively large and lies lation. The internal jugular vein exits the skull through high in the left chest. These favor the right internal jugu- the jugular foramen, just anteromedial to the mastoid lar approach to central venous cannulation to minimize process.1 It joins the subclavian vein deep and just lat- complications.1,2 eral to the head of the clavicle1 (Figure 38-2). The surface There are three main approaches to the internal jugu- projection of the internal jugular vein runs from the ear- lar vein as defined by their relationship to the sternoclei- lobe to the medial clavicle, between the sternal and clav- domastoid muscle. These are the anterior, central, and

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Brachiocephalic veins Internal and external jugular veins Left subclavian vein

Superior vena cava

Right atrium

Inferior vena cava Common Aorta iliac vein

Anterior superior iliac spine

Inguinal ligament Femoral vein

Pubic symphysis FIGURE 38-1 The anatomy of the central venous system.

posterior approaches (Figures 38-4, 38-5, and 38-6). The ternal jugular vein and form the brachiocephalic trunk, central approach is most commonly used. These three which empties into the superior vena cava. approaches are summarized in Table 38-2. The subclavian veins are 1 to 2 cm in diameter in an adult. Fibrous connective tissue joins the subclavian SUBCLAVIAN VEIN vein to the clavicle and ﬁrst rib, preventing collapse of The subclavian vein begins as the continuation of the the vessel even in the event of a cardiac arrest. Anatomi- axillary vein at the lateral edge of the ﬁrst rib1,3–5 (Figure cally associated structures include the thoracic duct, 38-7). The subclavian vein courses anterior to the ante- which joins the left subclavian vein at its junction with rior scalene muscle, which separates it from the subcla- the left internal jugular vein. The right subclavian vein is vian artery. The subclavian vein descends to join the in- preferred to the left for central venous access for this

TABLE 38-1. CHARACTERISTICS OF THE VARIOUS ROUTES OF CENTRAL VENOUS CANNULATION

Internal jugular External jugular vein vein Subclavian vein Femoral vein

Risk of infection Low Low Low High Patient mobility Fair Poor Good Bedridden Trendelenburg required? Yes Yes Yes No, best for CHF or dyspnea Need to stop CPR? Probably Probably Yes No, may continue CPR Suitable for long-term use? Yes, but not if ambulatory No Yes—best choice No, remove within 2–3 days Risk of venous thrombosis Low Low Low High 0162t_c038_ 5/20/03 1:32 PM Page 316 mac111 mac111: 272_VE:

316 SECTION THREE / VASCULAR PROCEDURES

Left common Left subclavian carotid artery vein and artery Facial vein Aortic arch

Superior vena cava

Right brachiocephalic artery and vein Apex of lung Mastoid Internal process jugular vein

FIGURE 38-2 Anatomy and surface relationships of the internal jugular vein.

reason. The domes of the pleura lie posterior and infe- pulse. During CPR chest compressions, attempt punc- rior to the subclavian veins and medial to the anterior ture directly over the pulsations if an initial attempt at scalene muscles. The subclavian arteries lie immediately femoral vein cannulation medial to the pulse fails. posterior to the veins. The puncture site to enter the femoral vein must be at Subcutaneous fatty tissue, chest morphology, the least 1 to 2 cm inferior to the inguinal ligament, depend- close proximity of the pleura, and the close proximity of ing on the patient’s size. The femoral vein becomes the the subclavian artery make the subclavian vein the least external iliac vein superior to the inguinal ligament favored site for central venous access in children. This is (Figure 38-8). Blood can ﬂow freely into the retroperi- especially true in infants. An experienced practitioner toneal space,forming a potentially large and externally should perform the procedure if this route must be used invisible hematoma if the posterior wall of the femoral in a neonate, infant, or small child. vein is punctured by a through-and-through needle track above the inguinal ligament. It is imperative to FEMORAL VEIN puncture the femoral vein inferior to the inguinal The puncture site for femoral vein cannulation lies ligament! medial to the femoral artery and inferior to the inguinal ligament1,2,6 (Figure 38-8). The femoral vein lies within the femoral sheath and just medial to the femoral artery INDICATIONS in the groin. This relationship can be remembered by the mnemonic “toward the NAVEL.” This describes, from The internal jugular route is acceptable for central ve- lateral to medial, the contents of the femoral sheath nous access in most cases. It allows ready access to the (femoral Nerve, femoral Artery, femoral Vein, Empty superior vena cava for long-term central venous access, space, and Lymphatics). The femoral artery lies at the caustic infusions, and monitoring of central venous midpoint of a line connecting the symphysis pubis and pressure. Pulmonary artery catheters and transvenous the anterior superior iliac spine.1,6 The femoral vein lies pacing wires can be introduced through the right inter- approximately 1 cm medial to the femoral artery pulse in nal jugular vein. The internal jugular vein is accessible an adult.3,7 It lies approximately 5 mm medial to the without terminating CPR efforts, although chest com- femoral artery in infants and young children.3,7 The pressions and the lack of carotid pulsations make access- femoral venous pulse may be felt instead of the arterial ing it difﬁcult. The risk of a pneumothorax is probably 0162t_c038_ 5/20/03 1:32 PM Page 317 mac111 mac111: 272_VE:

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A C

FIGURE 38-3 Ultrasonic cross sections of the left internal jugular vein (IJV) and carotid artery (CA). A. The patient is supine. B. With gentle external pressure applied, the low- pressure internal jugular vein collapses easily while the carotid is still patent. C. The Valsalva maneuver or placement of the patient in the Trendelenburg position dilates the internal jugular vein.

less with the internal jugular vein cannulation as position. Femoral venous access is relatively easy during opposed to the subclavian vein route, although patient CPR and often does not require the cessation of chest mobility is less and discomfort is greater. In a coagulo- compressions. The femoral vein is easily compressible. pathic patient, the internal jugular vein puncture site is This makes it preferable to the subclavian vein in coagu- compressible, but hematoma formation may lead to lopathic patients or those undergoing thrombolysis, compromise of the airway. although peripheral access would be preferred in these The subclavian vein is the preferred route for longer- cases.8 There is no risk of injury to the airway, pleura, or term central venous access. This site allows for ambula- carotid arteries in very young or combative patients. tion (unlike a femoral line) and neck movement without Femoral central venous lines are generally preferred for discomfort (unlike a jugular line). The catheter is con- initial central venous access in the very young or com- cealable under clothing, making outpatient use more bative patient if deep sedation or neuromuscular paraly- acceptable. sis is contraindicated or otherwise unnecessary.3 The femoral vein is often the preferred route for emergency central venous cannulation in many patients. The indications are the same as for any central CONTRAINDICATIONS venous access with a few exceptions. The femoral vein is not a suitable route for ambulatory patients beyond the The usual contraindications to any invasive proce- initial resuscitation and stabilization period, as patients dure apply to central venous access. Cellulitis or overly- with femoral central venous lines must be conﬁned to ing infection at the puncture site is a contraindication to bed. Femoral venous access is easily obtained in pa- central venous access. An alternative should be sought if tients with respiratory distress and pulmonary edema, the patient is combative, agitated, or uncooperative. since they do not need to be placed in the Trendelenburg These patients require sedation and/or paralysis prior to 0162t_c038_ 5/20/03 1:32 PM Page 318 mac111 mac111: 272_VE:

318 SECTION THREE / VASCULAR PROCEDURES

FIGURE 38-4 Central approach to the right internal jugular vein.

insertion of the central venous line. Distorted anatomic nel capable of managing complications are immedi- landmarks due to fractures, deformities, obesity, previ- ately available. ous catheterization at the site, surgery, or trauma are relative contraindications. There is a small but real risk of INTERNAL JUGULAR VEIN CANNULATION serious morbidity and even death due to the procedure. Anatomic distortion of the neck, such as from subcu- Do not place a central venous line unless a peripheral taneous emphysema or a hematoma, may make place- line is inadequate or unobtainable and unless person- ment of an internal jugular line difﬁcult and hazardous.

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FIGURE 38-6 Posterior approach to the right internal jugular vein.

Known severe carotid artery stenosis or atherosclerosis venous line is preferable in this case. Successful internal on the desired side of cannulation is a relative con- jugular cannulation requires the patient to be placed traindication to internal jugular vein cannulation. Acci- supine and preferably in 15 to 30 degrees of Trendelen- dental carotid artery puncture during line placement burg tilt. This may be impossible in a patient with severe may result in plaque rupture and subsequent stroke. The pulmonary compromise. The femoral route is preferred vein may be collapsed and difficult to access in the hypo- in this case. Internal jugular vein cannulation is difficult volemic patient. Other contraindications to cannulating in children under 1 year of age due to poor landmarks the internal jugular vein include cervical spine fractures and a very short neck.3 Internal jugular cannulation is (actual or suspected) or penetrating neck injuries. contraindicated in any child who cannot be adequately The subclavian or femoral route may be preferable in immobilized or paralyzed after insertion of the central some circumstances. The subclavian route is probably a venous line. Internal jugular cannulation will be more better choice for long-term lines in ambulatory patients, difficult if the patient’s neck cannot be turned. as for hemodialysis. The limited neck mobility due to an A left bundle branch block is a relative contraindica- internal jugular line is very uncomfortable. Ongoing or tion to central venous cannulation. The guidewire can impending thrombolytic administration is a contraindi- induce complete heart block when it enters the right cation to internal jugular puncture. A femoral central ventricle.9 Extreme caution should be used if an internal

TABLE 38-2. APPROACHES TO THE INTERNAL JUGULAR VEIN

Central Anterior Posterior

Insertion landmark Superior apex of the triangle Medial edge of the Lateral edge of sternocleidomastoid formed by the two heads of the sternocleidomastoid muscle muscle, 1/3 of the way from the sternocleidomastoid muscle at level of thyroid cartilage clavicle to the mastoid process and the clavicle Angle with skin 30° (child), 45–60° (adult) 30° (child), 45° (adult) 30–45°, dive under the border of the sternocleidomastoid muscle Aim toward Ipsilateral nipple Ipsilateral nipple Sternal notch Internal jugular vein Within 3 cm Within 3 cm Within 5 cm depth in an adult 0162t_c038_ 5/20/03 1:32 PM Page 320 mac111 mac111: 272_VE:

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External External jugular vein Stellate jugular vein ganglion Vertebral Internal artery jugular vein Scalenus anterior Esophagus muscle Internal jugular Brachial vein plexus Inferior trunk of brachial plexus Subclavian Trachea artery

Brachiocephalic artery Subclavian artery C D Pleura Subclavian Subclavian vein vein First rib Sternum Axillary Clavicle ABvein

Scalenus anterior Sternocleidomastoid muscle muscle Subclavian Subclavian artery Clavicle Dome of vein Dome of pleura Subclavian pleura artery Clavicle

Subclavian vein First rib

Pectoral muscles Pectoral muscles

CD First rib

FIGURE 38-7 The anatomy of the subclavian vein. A. The right subclavian vein. B. Magniﬁed view of the right subclavian vein demonstrating adjacent structures that may be injured during attempted cannulation. C. Sagittal section through the midclavicle. Note that the ﬁrst rib protects the subclavian artery during an infraclavicular approach to the subclavian vein. D. Sagittal section through the medial third of the clavicle. Note the proximity of the subclavian artery and pleural dome to the subclavian vein.

jugular or subclavian central line is necessary. Avoid in- Current or imminent systemic thrombolysis is an ab- serting the guidewire into the heart. Transcutaneous and solute contraindication to placing a subclavian vein transvenous cardiac pacing equipment should be read- catheter.8 Subclavian vein cannulation should be per- ily available. formed on the contralateral side if the patient is relying on a single lung. Chest wall deformities, distorted SUBCLAVIAN VEIN CANNULATION anatomy, and suspected vascular injury to the chest or The subclavian vein is incompressible and should be ipsilateral upper extremity are also contraindications. accessed with care in any patient who is coagulopathic. This route should also be avoided if the patient has had 0162t_c038_ 5/20/03 1:33 PM Page 321 mac111 mac111: 272_VE:

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Peritoneum Anterior superior iliac spine

Urinary bladder

Inguinal ligament Pubic symphysis

Femoral artery

Femoral vein

FIGURE 38-8 Anatomy of the femoral vein.

prior surgery or trauma to the clavicle, the first two ribs, EQUIPMENT or the subclavian vessels. Povidone iodine solution Sterile drapes or towels FEMORAL VEIN CANNULATION Local anesthetic solution Contraindications to femoral line placement include 25 gauge needle infection, venous thrombosis, or significant trauma to 5 mL syringes the ipsilateral lower extremity or groin area. Abdominal “Finder” needle, usually 22 gauge for an adult trauma may result in an interruption of the inferior vena 5 mL syringe with a nonlocking hub cava, allowing any infused fluid or blood to flow into the Thin-walled introducer needle or catheter-over-the- abdomen rather than into the central circulation. Dur- needle ing CPR, blood return below the diaphragm is reduced Guidewire and a femoral catheter must end near the level of the Gauze 44 squares diaphragm for medications to be most effective.6 Sterile gloves Catheterization via the internal jugular vein or sub- Central venous line clavian vein is usually easier if the purpose of central Dilator venous access is pulmonary artery catheterization or #11 scalpel blade transvenous cardiac pacing. These procedures often Nylon or silk suture, 3–0 or 4–0 require fluoroscopy when they are performed through Sterile saline the femoral vein. Central venous pressures measured Needle driver through a femoral vein catheter may be inaccurate Tape and catheter site dressing material unless the patient is perfectly supine. Catheter clamp, if supplied with the kit 0162t_c038_ 5/20/03 1:33 PM Page 322 mac111 mac111: 272_VE:

322 SECTION THREE / VASCULAR PROCEDURES

A variety of standard kits are commercially available A (Figure 38-9). They contain all required equipment except local anesthetic solution and sterile gloves. The appropriate catheter should be chosen based on the patient’s needs. The optimal catheter lengths for patients of different ages are summarized in Table 38-3. Catheters with between one and four lumens are available. Multiple-lumen catheters are available in a variety of sizes and allow simultaneous venous pressure measurement, administration of numerous medications, and venous sampling without disconnecting the infusion apparatus. Disadvantages of multiple-lumen catheters over single-lumen catheters include smaller lumen sizes for a given catheter’s outside diameter, greater cost, and the need to maintain unused lumens. There is probably no increased risk of infection in using triple-lumen versus single-lumen catheters.10–12 Some comparisons between these devices are summarized in Table 38-4. B Percutaneous sheaths are intended primarily for the introduction of intravascular devices, such as pulmonary artery catheters and transvenous pacing wires. They are most often used in the Emergency Department as a large- bore line for the rapid resuscitation of hypotensive and hypovolemic patients. Sheaths are available in many sizes and conﬁgurations. Many models have an ad- justable hemostasis valve that may be removed and a side port that allows infusion while the main lumen is being used for monitoring. The equipment required for subclavian vein cannulation is the same as that for internal jugular vein cannulation. Subclavian vein catheters must be slightly longer or inserted farther than internal jugular vein catheters. Left- sided catheters must be a few centimeters longer or inserted farther than right-sided catheters. The longer needle should be used for subclavian vein cannulation if the kit used has two different lengths of introducer needles.

PATIENT PREPARATION

The procedure, its risks, and its benefits should be ex- plained to the patient and/or their representative. Ob- tain an informed consent for the procedure unless it is being performed emergently. Place the patient in the FIGURE 38-9 Equipment needed for central venous Trendelenburg position if catheterization of the internal catheterization. A. A commercially available central venous jugular vein is being attempted. Position the patient in line kit. B. Examples of different catheter types available. at least 15 degrees of Trendelenburg to prevent an air From left to right: single-lumen, double-lumen, triple-lumen, embolism. Rotate the patient’s head toward the side and introducer sheath (Cordis). opposite that to be cannulated. The subclavian vein is fixed to the surrounding tissues adducted to the torso or in slight abduction if the deltoid and will neither collapse nor distend; therefore the Val- muscle is very large. Avoid placing rolled towels between salva maneuver or extremeTrendelenburg position is not the shoulder blades, as this can decrease the distance necessary.Head rotation is neither necessary nor helpful. between the clavicle and first rib, compress the subcla- On the side to be cannulated, place the patient’s arm vian vein, and make the procedure more difficult.13 0162t_c038_ 5/20/03 1:33 PM Page 323 mac111 mac111: 272_VE:

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TABLE 38-3. CATHETER SIZES AND TYPES

Catheter size Number of Minimum catheter (French) lumens Patient size Venous access site length (cm)*

2 1 Infant Femoral, internal jugular, external 5 jugular, or subclavian 31 5 kg Femoral, internal jugular, external 5 jugular, or subclavian 4 1, 2 5–10 kg Femoral 5 10–15 kg Femoral, internal jugular, external 8–12 jugular, or subclavian 5 1, 2, 3 15 kg Femoral, internal jugular, external 12–15 jugular, or subclavian 7 1 (sheath), 2, 3 40 kg Femoral, internal jugular, external 15–25 jugular, or subclavian 8 and larger 1 (sheath), 2, 3, 4 Adult Femoral, internal jugular, or subclavian 15–25

* The longer end of the catheter length range is for use in the subclavian veins, with the longest catheters needed for the left subclavian vein. SOURCE: Adapted from references 3, 7, and 37.

Place the patient supine or in slight reverse Trende- suturing the catheter in place. This allows the local anes- lenburg if femoral vein catheterization is being at- thetic to diffuse throughout the area and take effect tempted. The Trendelenburg position is contraindicated before the main procedure begins. Any distortion of due to the risk of venous air embolism. Slight external anatomic landmarks caused by anesthetic inﬁltration rotation and abduction of the extremity may be helpful. decreases as the anesthetic is absorbed into the subcu- It is easier for a right-handed operator to perform the taneous tissues. procedure on the patient’s right side. Apply electrocardiographic monitoring, pulse oxime- Identify the anatomic landmarks for the procedure try, and noninvasive blood pressure monitoring to the after positioning the patient. Clean any dirt and debris patient and administer supplemental oxygen. Electro- from the area of the puncture site. Apply povidone cardiographic monitoring during insertion of a central iodine solution and allow it to dry.14 It is recommended line is recommended due to the risk of ventricular dys- to prepare the entire neck and clavicular area if the rhythmias should the guidewire or catheter enter the internal jugular or subclavian routes are attempted so right ventricle. It is preferable to have a designated that, if access to one site is unsuccessful, another site person—physician or nurse—whose only job is to watch may by accessed without reprepping and draping. the monitoring equipment. The patient’s face and chest Due to the risk of inducing a pneumothorax, attempts will be draped for the internal jugular or subclavian vein at contralateral internal jugular or subclavian vein cannulation procedure. The operator will be focused on cannulation after an unsuccessful attempt must be the procedure and unaware of any sudden patient dete- delayed until a chest radiograph is checked to prevent rioration, ventilator disconnect, or other irregularities. bilateral pneumothoraces. Resuscitation equipment should be immediately avail- Inﬁltrate the subcutaneous tissues at the needle able. A postinsertion chest radiograph to verify line puncture site with a generous volume of local anesthetic placement and the lack of a pneumothorax must be solution, including any areas that will be used for immediately available.

TABLE 38-4. COMPARISONS BETWEEN CENTRAL VENOUS CATHETER TYPES

Single-lumen Multiple-lumen Sheath (Cordis)

Minimum outer diameter Smallest Intermediate Largest Infusion rate Moderate Lowest (resuscitation catheters Fastest (for central lumen; side with larger lumen available) port is slower) Simultaneous infusions, or No Yes Yes, if central lumen and side infusion while monitoring port both used Length Varies, fairly long Long Short Allows device insertion No No Yes (pulmonary artery lines and transvenous pacemakers) 0162t_c038_ 5/20/03 1:33 PM Page 324 mac111 mac111: 272_VE:

324 SECTION THREE / VASCULAR PROCEDURES

Prepare for the procedure. Apply sterile gloves, a on insertion or removal.Doing so may injure the vessel, sterile gown, and a face mask if the situation is not a break the guidewire,and/or embolize the guidewire. life-threatening emergency. Some physicians prefer to Attach the thin-walled introducer needle to a 5 mL sy- double-glove. If one glove becomes contaminated, it ringe containing 1 mL of sterile saline or local anesthetic can be discarded and the procedure continued without solution. The specially designed introducer needle in- interruption. Open the desired venous access kit. Per- cluded with the catheter should be used, as it has a rela- form a quick inventory and identify all necessary equip- tively thin wall and a larger internal diameter relative to ment before beginning the procedure. Set up a sterile its external diameter. It has a shorter bevel than a con- field next to the patient and within easy reach. Place the ventional hypodermic needle. It also has a tapered hub equipment that must be immediately at hand on to guide the guidewire into the needle proper. the sterile field. This includes a sterile drape, syringe, If there is doubt about the exact location of the vein, it large-bore hollow needle, guidewire, and gauze squares. may first be located with a small “finder” needle. Insert a Any other equipment, including the catheter itself, may 25 or 27 gauge needle attached to a 5 mL syringe through be temporarily set aside on a bedside stand. the skin puncture site previously chosen. Advance the needle at a 30 to 60 degree angle to the skin while apply- ing negative pressure to the syringe. A flash of blood sig- INTERNAL JUGULAR VEIN nifies that the tip of the needle is within the vein. Note CATHETERIZATION TECHNIQUES the depth and location of the vein. Remove the finder needle. Alternatively, the finder needle may be left in CENTRAL APPROACH TO THE INTERNAL place for reference. JUGULAR VEIN Insert the introducer needle at a 30 to 60 degree angle While an internal jugular vein cannula can be inserted at the apex of the triangle formed by the sternal and using the over-the-needle and through-the-needle tech- clavicular heads of the sternocleidomastoid muscle and niques, the Seldinger technique is often preferred.15,16 the clavicle (Figure 38-4). This point is just lateral to the See Chapter 36 and Table 38-5 for a more complete carotid artery pulse.2,3 Direct the introducer needle discussion. The Seldinger technique uses a flexible toward the ipsilateral nipple. Shallower angles make it guidewire, inserted through a special thin-walled hollow necessary to traverse a greater amount of subcutaneous needle, to guide a catheter of any desired length through tissues and structures before entering the vessel. Steeper the skin and into the central circulation. This technique angles make insertion of the catheter over the guidewire is described below and summarized in Table 38-6.2 difficult, as the guidewire tends to kink. Shallower angles Clean, prep, and drape the area as described previ- are generally necessary in children whose vessels are ously. Place the patient in the Trendelenburg position smaller. Inject a small amount of the fluid in the syringe with the head down 15 to 30 degrees. Rotate the patient’s to remove any skin plug that may block blood return head away from the side that will be cannulated. Exces- once the vein has been penetrated. sive rotation will distort the anatomic landmarks and Apply negative pressure to the syringe by withdraw- may bring the internal jugular vein closer to the carotid ing the plunger. Advance the introducer needle into the artery. vein (Figure 38-10A). If the vein is not located within 3 to Several cardinal rules for the insertion of the 5 cm of the skin—this distance will vary depending on catheter should be observed. Always occlude the open the patient’s size and the target vessel’s location—stop hub of a needle or catheter in a central vein to prevent advancing the introducer needle. Withdraw the needle an air embolism. Never let go of the guidewire, so as slowly while continuing to aspirate. Often, the vessel will to prevent its embolization into the central venous have been completely traversed and no blood will return circulation.Neverapplyexcessiveforcetotheguidewire due to collapse of the vein by the pressure of the skin

TABLE 38-5. COMPARISON OF CATHETERIZATION METHODS

Seldinger Catheter-over-the-needle Catheter-through-the-needle

Insertion needle Small Large Largest Speed Slowest Fastest Fast Number of steps 4 12 Risk of catheter shear None Low Highest Catheters and lumens Single- or multiple-lumen, Single-lumen only Single-lumen only available sheath/introducer Rate of infusion Highest (with sheath) Moderate Low to moderate 0162t_c038_ 5/20/03 1:33 PM Page 325 mac111 mac111: 272_VE:

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TABLE 38-6. SUMMARY OF THE SELDINGER METHOD OF CENTRAL VENOUS CANNULATION*

Step Action Tips and caveats

1 Prep and drape the skin puncture site. For internal jugular vein, prepping down to the clavicle and up to the jaw will enable an attempt at the ipsilateral subclavian vein (or vice versa). 2 Anesthetize the puncture site if not already done. Anesthetize the suture sites also. 3 Uncap the distal lumen. Additional lumens may be flushed at this point or after insertion, as desired. 4 Locate the vein using the finder needle and aspirating syringe. Internal jugular vein should be reached within 3 cm. Stop advancing after 4–5 cm if the vein is not located. 5 Remove the finder needle, noting the direction and depth of A few drops or a line of blood may be left on the skin as the the internal jugular vein. Or withdraw the needle slightly so it finder is withdrawn to show the proper direction. is outside the internal jugular vein and leave it in place as a guide. 6 Insert introducer needle on a syringe along the “finder’s” path Syringe must have a nonlocking hub. A little saline in the until venous blood is aspirated. Alternatively, an introducer syringe allows any occluding skin plug to be ejected. The vein catheter and needle assembly can be used to cannulate the is often located on withdrawal of the needle, since the friction internal jugular vein; the needle is then withdrawn. of the large needle in the tissues can compress the internal jugular vein. 7 Disconnect the syringe from the needle, immediately Do not move the needle at all! Keep the hand holding the occluding the open needle hub to prevent air embolism. needle in contact with the patient’s skin to prevent movement. 8 Insert the guidewire through the introducer needle and into Do not move the needle! Do not force the guidewire—it should the vein. pass easily! 9 Advance the guidewire into the vein to the desired depth or The guidewire must be securely in the vein, not just in the until ventricular ectopy is seen on the ECG monitor. subcutaneous tissue. 10 Withdraw the introducer needle a few millimeters and use the Keeping the needle in place eliminates any possibility of scalpel to enlarge the puncture site slightly. cutting the guidewire. 11 Remove the introducer needle. Never let go of the guidewire! 12 Thread the dilator over the guidewire until it can be grasped Always keep a firm grip on the guidewire! outside the hub, then insert and withdraw the dilator. 13 Thread the catheter tip over the guidewire and withdraw the Never let go of the guidewire. guidewire from the skin until it can be grasped at the infusion hub. 14 Insert the catheter to the desired depth; most catheters are The tip of the catheter should be in the superior vena cava, at marked in centimeters, with larger markings every 5 and the level of the manubriosternal angle. 10 cm. Introducer sheaths should be inserted completely. 15 Holding the catheter in place, remove the guidewire. Occlude Do not apply excessive force to the guidewire. If it is trapped, the open hub with a gloved finger to prevent air embolism. withdraw the catheter a few centimeters and try again. Do not break the wire! 16 Attach a syringe to the catheter hub and aspirate blood, taking Other lumens may be aspirated, flushed, and clamped. samples as desired; then flush the lumen with saline and begin the desired venous infusion. 17 Verify intravenous placement before suturing the catheter in If the patient’s blood travels up the intravenous tubing, the place. catheter is in the carotid artery! 18 Remove the patient from the Trendelenburg position. 19 Suture the catheter to the skin with sutures and tape. Take care not to puncture the catheter or to occlude it with a tight suture. 20 Apply a dressing to the catheter site. 21 Verify catheter tip position by chest x-ray. Catheter tip must be in the superior vena cava, not in the right atrium. Tip should be above the azygos vein and the carina, with the tip parallel to the vessel wall.

* The central approach to the internal jugular vein is used as an example, although the same technique is used for other approaches and central veins.

being forced inward as the introducer needle passes carotid artery pulse, as even gentle pressure may col- through it. Under normal physiologic conditions, veins lapse the internal jugular vein (Figure 38-3B). have very low pressures within them and are easily col- Stabilize and hold the introducer needle perfectly still lapsed by external pressure. If no blood is aspirated with the nondominant hand once blood returns in the while withdrawing the needle, withdraw the introducer syringe. The carotid artery has been entered if the blood needle to the subcutaneous plane and redirect it slightly is bright red and/or forces the plunger of the syringe medially. Avoid putting continuous pressure on the back. Remove the syringe. Blood should ﬂow slowly and 0162t_c038_ 5/20/03 1:33 PM Page 326 mac111 mac111: 272_VE:

326 SECTION THREE / VASCULAR PROCEDURES

FIGURE 38-10 The Seldinger technique. A. The vein is punctured by the introducer needle and blood is aspirated. B. The syringe has been removed. The guidewire is inserted through the introducer needle and into the vein. C. The introducer needle and guidewire sleeve are withdrawn over the guidewire. D. The skin puncture site is enlarged. E. The dilator is advanced over the guidewire until the hub is against the skin; then it is removed. F. The catheter is advanced over the guidewire and into the vein. G. The guidewire is withdrawn through the catheter. 0162t_c038_ 5/20/03 1:33 PM Page 327 mac111 mac111: 272_VE:

CHAPTER 38 / CENTRAL VENOUS ACCESS 327

freely from the hub of the needle. The introducer needle (Figure 38-12A). Apply gentle traction on the curved is in the carotid or subclavian artery if blood squirts out guidewire tip with the thumb and the second and third the introducer needle hub. If blood dribbles out or does fingers in order to straighten the guidewire (Figure not flow from the hub and the patient has spontaneous 38-12B). The guidewire can then be inserted into the circulation, reattach the syringe and reposition the in- introducer needle hub without the use of the sleeve. troducer needle until free flow is obtained. Occlude the Advance the guidewire through the introducer needle open hub of the introducer needle with the thumb of the and into the vein (Figure 38-10B). The guidewire should nondominant hand while keeping the small finger of the advance easily into the vein. Never force the guidewire. hand in contact with the patient’s skin. The operator’s Guidewire resistance may indicate that the introducer proprioceptive reflexes will prevent movement of the needle is not within the vein, is against the wall of a ves- introducer needle by maintaining contact with the sel, or is caught as the vessel bends. Slightly withdraw the patient’s skin. Even a millimeter of movement may re- guidewire, rotate it slightly, and readvance it. The use of sult in failure to stay within the lumen of the vein. force will kink the guidewire and may cause it to Prepare the guidewire (Figure 38-11). Grasp the damage the vein and adjoining tissues. Advance the guidewire and its sleeve with the dominant hand. The guidewire 5 to 10 cm into the vessel or until ectopic beats tip of the guidewire has a “J” shape when the sleeve is are seen on the cardiac monitor.Withdraw the introducer retracted (Figure 38-11A). Slide the sleeve forward to needle and guidewire sheath while securely holding straighten out the “J” of the guidewire (Figure 38-11B). Insert the wire sleeve into the hub of the introducer needle (Figure 38-11C). Advance the guidewire through A the sleeve and into the introducer needle. Never let go of the guidewire! One end of the wire must always be held to prevent loss of the wire and embolization into the central circulation. Do not simply reverse the guidewire if the sleeve used to straighten the curved end of the guidewire is lost. The straight end of the guidewire can puncture the wall of the vein. Grasp the guidewire between the fourth and fifth fingers and the palm of the dominant hand

FIGURE 38-11 Guidewire preparation. A. The plastic FIGURE 38-12 Straightening the “J” tip. A. Grasp the sleeve is retracted, showing the “J” tip. B. The plastic guidewire between the ring and small ﬁngers and the palm. sleeve is advanced to cover the guidewire tip, allowing the B. Apply traction using the thumb and index ﬁngers, wire to be threaded into the introducer needle. C. The stretching the outer coil of the wire over the solid core to sleeve is inserted into the hub of the introducer needle. straighten the “J” tip. 0162t_c038_ 5/20/03 1:33 PM Page 328 mac111 mac111: 272_VE:

328 SECTION THREE / VASCULAR PROCEDURES

the guidewire (Figure 38-10C). Grasp the guidewire with Withdraw any necessary blood samples from the the nondominant hand as soon as the guidewire is visible catheter. Attach infusion tubing or a heparin lock to the between the tip of the introducer needle and the skin. port and flush the catheter to prevent a blood clot from Finish removing the needle over the guidewire. obstructing the lumen. If a multilumen catheter is in- Make a small incision in the skin adjacent to the serted, flush any other lumens after first withdrawing guidewire using a #11 scalpel blade (Figure 38-10D). any air (Figure 38-13). Securely attach the catheter to the Place the dilator over the straight end of the guidewire skin with nylon or silk sutures. Cover the skin puncture (Figure 38-10E). Advance the dilator over the guidewire, site with a sterile dressing. through the skin, and into the vein. Continue to advance the dilator until its hub is against the skin. Do not release hold of the guidewire at any time. Remove the ANTERIOR APPROACH TO THE INTERNAL dilator over the guidewire. JUGULAR VEIN Place the catheter tip over the guidewire. Advance the The skin puncture site is at the anterior border of the catheter over the guidewire and into the vein to the sternal head of the sternocleidomastoid muscle, just lat- desired depth (Figure 38-10F). Do not release hold of eral to the carotid artery2,4,6 (Figure 38-5). Enter the skin the guidewire. Gently rolling or twisting the catheter at a 45 to 60 degree angle. Direct the introducer needle between the thumb and forefinger may aid in its ad- toward the ipsilateral nipple. The internal jugular vein in vancement. Hold the catheter securely in place and an adult should be encountered within 3 to 5 cm. If the remove the guidewire (Figure 38-10G). Occlude the open vein is not encountered by 5 cm, withdraw the tip of the catheter lumen with a sterile-gloved finger to prevent air introducer needle to the subcutaneous space and redi- embolization and excessive blood loss. rect it slightly medially. The remainder of the procedure Attach a syringe to the catheter hub and aspirate is as described for the central approach above and in blood to confirm that the catheter is within the vein. Table 38-6.

FIGURE 38-13 Aspiration and flushing of catheters. A. Any air in the lumen of the tubing is aspirated into the syringe of flush solution. The syringe must be held upright, as shown. B. Stop aspirating once all the air is removed from the catheter and blood begins to enter the syringe. C. Flush solution is injected until the lumen is filled and contains no blood. This usually requires 2 to 4 mL of flush solution. 0162t_c038_ 5/20/03 1:33 PM Page 329 mac111 mac111: 272_VE:

CHAPTER 38 / CENTRAL VENOUS ACCESS 329

POSTERIOR APPROACH TO THE INTERNAL caudal to the junction of the medial and middle thirds of JUGULAR VEIN the clavicle. The subclavian vein lies just posterior to the Enter the skin at the posterior edge of the sternoclei- clavicle at this site. The first rib lies between the pleural domastoid muscle, one-third of the way from the clavi- dome and the subclavian vein. Direct the introducer cle to the mastoid process2,4,6 (Figure 38-6). Alterna- needle just superior and posterior to the suprasternal tively, the point where the external jugular vein crosses notch while staying as close to the frontal (coronal) the lateral border of the sternocleidomastoid muscle plane as possible. The needle and syringe should be can be used. Direct the introducer needle under the parallel to the bed (Figure 38-14). Placing the nondomi- muscle at a 30 to 45 degree angle to the skin and toward nant index finger in the sternal notch will help to guide the sternal notch. Place the index finger of the nondom- placement (Figure 38-14). inant hand in the sternal notch to provide a landmark Some practitioners prefer to enter the skin inferior to with the patient draped. In an adult, the internal jugular the clavicle at the deltopectoral groove, or the point just vein should be encountered within 5 centimeters. This lateral to the midclavicular line along the inferior sur- approach is not recommended in children.3 The re- face of the clavicle. This is the point where the skin may mainder of the procedure is as described for the central be maximally depressed. Direct the introducer needle approach above and in Table 38-6. parallel to the bed and toward the sternal notch. This entry site may make it easier to keep the introducer needle in the coronal plane. The distance before enter- SUBCLAVIAN VEIN ing the subclavian vein is longer than in the preceding CATHETERIZATION TECHNIQUES approach and the protection offered by the first rib is lost. The technique is identical to that described above for One of the editors (R.R.S.) prefers to use a different internal jugular vein cannulation except for the puncture landmark. Palpate the bony tubercle, or protrusion, on site. Two techniques, infraclavicular and supraclavicular, the inferior surface of the clavicle and approximately are described below and summarized in Table 38-7. one-third to one-half the length of the clavicle from the sternoclavicular joint. The advantage of this site is that it INFRACLAVICULAR APPROACH TO THE is a definitive landmark and avoids approximating dis- SUBCLAVIAN VEIN tances, as described for the other sites above. Insert the The infraclavicular approach to the subclavian vein is introducer needle parallel to the bed and aimed just most often used. It is commonly thought to be easier to posterior to the sternal notch. perform and less likely to result in a pneumothorax than The bevel of the introducer needle should be oriented the supraclavicular approach, although data for this caudally, as should the “J” in the guidewire. This position belief are lacking.17 Some physicians prefer not to use a will allow the guidewire to enter the innominate vein finder needle for infraclavicular subclavian vein cannula- and superior vena cava rather than being directed up- tion as there is no danger of penetrating the carotid artery. ward into the internal jugular vein or across to the con- This also makes as few needle passes near the pleura as tralateral subclavian vein (Figure 38-15). Once venous possible in order to decrease the risk of a pneumothorax. blood is aspirated, the Seldinger technique for catheter Estimate the distance from the skin puncture site to the insertion is otherwise the same as previously described superior vena cava (i.e., the manubriosternal junction). for internal jugular vein cannulation. Aspiration of Several different skin entry sites are described in the bright red blood under pressure indicates subclavian literature. Some feel that the preferred entry site is 1 cm artery puncture, which will be incompressible. Remove

TABLE 38-7. COMPARISON OF SUBCLAVIAN VEIN CANNULATION ROUTES

Infraclavicular approach Supraclavicular approach

Entry site Just inferior to the clavicle at the 1 cm lateral to the clavicular head of the sternocleidomastoid midclavicular line muscle, 1 cm posterior to the clavicle Needle orientation Keep as close to the coronal plane as Tip aimed 10 degrees anterior to the coronal plane possible Needle bevel and “J” wire Medially and caudally Medially directed (FIG) Aim toward Just posterior to the sternal notch Contralateral nipple, needle bisects angle formed by the clavicle and the clavicular head of the sternocleidomastoid muscle Distance from skin to 3–4 cm 2–3 cm subclavian vein 0162t_c038_ 5/20/03 1:34 PM Page 330 mac111 mac111: 272_VE:

330 SECTION THREE / VASCULAR PROCEDURES

Clavicle

Subclavian Dome of vein pleura Subclavian artery Clavicle

First rib

Subclavian vein A First rib B

FIGURE 38-14 Infraclavicular approach to subclavian vein cannulation. A. Frontal (oblique) view of the procedure. B. Sagit- tal section through the medial third of the clavicle. Note the proximity of the pleura and subclavian artery.

the introducer needle and observe the patient for signs Estimate the distance from the skin puncture site to of signiﬁcant hemorrhage over the next several hours. the superior vena cava to guide the catheter insertion Aspiration of air indicates penetration of the pleura. Ob- depth. The skin is entered at a point 1 cm lateral to the servation with serial chest radiographs for at least the lateral border of the clavicular head of the sternocleido- next 6 to 24 hours is essential to evaluate the size of the mastoid muscle and 1 cm superior to the clavicle20 resulting pneumothorax. (Figure 38-16). The introducer needle should bisect the angle formed by the clavicle and the lateral border of SUPRACLAVICULAR APPROACH TO THE the sternocleidomastoid muscle (Figure 38-16A). Direct SUBCLAVIAN VEIN the introducer needle toward the contralateral nipple or While most practitioners are more comfortable with a point just superior and posterior to the sternal notch. the infraclavicular approach to the subclavian vein, the Orient the introducer needle bevel medially (Figure 38- supraclavicular approach offers some advantages. The 15). The subclavian vein should be entered within 2 to subclavian vein is closer to the skin. The route from a 3 cm in an adult. The length of catheter inserted will be a right-sided skin puncture site to the superior vena cava few centimeters less than that for the infraclavicular is more direct. It allows easier access to the superior vena approach. cava while avoiding the hazards of a left-sided puncture Alternative skin entry sites and approaches have been (i.e., the thoracic duct). The skin entry site is more acces- described. Enter the skin 1 cm medially and 1 cm superi- sible during CPR and requires less interruption of exter- orly to the midpoint of the clavicle with the introducer nal chest compressions.18 With experience, the compli- needle directed toward the ipsilateral sternoclavicular cation rate for the supraclavicular approach is probably joint.21 The skin can be entered just posterior to the clav- lower than that for the infraclavicular approach.17,19 icle, at the junction of the medial and middle third of the 0162t_c038_ 5/20/03 1:34 PM Page 331 mac111 mac111: 272_VE:

CHAPTER 38 / CENTRAL VENOUS ACCESS 331

enter the skin 1 to 2 cm inferior to the inguinal ligament and 0.5 cm medial to the femoral artery pulse. The cannulation technique is as described previously for the internal jugular vein. Two site-speciﬁc considerations deserve mention.2,3,6 The use of a ﬁnder needle is unnecessary, since there are no vital structures in the area other than the femoral artery that is compressible if it is punctured. The introducer needle is directed at a 45 to 60 degree angle to the skin and parallel to the long axis of the thigh. Shallower angles may be necessary in very small and thin patients. Use caution to avoid puncturing the posterior wall of the vein above the inguinal ligament, since this can result in a retroperitoneal hemorrhage.

ALTERNATIVE TECHNIQUES

USE OF THE SELDINGER-HUB INTRODUCER CATHETER Some central venous access kits, including some manufactured by Arrow (Arrow International, 800-523- 8446), include a catheter-over-the-needle with a tapered hub that can be used in place of the thin-walled introducer needle. This technique has the advantage of allowing the introducer catheter to remain in place FIGURE 38-15 Introducer needle bevel orientation for while venous placement is verified. It provides less likeli- subclavian vein cannulation. Varying the orientation of the hood of the vein being lost as the aspiration syringe is introducer needle bevel for infraclavicular and supraclavic- removed and the guidewire advanced. A guidewire ad- ular techniques helps guide the “J” shaped guidewire into vanced through the introducer catheter cannot become the superior vena cava. sheared off, as when it is inserted through the needle. The vein is entered with the catheter-over-the-needle assembly attached to an aspirating syringe, as described clavicle, with the introducer needle directed toward the previously. Once the flashback of blood is obtained, ipsilateral sternoclavicular joint and parallel to the coro- advance the catheter-over-the-needle 2 mm further into nal plane.22 This last approach is probably the simplest, the vein. This will ensure that the tip of the introducer although the study cited was performed on cadavers catheter is within the vein. Hold the hub of the needle rather than live patients. securely. Advance the catheter into the vein until its hub is against the skin. Withdraw the needle. If necessary, the introducer catheter may be attached to a pressure FEMORAL VEIN transducer and the venous waveform verified to con- CATHETERIZATION TECHNIQUE firm venous rather than arterial placement. Blood gas measurements may also be performed. Advance the The use of an ECG monitor is still recommended even guidewire through the introducer catheter and into the though the short guidewire may not reach the heart. vein. The remainder of the procedure is as previously Particular care must be taken if the patient has a pre- described. existing left bundle branch block, as complete heart block may result if the guidewire or catheter enters the MULTIPLE-LUMEN CATHETERS right ventricle.9 Premeasuring from the insertion site to Prior to skin puncture, remove the cap from the distal the xiphoid process will give the maximum depth of port’s injection hub. It is usually marked “distal.” It is col- catheter insertion. ored brown in the Arrow kits. The other lumens may be The introducer needle should enter the skin 2 to 4 cm flushed with saline or heparin solution and recapped or inferior to the midpoint of the inguinal ligament and left capped and flushed later (Figure 38-13). Heparin 1 cm medial to the femoral artery pulse (Figure 38-17). In concentrations no higher than 100 U/mL should be an infant or young child, the introducer needle should used to avoid temporarily anticoagulating the patient.23 0162t_c038_ 5/20/03 1:34 PM Page 332 mac111 mac111: 272_VE:

332 SECTION THREE / VASCULAR PROCEDURES

Subclavian vein Pleura

Clavicle

First rib

Subclavian artery

A B

FIGURE 38-16 Supraclavicular approach to subclavian vein cannulation. A. From the insertion point 1 cm superior to the clavicle and 1 cm lateral to the border of the sternocleidomastoid muscle, direct the introducer needle tip at a 45 degree angle to the transverse and sagittal planes and slightly anterior toward the contralateral nipple. B. Sagittal section through the medial third of the clavicle. Note that the introducer needle track must be directed anteriorly to avoid the subclavian artery and the dome of the pleura.

The introducer needle and guidewire are inserted as PEDIATRIC CONSIDERATIONS described previously. Place the multiple-lumen catheter tip over the guidewire. Advance the catheter until The anterior or central approach to the internal jugu- the guidewire emerges from the distal port hub (Figure lar vein is preferred for children.3 Appropriate catheter 38-18). Insert the catheter to the desired depth. Remove sizes and lengths are shown in Table 38-3. The child the guidewire. Flush the distal lumen and connect it to must be sedated and immobilized prior to attempts at the desired infusion. If not done previously, aspirate and cannulation of the internal jugular or subclavian vein. flush the other lumens with the desired solution (Figure The femoral vein is the vein of choice if central venous 38-13). access is needed in a combative child who cannot be completely restrained. The patient need not be in Tren- PERCUTANEOUS INTRODUCER delenburg position, the consequences of a misdirected SHEATH (CORDIS) needle are less severe, and the procedure is less threat- The insertion technique differs slightly from those ening as the face is not draped.7 A shallower angle of skin described above (Figure 38-19). Insert the plastic dilator entry than in an adult is necessary to access the femoral into the lumen of the sheath. The entire assembly must vein. Enter the skin 1 to 2 cm inferior to the inguinal be advanced over the guidewire as a unit rather than ligament and 0.5 mm medial to the femoral artery. utilizing separate dilation and insertion steps (Figure 38-19C). A correspondingly larger skin nick must be made with the scalpel, since the sheath is usually of ASSESSMENT larger diameter than a catheter. Advance the dilator- sheath unit over the guidewire and into the vein (Figure Examine the patient. Examine the lung fields carefully 38-19D). A twisting motion may aid in its advancement. to exclude a significant pneumothorax.Vital signs should Continue to advance the unit until the hub of the be rechecked. Obtain a portable anteroposterior chest sheath is against the skin (Figure 38-19E). Remove the radiograph to verify line tip placement in the superior guidewire and dilator as a unit (Figure 38-19E). The re- vena cava and rule out a procedure-related pneumotho- mainder of the procedure is as described previously. rax. Check the catheter site for hematoma formation or 0162t_c038_ 5/20/03 1:34 PM Page 333 mac111 mac111: 272_VE:

CHAPTER 38 / CENTRAL VENOUS ACCESS 333

FIGURE 38-17 Femoral vein cannulation. The skin puncture site is 1 cm medial to the femoral artery pulse and 2 to 4 cm inferior to the inguinal ligament. Di- rect the introducer needle posteriorly at a 45 to 60 degree angle while aspirating.

hemorrhage along the dilated catheter track. Control any nitely intravascular. Do not attempt to advance the hemorrhage with direct pressure. catheter once the guidewire has been removed. Check the function of the catheter by aspiration and Check the position of the catheter tip on the chest infusion through all ports, as discussed above. A proxi- radiograph. The catheter must not be in the heart due mal lumen may be extravascular if it fails to aspirate to the risk that erosion through the thin right atrial blood easily. A catheter may be exchanged over a wall will result in a pericardial hemorrhage and tam- guidewire as long as the distal tip of the catheter is deﬁ- ponade.24,25 Landmarks for an internal jugular or sub-

Proximal port Guidewire

Distal port

2 1

Proximal orifice (2)

Clamp Distal orifice (1)

Guidewire Central vein FIGURE 38-18 Inserting a multiple- lumen catheter. The guidewire exits through the uncapped distal port. The proximal port(s) must be clamped or capped to prevent air embolism. 0162t_c038_ 5/20/03 1:34 PM Page 334 mac111 mac111: 272_VE:

334 SECTION THREE / VASCULAR PROCEDURES

FIGURE 38-19 Inserting an introducer sheath. A. The sheath. B. The dilator. C. The dilator is inserted into the sheath and the unit is threaded over the guidewire. D. Advance the unit over the guidewire and into the vein using a twisting motion (arrow). E. The dilator and guidewire are removed as a unit, leaving the sheath in place.

clavian vein catheter tip include the following: above used for intravenous infusion. Lines placed from the the level of the carina, above the azygos vein, and subclavian vein into the jugular system must be re- at/above the manubriosternal junction. The tip of the placed. Catheters in or below the right atrium must be catheter should be parallel to the vein to prevent ero- pulled back immediately to prevent perforation of the sion through the wall of the vein. If the catheter crosses myocardium. over to the opposite subclavian vein and the patient Most femoral vein catheters can be fully inserted. Pre- cannot tolerate an attempt at repositioning, it may be measurement is recommended to make sure that the 0162t_c038_ 5/20/03 1:34 PM Page 335 mac111 mac111: 272_VE:

CHAPTER 38 / CENTRAL VENOUS ACCESS 335

catheter tip will not reach the right atrium. If there is any the catheter to the skin. Ask the patient to exhale and doubt about the catheter position, postinsertion ab- hold his or her breath. Briskly remove the catheter and dominal and chest radiographs should be obtained. The cover the puncture site with a gauze dressing. The track tip of the catheter must be at or below the xiphoid from the skin surface to the vein can be a source of a process of the sternum. Reassess the distal neurovascu- fatal venous air embolism.31 If the catheter had a large lar status of the lower extremity after line placement. diameter or remained in place for more than 2 to 3 days, apply an occlusive dressing to the site for the first 1 to 2 days after the catheter has been removed. The skin AFTERCARE puncture site should be observed for signs of infection twice a day for 48 hours. The catheter must be sutured in place to prevent mal- positioning of the line. Tie a surgeon’s knot at the skin, then secure the suture to the hole(s) provided in the COMPLICATIONS catheter wings. A catheter clamp is often provided in the kit for longer catheters. It too should be sutured in place. INTERNAL JUGULAR VEIN CATHETERIZATION The clamp holds the catheter in place by friction. It is Internal jugular venous access has a myriad of poten- not a guarantee that the catheter will not move. Catheter tial complications.24,32–35 Infection can be either at the depth should be checked daily by inspection and by fre- local site or in a systemic line due to bacteremia and quent chest radiographs. Movement of the patient’s sepsis. A pneumothorax can occur during line place- head and neck may move the tip of the internal jugular ment. A hemothorax may be life-threatening, especially vein catheter by as much as 4 cm.26 if a venopleural fistula is created. A chylothorax occurs if Introducer sheaths have large lumens and present a the thoracic duct is lacerated. Occasionally, carotid significant risk of causing an air embolism. Cap the artery puncture can result. It may be complicated by a main lumen if it is not being used for an infusion. Any stroke if the blood supply to the brain is interrupted or if built-in diaphragm is not a reliable means of preventing a plaque embolizes. Airway compromise can occur due an air embolism.27 Do not use the dilator as an occluder to the formation of a hematoma and compression of the or infusion port, as the stiff plastic can easily erode airway. An air embolism can occur if the catheter lu- through the wall of the vein. An occlusive dressing can mens are left open to the air during insertion or if con- be used if no occluder is available. nections loosen and separate at a later time. Right ven- The skin puncture site should be checked regularly tricular irritation from the catheter tip can cause cardiac for signs of infection. Cellulitis or purulent drainage re- dysrhythmias. Puncture of the right atrial wall can lead quires a new central venous line at another site. Remem- to pericardial tamponade and death. The guidewire can ber to restrain any patient who is uncooperative so as to become entrapped, necessitating surgical or interven- prevent inadvertent removal of the central line. tional radiology removal. Embolization of the guidewire While the short-term infection rate of femoral lines or catheter parts occurs with improper use of the equip- compares favorably with that in other central lines, some ment. Anaphylactic reactions to antibiotic-impregnated precautions are necessary to prevent soilage of the catheters have been reported. The cardiac monitors site.28,29 Consider the judicious use of bladder catheteri- should be observed during the procedure to prevent the zation in patients who are incontinent of urine and of death of a critically ill patient from being unnoticed rectal tubes in patients with loose stools. Patients with while the catheter is being inserted. Thrombosis of the percutaneous femoral vein catheters must be confined catheter or vein may lead to pulmonary embolism. to bed to prevent catheter dislodgment and hemorrhage Many of these complications can be prevented if the around the catheter. Frequent assessment for venous procedure outlined above is followed carefully. Compli- thombosis in the lower extremity is essential. It is recom- cations during catheterization occur in proportion to mended that femoral lines be discontinued when an the operator’s inexperience.33 If the patient is unlikely to alternative venous access site is available or within survive a mistake, the most experienced person avail- 3 days, whichever is sooner.30 able should perform the procedure!

REMOVAL OF THE CENTRAL VENOUS SUBCLAVIAN VEIN CATHETERIZATION CATHETER Complications of subclavian vein cannulation are When removing a central venous catheter from the similar to those of internal jugular vein cannulation, as internal jugular or subclavian vein, place the patient in described above. While there is no risk of carotid artery the Trendelenburg position. To remove a femoral vein injury if the procedure is performed correctly, the sub- catheter, place the patient supine. Remove the dressing clavian artery can be lacerated if the needle is advanced overlying the skin puncture site. Cut the suture securing too deeply. Malposition of the catheter tip, usually due 0162t_c038_ 5/20/03 1:34 PM Page 336 mac111 mac111: 272_VE:

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to overinsertion of the catheter, is common. Lacerations cannulation does present very real risks to the patient of the thoracic duct can be avoided by performing the that must be balanced against the need for the proce- procedure on the right side, avoiding overpenetration dure and other alternatives. Subclavian vein access is with the introducer needle, and avoiding directing the the least preferred route in young children due to their needle too superiorly toward the junction of the subcla- small size, the proximity of the pleura, and the proximity vian vein and internal jugular vein. Other complications, of the subclavian artery.3 such as injury to the brachial plexus and phrenic nerve, Femoral vein cannulation is an essential emergency are uncommon. They can be prevented by avoiding skill. It allows the easiest central venous access in most overinsertion of the needle during the procedure and patients with the lowest risk of catastrophic immediate avoiding needle paths superior and posterior to the complications compared to jugular and subclavian ac- subclavian vein. cess procedures. A pneumothorax is a very real risk with subclavian vein catheterization.The procedure should not be performed unless personnel are immediately available REFERENCES who can deal with this complication.36 The risk of a pneumothorax is probably higher in obese patients, who 1. Williams PL, Warwick R: Gray’s Anatomy, 36th ed. may have distorted anatomic landmarks and in whom a Philadelphia: Saunders, 1980:629–765. more acute angle is required to enter the subclavian 2. Barker WJ: Central venous catheterization: internal vein. Patients with emphysema may have higher pleural jugular approach and alternatives, in Roberts JR, domes and less pulmonary reserve in the event of a Hedges JR (eds): Clinical Procedures in Emergency pneumothorax. Medicine, 2nd ed. Philadelphia: Saunders, 1991:340–351. FEMORAL VEIN CATHETERIZATION 3. Lavelle J, Costarino A: Central venous access and Deep venous thrombosis of the femoral and more dis- central venous pressure monitoring, in Henretig tal veins is a recognized complication of femoral venous FM, King C (eds): Textbook of Pediatric Emergency lines.30 Inadvertent cannulation of the femoral artery Procedures. Baltimore: Williams & Wilkins, may occur. This is particularly true during an episode of 1997:251–278. severe hypotension or cardiac arrest. If such an episode 4. Sutariya BB, Berk WA:Vascular access, inTintinalli goes unrecognized, infusion of vasopressors into the JE, Kelen GD, Stapczynski JS (eds): Emergency Medi- artery may result in ischemic injury to the distal limb. cine: A Comprehensive Study Guide, 5th ed. New York: McGraw-Hill, 2000:102–111. 5. Dronen SC: Central venous catheterization: subcla- SUMMARY vian vein approach, in Roberts JR, Hedges JR (eds): Clinical Procedures in Emergency Medicine, 2nd ed. Central venous access is often necessary in critically Philadelphia: Saunders, 1991:325–340. ill patients and in those with poor peripheral veins. 6. Cummins RO: Advanced Cardiac Life Support. Dal- Mastery of these techniques is essential for anyone who las: American Heart Association,1994, chap 6:1–13. will be caring for acutely ill and unstable patients. 7. Yeh TS: Deep venous lines, in Yeh TS, Hanson JH While all approaches to the central circulation have ac- (eds): My Way—A Resident Handbook for the Pedi- ceptably low complication rates (1 to 5 percent) when atric ICU, 2nd ed. Oakland, CA: Children’s Hospital performed by experienced providers, they all carry real Oakland, 1992:19–22. risks to the patient.17,24 Be certain that there is no safer 8. Lee HS, Quinn T, Boyle RM: Safety of thrombolytic peripheral access alternative before placing a central treatment in patients with central venous cannula- venous line. tion. Br Heart J 1995; 73:359–362. The internal jugular vein is a good choice for central 9. Eissa NT, Kvetan V: Guide wire as a cause of com- venous access in nonambulatory patients. The right in- plete heart block in patients with preexisting left ternal jugular vein provides easy access to the superior bundle branch block. Anesthesiology 1990; vena cava for monitoring and for infusion of solutions 73:772–774. too concentrated or irritating for peripheral veins. This 10. Gil RT, Kruse JA, Thill-Baharozian MC, et al: Triple- route poses a slightly lower risk of complications than vs. single-lumen central venous catheters. Arch In- the subclavian route.33,35 tern Med 1989; 149:1139–1143. The subclavian vein provides easy access to the cen- 11. Farkas J-C, Liu N, Bleriot J-P, et al: Single- versus tral circulation. Subclavian vein catheters are more eas- triple-lumen central catheter-related sepsis: a ily tolerated by awake and ambulatory patients than are prospective randomized study in a critically ill pop- internal jugular or femoral catheters. Subclavian vein ulation. Am J Med 1992; 93:277–282. 0162t_c038_ 5/20/03 1:34 PM Page 337 mac111 mac111: 272_VE:

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