Central Venous Access

 

Basem F. Khishfe, MD

Rashid E. Kysia, MD

Key Points

• The abil ity to access the centra l venous circulation is an

imperative ski ll for emergency physicians and is often

needed for l ife-savi ng measures.

• The central venous circulation can be accessed both

above and below the diaphragm. The site should be

INDICATIONS

The most common reason for placement of a central

venous catheter in the emergency department (ED) is for

resuscitation of the critically ill medical or trauma patient.

Medical patients may require central access for large volume fluid resuscitation, central venous pressure monitoring, IV pressors or other medications caustic to the

peripheral veins (dextrose, hypertonic saline, total parenteral nutrition), transvenous pacing, or emergent dialysis.

Trauma patients most often require central access for

large-volume resuscitation with both fluids and blood.

Central access is also used in ED patients with difficult

peripheral IV access.

CONTRAINDICATIONS

Central access should not be attempted when peripheral

access is obtainable and no other indication is present.

Central access should be avoided at sites with overlying

cellulitis or other anatomic abnormalities such as extensive

trauma that may cause distorted anatomic landmarks.

Known coagulopathy is an absolute contraindication to

subclavian vein cannulation (noncompressible site) and a

relative contraindication for internal jugular and femoral

cannulation. Finally, patients must be able to cooperate

during the procedure by remaining still. An uncooperative

8

chosen based on reason for access as well as body

habitus and pattern of injury for trauma patients.

• Although the overall complication rate for centra l line

placement is low for experienced providers, serious

complications may occur.

patient is a relative contraindication that may require sedation before the procedure.

EQUIPMENT

Most of the equipment needed to perform central venous

cannulation can be found in commercially available central

line kits (Figure 3-1). Kits include povidone-iodine swabs,

guidewire introducer needle, J-tip guidewire, multiple

5-mL syringes, 1% lidocaine, 22- and 25-gauge needles for

local anesthesia, #1 1 blade scalpel, dilator, central line, and

silk suture on a cutting needle.

There are multiple types of central lines. In general, 1 of

2 types is used in the ED (Figure 3-2). A triple-lumen catheter is used for patients who require multiple different

medication drips or when there is difficulty obtaining

peripheral venous access. A sheath introducer (Cordis) catheter is shorter and wider and is used for introducing transvenous pacers, Swan-Ganz catheters, and for rapid infusion

of fluid and blood products in the hypotensive patient.

These larger catheters can achieve flow rates up to 1 L/min.

PROCEDURE

The procedure including risks and benefits should be

completely explained to the patient or their representative. Informed consent should be obtained unless the

CENTRAL VENOUS ACCESS

Figure 3-1 . Tri ple lumen kit.

procedure is performed emergently. First locate the

appropriate anatomical landmarks for the chosen site

(see later). Next, apply povidone-iodine to the area of

needle insertion followed by the sterile drape. Then

.A. Figure 3-2. From left to right: A. sheath i ntroducer

kit (Cord is) with dilator. B. Triple lumen catheter.

C. triple lumen dilator.

anesthetize the area of needle insertion with lidocaine.

Once the preparation is complete, Seldinger technique

should be followed in a stepwise fashion to complete the

procedure .

..... Seldinger Technique

1. Use a large-bore needle with syringe to cannulate the

vein. There should be free flow of dark nonpulsatile

blood into the syringe with traction on plunger

(Figure 3-3A).

2. Thread the guidewire through the needle until 3-5 em

of the guidewire remains (Figure 3-3B). If resistance is

met, withdraw the wire and confirm that the needle is

in the vessel. Attempt to rethread the wire.

3. When the guidewire is in place, remove the needle

(Figure 3-3C). Never let go of the guidewire during any

part of the procedure because it can migrate fully into

the vessel.

4. Using a #1 1 blade scalpel, make a superficial stab incision in the skin at the site that the guidewire enters

(Figure 3-3D).

5. Pass the dilator over the wire and thread into the vessel

(Figure 3-3E). (For the Cordis catheter, the dilator and

catheter are inserted together.)

6. Remove the dilator and thread the triple lumen over the

wire, backing out the wire until it protrudes 2-3 em out

of the brown port.

7. Holding the free wire with one hand, thread the line

into the vein (Figure 3-3F).

8. Remove the wire and confirm placement with aspira ­

tion of blood (Figure 3-3G). Secure the catheter in

place with suture.

Internal jugular vein cannulation can be achieved by

multiple approaches. The central approach is described

here (Figure 3-4). Position the patient supine and in

slight Trendelenburg position, with the head rotated

75 degrees to the opposite side. Palpate the triangle

formed by the 2 heads of the sternocleidomastoid muscle.

Palpate the carotid artery pulse within this triangle. The

vein is lateral to the artery in this location and is widest

just below the level of the cricoid cartilage. Insert the

needle at the apex of the triangle, aiming toward the ipsilateral nipple with 30 degrees of angulation. The vein

should be entered within 2-3 em of needle advancement.

If unsuccessful, withdraw slowly, as the vessel, if punctured, may have been compressed during advancement

and will be pulled open on withdrawal. Do not palpate

the carotid pulse while attempting to cannulate the internal jugular vein. The slight compression that results can

compress the vein, making it more difficult to access.

Cannulation of the right internal jugular is preferred over

the left because of the straight line into the right atrium

CHAPTER 3

Figure 3-3. The Seldinger tech nique. (Reprod uced with permission from Reichman EF and Simon RR. Emergency

Medicine Procedures. New York: McGraw-Hill, 2004. Figure 38-1 0.)

CENTRAL VENOUS ACCESS

Figure 3-4. Internal jugular vein catheterization.

(Reproduced with permission from Dunphy JE, Way

LW. Current Surgical Diagnosis Er Treatment. 5th ed.

La nge, 1 981 .)

and the presence of the thoracic duct and a higher pleural

dome on the left side.

The subclavian vein can also be cannulated by multiple

approaches. The infraclavicular approach is described here

(Figure 3-5). Position the patient supine and in slight

Trendelenburg position. Place a rolled sheet or towel

between the patient's scapulas to allow the shoulders to fall

backward and flatten the clavicles. Insert the needle 1 em

inferior to the clavicle, at the junction of the middle and

medial thirds. Direct the needle under the clavicle and

toward the suprasternal notch, with the needle parallel to

the chest wall. The vein should be entered within 4 em of

needle advancement.

The femoral vein has a single approach. Palpate the

femoral artery 2 em below the inguinal crease. The vein

is usually 1 em medial to the artery at this location.

Insert the needle at a 45-degree angle to the skin, medial

to the femoral pulse, in a cephalad direction. In the

pulseless patient, palpate the anterior superior iliac spine

and the pubic tubercle. Draw an imaginary line connecting these 2 points. If this line is divided into thirds, the

vein will be located where the medial and middle thirds

intersect (Figure 3-6).

Figure 3-5. Subclavian vein catheterization.

(Reproduced with permission from Stone CK and

Humphries RL. Longe: Current Emergency Diagnosis

and Treatment. 57th ed. New York: McGraw-Hill,

2004-20 11. Figure 7-7.)

Empty space

Figure 3-6. Femoral vein anatomy. (Reprinted with

permission from Stone CK and Humphries RL. Longe:

Current Emergency Diagnosis and Treatment. 57th ed.

New York: McG raw-Hill, 2004-20 11. Figure 7-8.)

CHAPTER 3

COMPLICATIONS

Central venous access has multiple complications common

to each site, including bleeding, infection, arterial or

venous laceration, and air embolism. Site specific compli ­

cations include the following: for internal jugular, airway

compression from expanding hematoma, carotid artery

dissection, pneumothorax, and arrhythmia from cardiac

irritation; for subclavian, pneumothorax and arrhythmia;

for femoral, deep venous thrombosis, line sepsis, retroperitoneal bleeding, and bowel perforation.

SUGGESTED READING

Weber J, Schindlbeck M, Bailitz J. Vascular procedures. In: Simon

RR, Ross C, Bowman S, Wakim P. Cook County Manual of

Emergency Procedures. 1st ed. Philadelphia, PA: Lippincott

Williams & Wilkins, 20 12.

Wyatt CR. Venous and intraosseous access in adults. In:

Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka

RK, Meckler GD. Tintinalli's Emergency Medicine: A

Comprehensive Study Guide. 7th ed. New York, NY:

McGraw-Hill, 20 1 1.