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

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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).