Central Venous Access

Office of Graduate Medical Education

Perelman School of Medicine
University of Pennsylvania

Slides Courtesy of : Joan Hoch Kinniry ACNP-BC

Lead Practitioner , Critical Care Medicine, Procedure and Resuscitation Service
Central Venous Line Placement
 Goals
 Reduce anxiety about procedures
 Review basics
 Indications
 Complications
 Mechanics
 Improve familiarity with various catheter types
 Establish good habits and solid foundation
 Improve confidence and competency
 Ensure safe and sterile catheter placement
Central Venous Line Placement
 Indications
 Hemodynamic monitoring
 CVP / Scv02
 PA-Catheters (Swan-Ganz, RHC)
 Administration of hyperosmolar agents,
vasopressors and other medications
 Temporary transvenous cardiac pacing
 Hemodialysis and plasmapheresis
 Lack of peripheral access
Central Venous Line Placement
 Absolute contraindications
 None
 Relative contraindications
 Coagulopathy / thrombocytopenia
 Anatomic abnormalities
 Thrombus / stenosis
 Localized infection over insertion site
 Recent pacemaker insertion
Approach Advantages Disadvantages
Internal Control of bleeding Carotid artery injury
Jugular PTX uncommon Uncomfortable for Pt.
Lower infection rate (vs. Maintenance of dressings
femoral) Tracheostomies
PA-Cath (R) IJ IJ vein prone to collapse
Subclavian Maintenance of dressings Risk of PTX
More comfortable SC artery difficult to compress
Clearer landmarks (typically, SC vein is
SC vein less collapsible compressible)
Lowest infection rate PA- Should be avoided in
Cath (L) SC CKD/ESRD
Femoral No interference with CPR Highest infection rate
No risk of PTX Difficulty for PA-Cath
Femoral artery injury
DVT
NEJM 356;21 2007
 Central Venous Line Placement
 Complications-Immediate  Complications-Distant
 Failure to cannulate
 Pseudoaneurysm
 Catheter malposition
 Arteriovenous fistula
 Vessel laceration
 Hematoma
 Arrhythmia (wire or
catheter)
 Air embolism
 Pneumo / Hemo thorax
 Pneumo / Hemo thorax
 Air embolism
 Arrhythmia (catheter)
 Skin infection or bacteremia
 Stenosis or thrombosis of
vessel
 Thoracic duct injury-
chylothorax
 Nerve injury (brachial plexus,
sympathetic chain, phrenic)
 Cardiac tamponade
 Complication Rate / Site Comparison
IJ SC Fem
Pneumothorax (%) <0.1 -0.2 1.5 - 3.1 n/a

Hemothorax (%) n/a 0.4 – 0.6 n/a

Infection (rate per 1000 catheter days) 8.6 4 15.3

Thrombus (rate per 1000 catheter days) 1.2 – 3 0 – 13 8 – 34

Arterial Puncture (%) 3 0.5 6.25

Malposition low high low

NEJM 356;21 2007

Central Venous Line Placement

 Preprocedure Prep
 Informed consent process – use procedure specific consents
 Review procedure, indications and alternatives
 Risks / Benefits

 Obtain written consent

 Coordinate procedure timing with bedside RN

 Enter Bedside Procedure Order in SCM
 Review equipment check list for needed supplies
 Review Preprocedure Checklist
 Procedure sign posted

 Procedure cart at bedside

 Central Venous Line Placement
 Preprocedure Prep
 Perform Time out at bedside with RN – document in SCM
 Sterile Technique
 Chlorhexidine
 30 second friction scrub with 60 second dry time for dry site
 30 second friction scrub with 2 minute “soak” time for moist site
 Maximum Barrier Precautions
 Sterile Gloves
 Long-sleeved gowns
 Full field drape
 Masks/Caps for all participants & observers
 Sterilize from chin to nipple to shoulder to ear (allows both IJ
and SC to be accessed on the same side)
 Central Venous Line Placement
PROCEDURE
 All IJ lines must be done with US guidance
 All lines must be transduced before dilation (verified by
performing MD and RN)

DOCUMENTATION
 Consent
 Bedside Procedure Order in (SCM)
 Time Out (SCM)
 US vessel evaluation note
 Procedure Note
 IJ Anatomical Landmarks

Posterior belly of
Sternocleidomastoid
Clavicle

Anterior belly of
Sternocleidomastoid

Sternal Notch
 Subclavian Anatomical Landmarks

Clavicle
Turn

Insertion Point
and Trajectory

Sternal Notch
Femoral Anatomy Landmarks
 Catheter type Description Advantages Disadvantages
Standard Triple • 18 gauge x 2 Multiple access points Not optimal
Lumen (TLC) • 16 gauge resuscitation line for
7 Fr, 15 cm hemorrhagic shock

Multi-Access •Introducer(PA-Cath, TVP, •Multiple access •More difficult to insert

Catheter (MAC) “buddy catheter”) points •Sharper tip on dilator
9 Fr, 11.5 cm • 12 gauge •Hemorrhagic Shock increases risk of
• 9 Fr. Resuscitation Line misplacement
• 18 gauge x 2 (optional) •When used w/o •Shorter length with left
“Buddy catheter” sided placement

Percutaneous • Introducer (PA-Cath, Hemorrhagic Shock Limited access points

Introducer Sheath TVP) Resuscitation Line unless PA-Cath
(Cordis) • Usually 8.5 FR inserted

Trauma Line • Single lumen large bore Hemorrhagic Shock •Limited access points
central access Resuscitation line •No introducer sheath
• Usually 8.5 FR, 8.89cm

Hemodialysis Dual Usually 13.5 FR Used for HD and •Not to be used except
Lumen Catheter plasmapheresis in extreme emergency
for general IV access
 Infusion Rate Comparison

MAC
Distal (9fr) 33,000 cc/hr
Proximal (12g) 13,000 cc/hr
Distal w/ 8fr catheter 10,500 cc/hr

TLC
Distal (16g) 3,400 cc/hr
Medial (18g) 1,800 cc/hr
Proximal (18g) 1,900 cc/hr
 Choosing the Catheter Size
Pt. Height RIGHT LEFT RIGHT Internal LEFT Internal
Subclavian Subclavian Jugular Jugular

4'6" - 4'9" inches 12 16 13 17

4'10"- 5'1" inches 13 17 14 18

5'2" - 5'4" inches 14 18 15 19

5'5" - 5'8" inches 15 19 16 20

5'9" - 6'0" inches 16 20 17 21

6'1" - 6'4" inches 17 21 18 22

HD Catheters: 15 cm Right IJ, 20 cm Left IJ, 24 cm Femoral

Can adjust for particularly small or large patients
 Choosing the Catheter Size
• When deciding which site to use, consider if the
patient is a potential dialysis candidate.
• Avoid SC catheter placement

• Left sided hemodialysis catheters have a greater

chance of being malpositioned.
• For HD catheters risk of atrial perforation

• Always use the longest catheter available for groin

lines: 25” Cook CVC and 24” dual lumen HDC.
Proper Use of Adjustable Suture Wing

• Used to secure catheter when not inserted to manifold (“hub” aka - full catheter length)
• Must apply both white rubber clamp and red rigid fastener to avoid catheter migration
• secure with 4 sutures: adjustable suture wing and catheter manifold (hub)
• Do not bend catheter in excess in order to suture at catheter hub, keep straight as possible
•Dressing placed over adjustable suture wing only, manifold sutures open to air
• Provider procedure note documentation and daily RN documentations MUST include
catheter depth
•catheter depth or securement concerns
Documenting Catheter Depth
 Centimeter markings on catheter are used to determine catheter
depth
 Catheter length is printed on manifold (hub)
 Double hash mark equals full catheter length as indicated on
manifold
 Single hash marks indicate one centimeter increment
 Document catheter depth where catheter exits the skin in daily
access assessment
Double hash mark = Single hash mark = one
full catheter length centimeter increments

measure
5 cm increment catheter
numerical depth at
marking skin exit
Catheter length printed
on manifold
 Post-Line Insertion Chest X-ray
 Delayed PTX is not unusal – have low threshold
to obtain repeat CXR if clinical s/s PTX
 Single plane view of ICU CXR is suboptimal to
evaluate catheter malposition
 Transduce waveform via monitor --(can be done without
CXR, will demonstrate intravascular placement and
arterial vs venous vessel or extravascular placement)
 Blood gas if intravascular may be useful but clinical
conditions can confound interpretation
 If extravascular catheter is suspected t/c Chest CT w/
contrast
 Coagulopathic Patients

 Caution with INR > 2.5, PT or PTT > 2x normal, Plt <
50k, or untreated uremia (not on HD). The more
parameters fulfilled, increases the cumulative effect on
hemostasis.

 Consider correction (FFP, platelets, ddavp, HD)

 Consider IJ placement under US over SC

 Coagulopathic state and /or thrombocytopenia are

RELATIVE CONTRAINDICATIONS and warrant a
risk/benefit discussion with attending
 Helpful Reminders
 Recommend restraining all patients during central line placement.
(even awake or intact)
 Keep everything within reach (needles, wire, catheter, flush)
 Always place patient in trendelenberg (>15 degrees)
 For SC catheters, placing a rolled towel/sheet in between the
scapulae can help “open” the clavicular angle & allow easier
passage of the needle underneath the clavicle
 If wire does not pass:
 Re-attach syringe and aspirate (see if still in vessel)
 Lower angle of needle (and aspirate)
 If wire “clears” the tip of the needle, then consider structural
reason (thrombus, anatomic abnormality, ect.)
 If the wire does not come out easily, give GENTLE traction and try
rotating the wire. DO NOT pull firmly on the wire!
 Remove catheter and wire together if able

 If unable to remove wire call vascular

Ultrasound Guided Vascular Access
 Transducer
 Transmits and receives the ultrasound beam
 Contacts the patient’s skin
 Takes thin slices of object being imaged
 Rotated or angled to change views
 Beam Profile
 Width of the beam (1mm)
 Length of beam 38mm
Ultrasound Basics

 Fluid (i.e. blood) is black b/c near complete

transmission of U/S waves occurs
 Bone and air cause marked reflection and
appear white (in B – mode)
 Strong reflection creates an acoustic
shadow obscuring distal imaging (bone
shadow)
Ultrasound Basics

 Most large vessels are easily visualized

with U/S probes
 Arteries are pulsatile, difficult to compress and
thick walled
 Veins are non-pulsatile, easily compressible,
engorge w/ Trendelenburg or Valsalva and thin
walled
Transverse Orientation – IJ
Longitudinal Orientation – IJ
Transverse Orientation – Subclavian
Longitudinal Orientation: Subclavian
Guide wire in Longitudinal View
Jugular Vein Thrombosis
 Jugular Vein Thrombosis
 Acute thrombus can appear “black” or
“cloudy” on US exam
 Always evaluate the whole neck ensuring IJ
is fully compressible along the entire length
 Presence of small caliber anomalous
vessels can be indicative of past or present
clot or stenosis