Chapter 1: Central Venous Access

1) INFECTION CONTROL

a) Skin antisepsis

i) Use Chlorhexidine
(1) Lasts 6 hours
(2) Allow air dry for TWO minutes to maximize antimicrobial activity

b) Site selection

i) Avoid femoral vein to reduce the risk of catheter associated septicemia

2) CATHETERS

a) Catheter size

i) Expressed in term so of OUTSIDE diameter

ii) 1 French = 0.33 mm

b) Central Venous Catheters (CVCs)

i) Defined as catheters inserted into following sites:

(1) Internal jugular vein
(2) Subclavian vein
(3) Femoral veins
ii) Modern CVCs have triple lumens (French size 7) and have lengths: 6 in, 8 in, 12 in

c) Antimicrobial Coating

i) Reduces risk of catheter-related infections

ii) Two types:
 (1) Chlorhexidine + Silver sulfadiazine
(2) Minocycline + Rifampin
iii) Consider antimicrobial coated catheters if CVCs needed for >5 days

d) Peripherally Inserted Central Catheters (PICC)

i) Inserted into BASILIC or CEPHALIC vein and advanced into SVC

ii) Narrower and longer than CVCs  SLOWER flow

3) CANNULATION SITES

a) Internal Jugular Vein

i) Anatomy
(1) Located under SCM muscle, anterior and lateral to carotid artery
(2) At base of neck, IJV joins subclavian vein to form innominate vein
(a) Right and left innominate veins form SVC
(3) RIGHT side of neck preferred for cannulation of IJV because:
(a) Shorter distance: need only 15 cm to get to right atrium
(b) Straight course by vessels to right atrium

ii) Positioning
(1) 15 degrees below horizontal (Trendelenburg position) increases diameter of IJV by 25%
(a) Not advised in those with increased ICP
(2) Turn head <30 degrees into opposite direction to straighten vein
(a) > 30 degrees makes it worse because it stretches the vein and reduces the diameter
iii) Locating the vein
(1) Use ultrasound and get an image of the IJV and carotid artery
(a) Place U/S probe across triangle formed by two heads of SCM muscle
 iv) Complications
(1) Carotid artery puncture (1%) - worse
(2) Pneumothorax (1%)

b) Subclavian Vein (SCV)

i) Anatomy
(1) SCV is continuation of axillary vein after it passes first rib
(2) Runs underside of clavicle to thoracic inlet
(3) Joins IJV to form innominate vein
(4) Under the SCV is the anterior scalene muscle and the phrenic nerve. Under the anterior
scalene muscle is the subclavian ARTERY and brachial plexus
(5) Diameter of SCV does NOT vary with respiration (the IJV does) b/c of strong fascial
attachments
ii) Positioning
(1) Trendelenburg position
iii) Locating the vessel
(1) Use SURFACE anatomy by identifying clavicular head of SCM
(2) SCV lies underneath the clavicle and can be cannulated from above or below
iv) Complications
(1) Puncture of subclavian ARTERY (5%)
(2) Pneumothorax (5%)
(3) Brachial plexus injury (3%)
(4) Phrenic nerve injury (1.5%)
(5) Stenosis of the SCV (15-30%)
(a) Can appear days-months after
(b) Main reason why anyone needing AV fistula for hemodialysis should get SCV
cannulation in contralateral arm

c) Femoral Vein
 i) Anatomy
(1) Continuous of long saphenous vein, MEDIAL to artery
(a) (lateral) NAVEL (medial)
(b) Only 2-4 centimeters below skin
(c) Easier to cannulate in Abduction
(2) Locating the vein
(a) Place leg in ABDUCTION
(b) Palpate femoral artery pulse: below and medial to midpoint of inguinal crease
(c) Place U/S probe at palpable spot, vein identified by compressibility
(d) If U/S not available, place needle 1-2 cm medial to pulse and depth of 2-4 cm from
skin
(3) Complications
(a) Femoral artery puncture
(b) FV thrombosis (10%)
(i) Clinically silent
(c) Catheter related septicemia (0.1%)

d) PICCs

i) Inserted into BASILIC or CEPHALIC veins

(1) Basilic (medial aspect of arm) is preferred because:
(a) Larger diameter
(b) Straighter course up
ii) Pros over CVCs
(1) Patient comfort and mobility
(2) Eliminates risks associated with CVCs
4) IMMEDIATE CONCERNS

a) Venous air embolisms

i) Pathophysiology
(1) If the catheter hub is open to atmosphere, negative intrathoracic pressure can draw air
into venous circulation
(2) Fatal consequences if air entry >200 mL (3-5 mL/kg) over a few seconds
ii) Consequences
(1) Acute right heart failure
(2) Leaky pulmonary edema
(3) Acute embolic stroke (from air bubbles that pass through patent foramen ovale)
iii) Preventive measures
(1) Positive pressure ventilation
(2) Trendelenburg position (head down)
iv) Clinical presentation
(1) Clinically silent (most)
(2) Sudden onset of dyspnea and/or cough
(3) If severe, rapid progression to hypotension, decreased consciousness, mill wheel
murmur (mixing of air and blood in right ventricle)
v) Diagnosis
(1) Usually clinical
(2) If you have time, get Doppler U/S and detect air in heart
vi) Management
(1) Attach a syringe to hub of catheter and aspirate air out
(2) Pure oxygen breathing
(3) Place patient in left lateral decubitus position
(4) Chest compressions (force air out of pulmonary outflow tract and into pulmonary
circulation)

b) Pneumothorax

i) Seen with SUBCLAVIAN vein catheterization (5%)

ii) Portable CXR are INSENSITIVE, use U/S

c) Catheter location (5-25% are mal-positioned)

i) Proper Placement
(1) A properly placed CVC or PICC should be in SVC with catheter tip 1-2 cm above right
atrium
(a) Tracheal carina is located just above junction of SVC and right atrium.
(b) Tip should be above tracheal carina
(2) A catheter tip in right atrium increases risk of right atrial perforation and cardiac
tamponade