Central Venous Catheterization Careful consideration should be given for indications and routes of placement of central venous catheters

ers (CVCs) Full barrier precautions must be observed during the procedure to avoid infectious complications The internal jugular vein (IJV) site is most commonly used.Subclavian vein catheterization has the advantage of decreased incidence of catheter-related bloodstream infection (CRBSI);however,it has increased incidence of pneumothorax. Ultrasound guidance has decreased the incidence of complications during central venous catheterization. CRBSI is one the most common complications associated with CVCs and a common cause for nosocomial blood stream infections (BSIs). Clinical signs are unreliable because of poor sensitivity and specificity for establishing the diagnosis of CRSBI Two paired sets of blood cultures are recommended with at least one percutaneosly drawn to establish the diagnosis of CRSBI. Antibiotic therapy is often initiated empirically when CRBSI is suspected and tailored according to blood cultures and sensitivity Persistence of positive blood culture after three days of removal of catheter needs further investigation to rule out infective endocarditis and metastatic septic foci Mechanical complications can be avoided with adequate precautions and proper technique

Central venous catheterization Patient in intensive care units in the united states receive 15 million central venous catheter (CVC) days per years (1).placement of a central venous catheter is a routine event in the ICU,but should not occur without careful consideration of indications and route of placement. The most common indications for placement of CVCs are hemodynamic monitoring,administration of vasoactive agents,parenteral nutrition,other madications that are not well tolerated peripherally,temporary transvenous cardiac pacing,plasmapheresis of renal replacement therapy,and lack of peripheral venous access.volume resuscitation is not in and of it self an indication for placement of central lines.resistance to flow through a catheter is dependent on length and diameter;therefore,short large bore peripheral lines are better suited for rapid volume resuscitation than CVCs (2).Because it is difficult to obtain adequate peripheral access in hemodynamically compromised patients,it is still often necessary to place a CVC in patients experiencing shock. Approaches Central venous catheterization was made significantly safer and easier with the adoption of the guidewire dilation(seldinger) technique,which has largely replaced the catheter-throughneedle technique. Central venous catheterization can be obtained in a number of site it is important that appropriate sterile techniqes are followed.hand washing before the procedure,and full barrier

precautions including sterile gloves,a surgical gown,a mask,and a large sterile drape,have been shown to decrease the incidence of bloodstream infections (BSIs) (1). The procedure begins with determining the optimal site,identifying the relevant landmarks,and positioning the patient for ideal accessibility and operator comfort.The common sites used are the internal jugular veins (IJVs),the subclavian veins(SVs),the femoral veins (FVs),and peripherally inserted central catheters(PICCs) placed via the brachial veins.The advantage and disadvantages of each approach are listed in table 1-1. The PICC line,although a useful tool in certain setting,currently has little utility in the intensive care unit (ICU) because of difficulty in obtaining brachial vein access in ICU patients,frequency of malposition,and frequent necessity for fluoroscopy for proper positioning.it may have a role in the ICU in more stable patients who require long-term access for parenteral feedings. The Internal Jugular Vein Site The decision between the IJV,SV,and FV sites should be decided by factors that include the patients body habitus,the indication for the central line (i.e.,need for hemodynamic monitoring),the presence of coagulopathy,and operator comfort. The internal jugular jugular vein has the advantages of easier placement of transvenous pacemaker leads and pulmonary artery catheters especially when placed on the right side.other advantages of the IJV are that it can be used for central venous pressure (CVP) monitoring,and direct pressure for hemostasis can be applied to the IJV site in the event of serious bleeding.Disadvantages are that the IJV may be difficult to access in emergency situations,such as during cardiopulmonary resuscitation when the airway is being established and hemodynamic collapse may be present.Also,the IJV site may be less comfortable than either the SV or FV site for patients who are awake and alert.Refer to figure 1-1 for surface anatomy and various approaches for internal jugular vein cannulation. Internal Jugular Vein Posterior Approach The needle is inserted at the posterior lateral margin of the sternoleidomastoid (SCM) muscle 5 cm cephalad from the sternoclavicular joint near the margin of the external jugular vein and the posterior margin of the sternocleidomastoid muscle (3).After adequate local anesthetization with 1% lidocaine,the needle is directed toward the contralateral ipple at a 15-degree angel to the sagittal plane with constant back pressure on the syringe.venipuncture occurs at approximately 4 to 7 cm of depth.if venipucncture dose not occur,the needle should be with-drawn slowly with continued back pressure on the syringe,because blood return may occur on withdrawal. After venipucncture occurs the syringe is removed,and the hub covered with a finger to prevent air embolization,a J guidewire is introduced through the needle.if the guidewire passes freely up to almost 20 cm,the needle is removed and the guidewire is held in place.with the guidewire in place,a small stab is made at the skin entry site and a vessel dilator is inserted down the guidewire and the removed.it is important that at all times the guidewire is controlled and sterility is maintained.with the distal lumen cap having been removed from the hub of the catheter before the procedure,the catheter is then inserted over the guidewire with the operator maintaining control of the guidewire at all times.the guidewire is removed when it protrudes from the end of the distal hub.

The distal hub is then capped and blood is aspirated from the distal port.the other port is flushed with normal saline.the other ports can be flushed with normal saline.The catheter is then sutured in place and dressed.The other approaches are identical in technique except for venipuncture site and plane of insertion. Table 1-1 Advantages and Disadvantages of central venous catheters Approach External jugular advantages Part of surface anatomy Coagulopathy not prohibitive Low pneumothorax rate disadvantages High failure rate Not ideal for prolonged venous access Poor landmarks in obese patients Difficult approach for threading catheters Not ideal for prolonged access Carotid artery puncture frequent Uncomfortable Difficult access with tracheostomies Contraindicated with increased intracranial pressure Difficult access during emergencies when airway control being established Hinger risk of pneumothorak Compression of bleeding site difficulty inter

Internal jugular

Pneumothorax uncommon High success rate Right IJ with straight path to SV (easier to pass catheter,less malposition)

Subclavian

Easier to maintain dressings Better landmarks in obesity Better access when airway control is being established

Internal jugular vein median approach The junction of the sternal and clavicular heads of the SCM are identified.The needle is inserted caudad to the junction of the two heads and directed toward the ipsilateral nipple at al nipple at a0 degree angel to the skin.The IJ is usually reached within 3 cm with this approach. Internal jugular vein anterior approach