Académique Documents
Professionnel Documents
Culture Documents
(Internal Medicine)
Editor(s): Todd W Thomsen, MD | Gary S Setnik, MD, FACEP
Contributor(s): Sean M. Burns, MD
Section Editor(s): David Feller-Kopman, MD
PRE-PROCEDURE
INTRODUCTION
See Figure 1.
Central venous lines are essential tools in the care of complicated patients, both
on inpatient wards and in the emergency department and intensive care unit.
They may provide access for blood draws, facilitate central administration of
fluids and medications, and allow direct measurement of cardiac filling pressure.
The three main approaches used to place central lines are the internal jugular,
subclavian, and femoral. This chapter reviews the subclavian approach; other
sites are detailed in separate chapters. See Central Venous Catheterization:
Internal Jugular Approach and Central Venous Catheterization: Femoral
Approach for further details.
INDICATIONS
Administration of agents into the central vasculature (see Figure 2)
o Central venous access is required to administer certain medications,
including most vasoactive and/or inotropic agents (i.e., vasopressors
such as dopamine and norepinephrine). In addition to expediting delivery of
these drugs to the heart and arterial system, central administration
decreases the risk of damaging peripheral tissue from the vasoconstrictive
effects of the medications.
o Patients needing total parenteral nutrition also require central access
because the osmolarity of the mixture exceeds what can safely be
administered into the peripheral circulation.
o Other hyperosmolar agents that are optimally infused through a central
line include concentrated potassium solutions, hypertonic saline solutions,
certain chemotherapeutic agents, and calcium chloride.
Central circulation and intracardiac access (see Figure 3)
o Measurement of central venous filling pressure within the right atrium
can be helpful in determining the volume status of a patient and can readily
be transduced via a central venous catheter in the internal jugular or
subclavian position.
o Specialized pulmonary artery (i.e., Swan-Ganz) catheters can be used
to measure pulmonary capillary wedge pressure, a means of approximating
left-sided filling pressure.
o Blood drawn from a central catheter can allow the measurement of mixed
venous (or central venous) oxygen saturation, often used to estimate
cardiac output.
o Temporary transvenous pacemakers can be inserted through central
venous catheters (more specifically, sheath introducer catheters) to provide
a more reliable and comfortable means of pacing than the transcutaneous
route. See Transvenous Pacing for further details.
Maintenance of venous access
o In acutely unstable patients, peripheral venous access may be inadequate.
o Patients requiring multiple medications in drip formulation can quickly run
out of access points.
o This problem is compounded in a chronically ill patient, who oftentimes has
insufficient peripheral access because of frequent blood drawing and
peripheral intravenous (IV) line placement.
o Central venous catheters provide reliable access for blood drawing and
administration of medication, until either peripheral access can be obtained
or less venous access is required.
Hemodialysis and plasmapheresis
o Emergency or short-term dialysis and plasmapheresis can be performed via
special central venous catheters (e.g. Quinton catheters).
Clinical Pearls: The subclavian vein approach is suitable for routine and
emergency central venous access. Advantages and disadvantages of the
subclavian approach include those listed in Table 1.
CONTRAINDICATIONS
Absolute contraindications
o Adequate peripheral IV access: Given the potential for serious morbidity
and the high rate of infection associated with central lines, they should be
used only when absolutely necessary. See Intravenous Cannulation for
further details. See Figure 4.
o Operator inexperience (unless supervised by an experienced
practitioner): Although placement of a central line is a relatively safe
procedure in experienced hands, those unfamiliar with the technique should
study the protocol beforehand to gain confidence and must be supervised at
all times during placement of a line.
o Uncooperative patient:
Placement of a central line requires that the patient remain still so that the
operator can define the anatomy accurately, concentrate on steps of the
procedure, and be vigilant for signs of complications.
Needles, scalpels, and sutures are necessary tools in this task.
Patients who are uncooperative have an unacceptably high risk of injury
and also expose the operator to increased risk.
Adequate steps must be taken to make the patient comfortable for the
length of the procedure before proceeding.
Relative contraindications
o Significant bleeding disorder: Coagulopathies and thrombocytopenia
increase a patient's risk for bleeding, but the hemorrhages are generally
mild and do not require transfusions.2
Clinical Pearls: Although traditional teachings recommend replacement
products (such as fresh frozen plasma or platelet concentrates) before central
catheterization, evidence from the literature suggests that this is not
necessary.2 The decision to use such products should be made on a case-by-
case basis.
See Figure 6.
Subclavian vein
oAs the subclavian vein crosses the first rib, it lies posterior to the junction
between the medial third and lateral two thirds of the clavicle.
o The vein has a diameter of 1 to 2 cm.
o Connective tissue fixes the subclavian to the first rib and clavicle, and thus
the vein does not collapse in cases of hypovolemia or cardiac arrest.3
o The subclavian arteries are located posterior to the veins and are separated
from them by the scalene muscles.
o The domes of the pleurae of the lungs may extend above the first rib on the
left but rarely extend this far on the right, and thus the right side is often
preferred for line insertion.
o Insertion on the right also avoids the risk of damage to the thoracic duct,
which is located near the junction of the left subclavian and left internal
jugular.
Clinical Pearls: If you are anticipating the use of a transvenous pacemaker or
pulmonary artery catheter, you should use either the left subclavian vein or the
right internal jugular vein. These approaches align the catheter trajectory with
the SVC and right atrium. See Transvenous Pacing for further details.
Two approaches can be used for the subclavian vein, as shown in Table 2 (see
Figure 11).
PROCEDURE
Explain the procedure to the patient. **OBTAIN CONSENT**
Use lay terms to describe why you need to insert a central venous line.
o
Inform the patient/decision maker of the proposed benefits of the
o
procedure, its major risks, and the potential management of any
complications (including insertion of a chest tube, surgery, and
cardioversion).
o If time allows, obtain written informed consent from the patient/decision
maker.
Prepare the patient.
o Place the patient on oxygen, a pulse oximeter, and a cardiac monitor.
o Place the patient in the 15- to 30-degree Trendelenburg position to
prevent air embolism and to distend the vein. See Figure 12.
o Raise the bed to the appropriate height so that you are comfortable reaching
the patient's neck without bending over or stretching. You will be standing at
the head of the bed during the procedure.
Clinical Pearls: Traditional teaching recommends that a towel be placed
between the scapulae to make the scapula more prominent. However, this
practice may compress the vein between the clavicle and first rib and make
catheterization difficult.4
Sometimes, resistance to insertion of the guidewire is met a third of the way in,
at the junction of the subclavian and internal jugular veins. If this occurs, try
increasing the degree of Trendelenburg positioning or turning the head to the
ipsilateral side with the intent of compressing the internal jugular vein.
Never let go of the guidewire once it is placed in the central venous
system; it can migrate into the venous system and require surgical
retrieval.
Prepare for catheter insertion.
o While holding the guidewire in place at all times to prevent migration,
remove the introducer needle.
o Nick the skin with the scalpel to enlarge the puncture site. See Figure 22.
Make sure that your incision is congruous with the hole in the skin that the
needle goes through.
Avoid cutting the guidewire with the scalpel.
Clinical Pearls: Failure to create a large enough nick with the scalpel will result
in difficult (or impossible) catheter insertion. This is especially the case with
sheath introducers.
To insert a triple-lumen catheter:
o Advance the dilator over the guidewire, through the skin and subcutaneous
tissue, and into the vessel. See Figure 23.
o You may encounter some resistance during this step; a slight rotating
motion may be helpful.
o Remove the dilator.
o You may notice more bleeding from the insertion site at this point; this is
normal.
Clinical Pearls: Remember, never let go of the wire during central venous
catheterization!
Advance the catheter over the wire and into the vessel. See Figure 24.
The external portion of the guidewire will protrude from the distal port as the
catheter is advanced.
During this process it is essential to always maintain control of the
wire.
If there is not enough wire external to the patient to protrude through the
distal port, withdraw the wire as needed before further catheter advancement.
Clinical Pearls: The catheter tip should be positioned in the SVC and not the
right atrium. In most adults, the right atrium is 10 to 15 cm from the subclavian
vein. Be sure that the catheter is not inserted deeper than this. Post-procedure
chest radiography will assist with proper depth of placement.
Hold the hub of the catheter with your nondominant hand and remove the
guidewire with your dominant hand.
Attach a syringe and withdraw blood from the port from which the guidewire
exited to confirm location within the lumen of a vein.
Flush the line with sterile normal saline, and place an end cap onto the port.
Flush the middle and proximal ports with saline to ensure patency.
To insert a sheath introducer:
o First, fully insert the dilator into the sheath introducer.
o Unlike the triple-lumen catheter, the sheath introducer and dilator are
inserted in the same step. See Figure 25.
o Advance the dilator and sheath introducer as a unit over the wire and into
the vessel.
o The external portion of the guidewire will protrude from the one-way valve
on the back of the sheath introducer.
o During this process it is essential to always maintain control of the
wire.
o If there is not enough wire external to the patient to protrude through the
valve, withdraw the wire as needed before further catheter advancement.
Clinical Pearls: The sheath introducer is a large catheter, and a considerable
amount of resistance may be encountered during advancement. A slight twisting
motion may be helpful.
Be sure to advance the dilator and the sheath as a unit. If the sheath gets
advanced ahead of the dilator, the leading edge of the sheath may kink, and
proper insertion into the vessel will be unsuccessful.
Once the sheath is fully advanced, remove both the dilator and the guidewire
as a unit.
Turn the one-way valve on the end of the sheath clockwise to close it.
Attach a syringe and withdraw blood from the side-arm port to confirm
intravenous placement, and then flush it with saline.
Final steps
o Take the patient out of the Trendelenburg position.
o Secure the catheter at the insertion site with suture. See Figure 26.
o Cover the site with a sterile transparent occlusive dressing (gauze should
not be used).
o Remove gown, gloves, hat, and mask with face shield. Clean your hands
with antimicrobial soap.
o Order a chest radiograph to check for line placement (the tip of the line
should be in the SVC) and to rule out pneumothorax.
POST-PROCEDURE
CARE
Confirmation of line placement
o Before use, a central venous line must have its placement confirmed with a
radiograph. See Figure 27.
o The tip of the catheter should lie within the SVC and not the right atrium.
Clinical Pearls: The tip of the catheter should be positioned no lower than the
carina to ensure proper placement in the SVC.