Manny Trujillo, Jr.

, MD
Department of Surgical Education
Spartanburg Regional Healthcare System
05.07.13
Objectives

Identify the anatomical structures
germane to the insertion of central
venous catheters

Describe the indications,
contraindications, and complications
of central catheter insertion


What is a Central Line?
Central line:
A catheter that is
passed through a vein
whose tip projects into
the central venous
system

Central venous system:
superior vena cava
inferior vena cava
brachiocephalic veins
internal jugular veins
subclavian veins
iliac veins
common femoral veins
Central Venous Cannulation
Indications
Emergency access
Inability to obtain
peripheral access
Administer
concentrated
fluids/vasoactive
drugs
Transvenous pacer or
pulmonary catheter
Temporary hemodialysis
catheter
Monitoring of central
venous pressure
Central Venous Cannulation
Contraindications
NO ABSOLUTE CONTRAINDICATIONS
Relative:
Coagulopathy
Trauma, prior surgery, radiation
Uncooperative pt
Overlying infection
Marked obesity
Vasculitis
Sclerotherapy
Multiple previous catheterizations at site
Subclavian Vein Cannulation
VHD XS#1322
R Pectoralis Major
R Subclavian
R Clavicle
R Sternal Head SCM
L Subclavian
Superior lobe L Lung
Subclavian Vein Cannulation
Pros

Lowest infection rate
Anatomic landmarks are
the most consistent
preferred in trauma pts
Cannulae are easier to
secure reduces
subsequent movement and
dislodgement



Cons

Avoid in pts with
bleeding coagulopathies
Risk of pneumothorax
Difficult to apply
pressure to inadvertent
subclavian artery
puncture

Subclavian Vein Cannulation
External Landmarks

Junction between the
medial and middle
thirds of the
clavicle
The lateral edge of
the
sternocleidomastoid
muscle where it
inserts into the
clavicle
Subclavian Vein Cannulation
1. Infiltration of local
anesthetic

2. Trendelenburg (head
down) position


Subclavian Vein Cannulation
3. Advance needle just
beneath the
clavicle toward
suprasternal notch
4. Return of free-
flowing venous
blood confirms
venipuncture

Subclavian Vein Cannulation
5. Pass guide wire
through needle
without undue
resistance
Subclavian Vein Cannulation
6. Enlarge skin exit
site with scalpel
Subclavian Vein Cannulation
7. Dilate skin/subcutaneous
tract (exercise
caution!)

Subclavian Vein Cannulation
8. Thread catheter over
guide wire
maintaining control
of guide wire at all
times

Subclavian Vein Cannulation
9. Remove guide wire

Subclavian Vein Cannulation
10. Situate catheter tip
at the atrial-caval
junction

Tip of line
near SVC/RA
junction
Subclavian Vein Cannulation
KEY:

Open Arrow R lateral
wall of SVC

Closed Arrow Junction
of lower SVC with
superior convexity of the
right cardiac
border/right atrial
appendage (SVC-RAA
junction)

Asterisk atrial-caval
junction (approx 1-2 cm
below SVC-RAA junction
in adults) target site
for central line tip
Subclavian Vein Cannulation
11. Secure the guide wire

Subclavian Vein Cannulation
1. Infiltration of local
anesthetic
2. Trendelenburg (head down)
position
3. Advance needle just beneath
the clavicle toward
suprasternal notch
4. Keep needle parallel to the
floor to avoid pneumothorax
5. Return of free-flowing venous
blood confirms venipuncture
6. Pass guide wire through
needle without undue
resistance
7. Enlarge skin exit site with
scalpel
8. Dilate skin/subcutaneous
tract (exercise caution!)
9. Thread catheter over guide
wire maintaining control of
guide wire
10. Remove guide wire
11. Situate catheter tip at the
atrial-caval junction
12. Secure catheter and place
sterile dressing
13. Obtain radiographic
confirmation

Percutaneous (Seldinger) Technique

Steps 1-2, 5-13 are applied to placement of IJ catheter
Steps 1, 5-10, 12-13 are applied to placement of a femoral catheter
Internal Jugular Vein Cannulation
VHD
XS#1283
R Sternocleidomastoid M.

R Internal jugular V.

R Common Carotid A.
L Anterior Scalene

L Middle Scalene
Internal Jugular Vein Cannulation
Pros

Lowest risk of
thrombosis
Decreased risk of
pneumothorax
Straight shot to the
right atrium (right IJ)
Compressibility of
vascular extravasation



Cons

More uncomfortable for pt
Risk of carotid artery
puncture
Higher risk of infection
than subclavian
(proximity to
aerodigestive secretions)
Anatomic variability
Internal Jugular Vein Cannulation
External Landmarks
Identify sternal and
clavicular heads of the
sternocleidomastoid
Visualize triangle
formed by the muscle
bellies
Palpate carotid pulse
(usually medial border
of medial head of SCM)

Internal Jugular Vein Cannulation
* In obese pts where landmarks are
not discernible, a reasonable rule of
thumb is 3 finger breadths lateral
from the tracheal midline and 3
finger breadths up from the clavicle
Ultrasound Guidance:
In numerous studies, ultrasound guidance has been shown
to increase the success of first-time catheter placement
and to decrease the risk of complications.
Significant reduction in arterial sticks, posterior wall
puncture, pneumothorax.
Pneumothorax; multiple studies show reduction of risk to
0-1% compared to historical controls of 5-6%
Improved function of lines (days of use), and greater
success at placement with first attempt

The vein and artery appear circular and black on the
ultrasound image; the vein is much more compressible when
gentle pressure is applied to the skin via the probe. The
needle appears echogenic and can be followed into the
image of the vein.

Internal Jugular Vein Cannulation
Internal Jugular Vein Cannulation
Internal jugular vein
Common Carotid
Artery
Ultrasound-guided IJ cannulation
Femoral Vein Cannulation
Pros
Can be accessed quickly
and expediently
Avoids disturbing
superior central venous
system for future
dialysis pts
Fairly consistent
anatomy


Cons
Highest rate of
infection
Highest rate of
thrombosis
High rate of kinking
with flexion of the hip

Femoral Vein Cannulation
Anatomic
Considerations
Femoral vein medial
and just deep to
femoral artery
Deep femoral vein
and saphenous veins
join at deep surface
and anteromedial
surface respectively


Femoral Vein Cannulation
NAVEL
Complications of Central Venous
Access
Other Complications:
Pseudoaneurysm
Line migration
Arrhythmias
Air embolism
Complications of Central Venous
Access
Pneumothorax
Complications of Central Venous
Access
Malposition
Complications of Central Venous
Access
Pseudoaneurysm
Central Venous Access Video
http://www.youtube.com/watch?v=HE5QhsPR
aPU

To know truly is to know by
causes.

- Francis Bacon, De Augmentis Scientiarum
mgtrujillo@srhs.com