Central venous access
- subclavian vein
- Internal jugular
- Femoral (also used for angiographic and radiological procedures)
- Peripherally-inserted central catheter (PICC)
- Transhepatic (rarely used)
- Irritant or hyperosmolar drugs, e.g. chemotherapy, parenteral nutrition
- Central venous pressure monitoring.
ComplicationsThese vary with the route and indication/device. For placements of central venous catheters subclavian vein catheterisation has a lower incidence of bacteraemia and symptomatic thrombosis compared to jugular or femoral vein catheterisation which in turn are less likely to cause pneumothorax. However subclavian vein catheterisation has the lowest overall complication rate by far.
- local puncture site infection
Operator & Training Issues
- Learning curve; some suggest 50 to gain proficiency, though not simply numbers
- Retention of skills
- Who should do them?
Seldinger technique (catheter over wire)
This is approximately at the T4 vertebral body and is above the pericardial reflection, i.e. outside the right atrium in which it could cause arrhythmias and also out of reach of the pericardium (reducing the risk of cardiac tamponade). Another paper suggests a distance from the tip of the catheter to the carina of ≤55mm as measured by chest radiograph.
Others suggest that the catheter can go up to 3cm below the carina, but should be as parallel to the flow of the vein as possible, not abutting the wall, to avoid thrombosis.
- Sterile technique, ideally 'no touch'.
- If dedicated for feeding, then should be used strictly for feeding only. Avoid taking blood or putting other routine drugs or fluids.
- ↑ Siddiqui AM, Harris GS, Movahed A, Chiang KS, Chelu MG, Nekkanti R. Transhepatic venous approach to permanent pacemaker placement in a patient with limited central venous access. World journal of clinical cases. 2015 Sep 16; 3(9):835-7.(Link to article – subscription may be required.)
- ↑ McGee WT, Ackerman BL, Rouben LR, Prasad VM, Bandi V, Mallory DL. Accurate placement of central venous catheters: a prospective, randomized, multicenter trial. Critical care medicine. 1993 Aug; 21(8):1118-23.
- ↑ Andrews RT, Bova DA, Venbrux AC. How much guidewire is too much? Direct measurement of the distance from subclavian and internal jugular vein access sites to the superior vena cava-atrial junction during central venous catheter placement. Critical care medicine. 2000 Jan; 28(1):138-42.
- ↑ Russell WC, Parker JL. Thirteen centimetre central venous catheters, lucky for all? Anaesthesia. 2003 Apr; 58(4):388.
- ↑ Pollard A, Johnson RV. Assessment of correct central venous line placement. Anaesthesia. 2002 Dec; 57(12):1223.
- ↑ Schuster M, Nave H, Piepenbrock S, Pabst R, Panning B. The carina as a landmark in central venous catheter placement. British journal of anaesthesia. 2000 Aug; 85(2):192-4.
- ↑ Orme RM, McSwiney MM, Chamberlain-Webber RF. Fatal cardiac tamponade as a result of a peripherally inserted central venous catheter: a case report and review of the literature. British journal of anaesthesia. 2007 Sep; 99(3):384-8.(Link to article – subscription may be required.)
- ↑ Wirsing M, Schummer C, Neumann R, Steenbeck J, Schmidt P, Schummer W. Is traditional reading of the bedside chest radiograph appropriate to detect intraatrial central venous catheter position? Chest. 2008 Sep; 134(3):527-33.(Link to article – subscription may be required.)
- ↑ Fletcher SJ, Bodenham AR. Safe placement of central venous catheters: where should the tip of the catheter lie? British journal of anaesthesia. 2000 Aug; 85(2):188-91.
- ↑ Muhm M. Ultrasound guided central venous access. BMJ (Clinical research ed.). 2002 Dec 14; 325(7377):1373-4.
- ↑ NICE Guidelines 49 (html). NICE Guidelines (pdf)
- ↑ McGee DC, Gould MK. Preventing complications of central venous catheterization. The New England journal of medicine. 2003 Mar 20; 348(12):1123-33.(Link to article – subscription may be required.)
- ↑ Graham AS, Ozment C, Tegtmeyer K, Lai S, Braner DA. Videos in clinical medicine. Central venous catheterization. The New England journal of medicine. 2007 May 24; 356(21):e21.(Link to article – subscription may be required.)
This article is a work in progress. Please feel free to contribute to it.