Central venous access

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Photograph of a quadruple lumen central venous catheter.

Several approaches.

Contents

Indications

Anatomy

Complications

These 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.
PMID link to reference awaited

Operator & Training Issues

  • Learning curve; some suggest 50 to gain proficiency, though not simply numbers
  • Retention of skills
  • Who should do them?
Anecbubble.pngZen and the art of cannulation
Many geometrical explanations of how to place a cannula in a central vein exist, but this is to a large extent implicit, kinaesthetic knowledge rather than explicit. It is important to know where the vein is, rather than to be able to recite a description of where it is. In the same vein as the "unwilled shot" in tennis, an approach of visualising the hidden vein below the skin, overlaying this picture on the visible one, and then placing the cannula where it should be is worth considering. Ultrasound equipment adds a dimension of techne to this.


Procedure

Seldinger technique (catheter over wire)

Distance

Determined by approach and patient.[2][3][4]

Post-procedure

Confirm position

A post-procedure chest radiograph should be requested to confirm the position and exclude any immediate complications.[5]

There are no fixed rules, but it is generally accepted that the tip should lie at approximately the level of the carina.[6]

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).[7] Another paper suggests a distance from the tip of the catheter to the carina of ≤55mm as measured by chest radiograph.[8]

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.[9]

Post-procedure care

  • 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.

Equipment

External Links

References

  1. 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.)
  2. 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.
  3. 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.
  4. Russell WC, Parker JL. Thirteen centimetre central venous catheters, lucky for all? Anaesthesia. 2003 Apr; 58(4):388.
  5. Pollard A, Johnson RV. Assessment of correct central venous line placement. Anaesthesia. 2002 Dec; 57(12):1223.
  6. 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.
  7. 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.)
  8. 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.)
  9. 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.
  10. Muhm M. Ultrasound guided central venous access. BMJ (Clinical research ed.). 2002 Dec 14; 325(7377):1373-4.
  11. NICE Guidelines 49 (html). NICE Guidelines (pdf)
  12. 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.)
  13. 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.