Central Venous Catheterization(without USG)

Runal Shah3rd year MEM

Kokilaben Dhirubhai Ambani Hospital.

Objectives

• Indications• Contraindications• Anatomy• Complications• Videos

Central Venous Catheterization

• Indications1) CVP monitoring2) High-volume/flow resuscitation3) Emergency venous access4) Inability to obtain peripheral venous access5) Repetitive blood sampling6) Administering hyperalimentation, caustic agents, or other

concentrated fluids7) Insertion of transvenous pacemakers8) Hemodialysis or plasmapheresis9) Insertion of PA cath

Central Venous Catheterization

• Contra-indications1) Infection over the placement site2) Distortion of landmarks by trauma or congenital anomalies3) Coagulopathies, including anticoagulation and thrombolytic

therapy4) Pathologic conditions, including superior vena cava

syndrome5) Current venous thrombosis in the target vessel6) Prior vessel injury or procedures7) Morbid obesity8) Uncooperative patients

Anatomy

Internal Jugular Vein cannulationPros:

• Good external landmarks• Improved success with USG• Less risk for pneumothorax

than with SV access• Can recognize and control

bleeding• Malposition of the catheter is

rare• Almost a straight course to

the SVC on the right side• Carotid artery easily

identified

Cons:

• More difficult and inconvenient to secure

• Possibly higher infectious risk than with SV access

• Possibly higher risk for thrombosis than with SV access

Right IJV cannulation

Right IJV cannulation

Right IJV cannulation

Anatomy

Subclavian venous cannulation

• Pros:– Good external

landmarks

• Cons:– “Blind” procedure– Unable to compress

bleeding vessels

Anatomy

Femoral Venous Cannulation• Pros:– Good external landmarks– Useful alternative with

coagulopathy

• Cons:– Difficult to secure in

ambulatory patients– Not reliable for CVP

measurement– Highest risk for infection– Higher risk for thrombus

Complications

Complications

Caveats & Helpful hints

• If there is a concern about possibility of bleeding – avoid Subclavian approach, as direct compression is difficult and surgical exploration is required.

• If anticipating Transvenous Pacemaker or PA catheter insertion, use either Right IJV or Left Subclavian approach, as this aligns catheter trajectory with SVC and RA.

• The catheter tip should be positioned in the SVC and not the right atrium. In most adults, the right atrium is 10–15 cm from the subclavian vein. Be sure that the catheter is not inserted deeper than this.

Caveats & Helpful hints

• If pneumothorax occurs and central access remains a priority, subsequent attempts should be made on the same side of the thorax as the pneumothorax to prevent the development of bilateral pneumothorax.

• If the pulse cannot be palpated (e.g., cardiac arrest), divide the distance from the anterior superior iliac spine to the symphysis pubis into thirds. The artery typically lies at the junction of the medial and the middle thirds and the vein is 1 cm medial to this location.

• Excessive contralateral head rotation increases overlap of the carotid by the internal jugular and may increase the risk for arterial injury.

Reference:

Roberts and Hedges’ Clinical Procedures in Emergency Medicine Expert Consult – 5th & 6th Edition