Central Venous Access

Mazen Kherallah, MD, FCCP

Indications Need for IV access and failure of peripheral access Peripheral access too painful or tenuous Long term IV access anticipated Medications indicated that are toxic to peripheral

veins Hemodynamic monitoring Volume resuscitation with large bore central lines Special procedure: Swan Ganz, dialysis,

plasmapheresis

04/22/23

Site Selection

Site Pro’s Con’s Subclavian Large vessel

Can tolerate high flow

Dressing easy to maintain

Less restrictive for patient

Lowest sepsis rate

Close to lung apex, risk of pneumothorax

Close to subclavian artery

Hard to control bleeding

04/22/23

Site SelectionSite Pro’s Con’s

Internal Jugular

Large vessel Easily located Easy access Short, straight

path to superior vena cava

Decreased risk of pneumothorax

Uncomfortable for patient

Difficult to maintain dressing

Close to carotid artery

Easily contaminated

Difficult maintenance with trach or neck injury

04/22/23

Site SelectionSite Pro’s Con’s

Femoral Easy access Large vessel Good access

duringresuscitation

Decreasedmobility

Increased riskof thrombosis,phlebitis &infection

Easilycontaminated

Close tofemoral artery

Dressingdifficult tomaintain

Choice of Site

Subclavian IJ FemoralSuccess Rate 90-95% 90-99% 90-95%

Arterial puncture 0.5-1% 10% 5-10%

Pneumothorax 1-5% 0-0.2% 0

Infectious rate Lowest Intermediate Highest

Access during cardiac arrest

2nd 3th 1st

Side of body preference

Left: angle of subclavian vein

Right: avoid thoracic duct

None

Coagulopathy present 3th 2nd 1st

Hypovolemia present 1st: vein supported by fibrous sheath

3th: vein collapses 2nd

Pacemaker 2nd 1st 3th

Anatomy of Great Vessels

Anatomy of Great Vessels

Anatomy of Great Vessels

Seldinger Technique

The Procedure Patient position:

Patient is moved to the side of the bed so physician would not lean over

The bed is high enough so physician would not have to stoop over

Patient should be flat without a pillow, Trendelenburg position if patient is hypovolemic

The head is turned away from the side of the procedure

Wrist restraints if necessary

The Procedure

Skin preparation: Prepare before putting sterile gloves Start at the center and work outward the

edges Allow time for the sterilizing agent to dry Disposable drape under the patient Betadine or Chlorhexidine are acceptable

solution and have activity against gram positive organisms

The Procedure

Drape: Large enough Handed sterilely by the assistant Hole in the area of placement

Prepare the tray: Handed sterilely by the assistant Prepare the equipment before starting

Anesthesia Use local anesthesia with lidocaine

YOUR ROLE AFTER THE INSERTION

Dispose all sharps Place an occlusive sterile dressing Flush lumens to maintain patency Obtain a chest x-ray (ask for order if physician doesn’t

mention it) Monitor site for bleeding Assess breath sounds Assess circulation Assess for hematoma Document insertion, site, dressing and flushing

USING THE CENTRAL LINE

Flush q shift, before and after use with NS. Some places also require heparin flush

Close clamps when not is use Check P&P of facility, but usually fluids are changed

every 24 hours, tubing changed every 48-72 hours Dressing is usually changed every 3 days Line can be used for blood drawing - withdraw and

waste 10 cc, then withdraw blood for samples If port becomes clotted, do not use - sometimes ports

can be opened up with urokinase (requires a doctor’s order)

Complications Immediate

Hemothorax Pneumothorax Arterial puncture Vessel erosion Nerve Injury Dysrhythmias Catheter malplacement Embolus Cardiac tamponade

Complications Delayed

Dysrhythmias Catheter malplacement Vessel erosion Embolus Cardiac tamponade Catheter related infection Thrombosis

Vascular Erosion/Cardiac Tamponade

Large vessel perforation is uncommon Vessel erosion more common with stiff

catheters, like dialysis catheters Cardiac tomponade occur mainly if the tip is

located in the RA Complication is fatal in 2/3 of cases

Air Embolism

Air is sucked in through the catheter due to negative intrathoracic pressure during inspiration

Air can be pushed with flushing the catheter if it was not pulled back before flushing

Complication is uncommon but can be fatal Manifests with hypoxemia, cardiovascular collapse,

mental status changes and livedo reticularis Place patient to left lateral position if suspected

Bleeding

More common in patients with coagulopathy Easily controlled with femoral or IJ sites Place local pressure and correct

coagulopathy

Arterial Puncture and Cannulation

If the artery is puncture local pressure is applied for 3-5 minutes, observe for hematoma formation

If the artery is cannulated, pulsatile reflux of blood can be noticed, blood gas analysis reveals arterial.

The catheter should not be used, and remove it after coagulopathy is corrected if present

Thrombosis

Sleeve fibrin surrounding the catheter (occurs on the majority of catheters)

Mural thrombus on the wall of the vein (10-30% of catheters)

Occlusive thrombus (1-10%)

Pneumothorax Most likely, pneumothorax is noticed after CXR is

seen, unless patient developed tension pneumothorax with hypoxemia, cardiopulmonary collapse and absent breath sound

Small pneumothorax may be watched closely without chest tube placement in the spontaneously breathing patients

Large pneumothorax requires chest tube placement Even small pneumothorax in patients on positive

pressure ventilation requires chest tube placement

Catheter-Related Sepsis

Late complications Femoral > IJ > subclavian Triple lumen > single lumen Large bore > smaller catheter Sterility of procedure Number of hub manibulations

Basic Pressure Measurements from Swan Ganz Catheter

Measurement Normal range

Central venous pressure <10 mm Hg

Right atrial pressure <10 mmHg

Right ventricular pressure, systolic 15-30 mm Hg

Right ventricular pressure, diastolic 0-8 mm Hg

Pulmonary artery pressure, systolic 15-30 mm Hg

Pulmonary artery pressure, diastolic 5-16 mm Hg

Pulmonary artery pressure, mean 10-22

Pulmonary artery wedge pressure, mean 8-12

Hemodynamic MonitoringPosition of Transducer

Components of the Atrial Waves

Differences in CVP and PCWP EKG correlation

Wave EKG correlate Description A In the P-R interval RA contraction

C End of QRS Closure of the tricuspid valve

V Near end of T wave Filling of the RA

X descent Downward slope of a wave

Y descent Downward slope of v wave

CVP Correlation with EKGNormal CVP Tracing

Reading the mean of an A wave

22+10/2=16

Spontaneous BreathingReading CVP

Spontaneous BreathingInsp./Exp. Ratio in Rapid Breathing

Spontaneous BreathingInsp./Exp. Ratio in Rapid Breathing

Hemodynamic MonitoringCentral Venous Pressure: normal 4-10

Increased CVP: Right heart failure Right myocardial infarction Cardiac tomponade Tricuspid insufficiency Left to right shunt Pulmonary emboli COPD and cor pulmonale ARDS Excess fluid Tricuspid stenosis

Decreased CVP hypovolumia Decreased venous return Excessive veno or

vasodilation Shock

Central Venous Pressure Tracings

Normal EKG tracing and right atrial pressure waveform

Atrial fibrillation

Atrioventricular dissociation

Central Venous Pressure Tracings

Normal EKG and right atrial waveforms

Tricuspid stenosis

Mild to moderate tricuspid insufficiency

Severe tricuspid insufficiency

Constrictive pericarditis

Large A wave Secondary to Loss of Atrioventricular Synchrony Simultaneous Atrial and Ventricular Contraction

Loss of A WaveAtrial Fibrillation