Emergency venous access for fluid resuscitation and drug infusion

 Central venous pressure and oxygen monitoring

 Infusions requiring central venous administration (vasopressors, hyperosmolar solutions, hyperalimentation)

 Routine venous access due to inadequate peripheral IV sites

 Introduction of pulmonary artery catheter

 Introduction of transvenous pacing wire

CONTRAINDICATIONS

 No absolute contraindications

 Relative Contraindications

    Coagulopathic patients (inability to compress)

    Overlying infection, burn, or skin damage at puncture site

    Distorted anatomy or trauma at the cannulation site

    Combative or uncooperative patients

    Penetrating trauma with suspected proximal vascular injury

    Pneumothorax on contralateral side (risk of bilateral pneumothoraces)

    Chronic obstructive pulmonary disease (COPD)

RISKS/CONSENT ISSUES

 Pain

 Local bleeding and hematoma

 Infection

 Pneumothorax/hemothorax (necessitating chest tube)

LANDMARKS

Right subclavian vein (SCV) approach is preferred because (1) pleural dome is lower on the right and (2) thoracic duct is on the left.

 Infraclavicular Approach (FIGURE 24.1)

    Place the left index finger on the suprasternal notch and the thumb on the costoclavicular junction

    Needle insertion is at the bisection of the medial and middle thirds of the clavicle

    Aim the needle toward suprasternal notch

    Needle bevel is oriented inferomedially to facilitate wire entry

 Supraclavicular Approach (FIGURE 24.2)

    Needle insertion is just above the clavicle, 1 cm lateral to the insertion of clavicular head of sternocleidomastoid (SCM)

    Aim to bisect angle between SCM and clavicle with the needle tip pointing toward the contralateral nipple

    Needle bevel is oriented medially

SUPPLIES

 Central Venous Catheter Kit

    Drapes, chlorhexidine prep (2), gauze

    Catheter (multiport, cordis, or hemodialysis)

    Guidewire within plastic sheath

    Lidocaine, anesthesia syringe, and small-gauge needle

    Three-inch introducer needle and syringe

    Dilator

    Scalpel

    Suture

 Sterile gloves, sterile gown, sterile cap and mask

 Sterile drapes

 Sterile saline flushes

 Sterile port caps

 Ultrasound machine (optional)

 Sterile ultrasound probe cover with sterile gel (optional)

TECHNIQUE

 Patient Preparation

    Cardiac monitoring to detect dysrhythmias triggered by the wire being advanced into the right ventricle

    Supplemental oxygen and continuous pulse oximetry monitoring

    Lower the head of the bed to 15 to 30 degrees in Trendelenburg position

    Place a rolled up towel or sheet in between the patient’s shoulder blades to elevate the patient’s clavicle and provide better access to the SCV (optional)

    Place the ipsilateral arm in abduction

    Sterilize clavicular insertion site, including ipsilateral neck in case subclavian vascular access fails and internal jugular (IJ) vascular access is necessary

    Wear surgical cap, eye protection, mask, sterile gown and gloves

    Drape with sterile sheets to cover the patient’s head and legs

Note: Unless immediate emergent access is necessary, the procedure must be performed in full sterile technique (i.e., cap, eye protection, mask, sterile gown, and sterile gloves).

 Analgesia

    Use a small-bore needle (25 gauge) to anesthetize the skin and subcutaneous tissue with 1% lidocaine

 Insertion

    Infraclavicular Approach

       Place the left index finger on the suprasternal notch and the thumb on the costoclavicular junction

       The needle insertion is at the bisection of medial and middle thirds of the clavicle

       Aim the needle toward the suprasternal notch with the bevel oriented inferomedially

       At a shallow angle to the skin, advance the needle just posterior to the clavicle at the junction of middle and medial thirds

       Apply posterior pressure on the needle to direct it under the clavicle, aiming toward suprasternal notch

       The needle should be parallel to the bed as it is advanced. Avoid advancing the needle posteriorly into the dome of the lung.

       Aspirate continuously while advancing the needle

       If redirecting the needle, always withdraw the needle to the level of skin first

       Once the vessel is located, free-flowing venous blood is aspirated

       Stabilize and hold the introducer needle in place with the nondominant hand

       Gently remove the syringe from the needle and occlude the hub with your thumb to minimize the risk of air embolism

    Supraclavicular Approach

       The needle insertion is just above the clavicle, 1 cm lateral to the insertion of clavicular head of SCM

       Aim to bisect the angle between SCM and clavicle with the tip pointing just caudal to the contralateral nipple

       Direct the needle 10 to 15 degrees upward from the horizontal plane, just posterior to the clavicle, again aiming just caudal to the contralateral nipple

       The needle bevel is oriented medially

       Note that the SCV is found more superficially in the supraclavicular approach than in the infraclavicular approach

       Aspirate continuously while advancing the needle

       If redirecting the needle, always withdraw the needle to the level of skin first

       Once the vessel is located, free-flowing venous blood is aspirated. Successful puncture usually occurs at a depth of 2 to 3 cm.

       Stabilize and hold the introducer needle in place with the nondominant hand

       Gently remove the syringe from the needle and occlude the hub with your thumb to minimize the risk of air embolism

 Seldinger Technique

    Advance the guidewire through the introducer needle. The wire should pass easily. Do not force the guidewire.

    Always hold on to the guidewire with one hand. Never let go of the guidewire.

    If resistance is met, withdraw the wire and rotate it, adjust the angle of needle entry, or remove the wire and reaspirate with the syringe to ensure the needle is still in the vessel

    When at least half of the guidewire is advanced, remove the needle over the wire. Keep one hand holding the wire at all times.

    Make a superficial skin incision with the bevel of the scalpel blade angled away from wire

    Ensure the incision is large enough to allow easy passage of the dilator

 Dilation

    Thread the dilator over the guidewire, always holding on to the wire

    Advance the dilator through the skin into the vessel with a firm, twisting motion while holding the guidewire with the nondominant hand

    Remove the dilator, leaving the guidewire in place

 Catheter Insertion

    Thread the catheter over the wire and retract the wire until it emerges from the catheter’s port

    While holding the guidewire, advance the catheter through the skin into the vessel to the desired depth. Optimal depth depends on patient size and is typically 10 to 15 cm for the right SCV and 14 to 19 cm for the left SCV.

    Withdraw the guidewire through the catheter

    Use a syringe to aspirate blood from the catheter to confirm placement in the vein

 Confirmation

    Manometry

    Blood gas analysis

    Sonographic confirmation of the catheter in the vein

    Post procedure chest x-ray (CXR)

       Confirm the catheter tip is in the superior vena cava just proximal to the right atrium

       Rule out pneumothorax

 Flush and Secure

    Aspirate, flush, and heplock all central line lumens

    Suture the catheter to the skin by using silk or nylon sutures

    Cover the skin insertion site with sterile dressing (bacteriostatic if available)

COMPLICATIONS

 Dysrhythmias

 Arterial puncture or cannulation

 Vessel laceration or dissection

 Pneumothorax or hemothorax

 Brachial plexus injury

 Phrenic nerve injury

 Tracheal puncture or endotracheal cuff perforation

 Guidewire embolism

 Air embolism

 Catheter tip embolism

 Catheter malposition

 Venous thrombosis

 Insertion site cellulitis

 Line sepsis

 Local hematoma

ULTRASOUND-GUIDED CENTRAL VENOUS ACCESS

 Use of ultrasound guidance to place IJ and femoral central venous catheters has been shown to increase success rates and decrease complications

 Current literature suggests that the use of ultrasound guidance can be helpful when placing subclavian central venous catheters

SONOGRAPHIC TECHNIQUE

 Place a high-frequency linear probe (5–10 MHz) just inferior to the middle and medial thirds of the clavicle with the probe marker pointed cephalad (a probe with a smaller footprint will allow better visualization of the subclavian anatomy)

 Obtain a transverse view of SCV inferior to the clavicle and superior to the 1st rib. Use color flow and/or Doppler to distinguish the artery from vein (FIGURE 24.3).

 Rotate the probe 90 degrees, visualizing the vein continuously, and obtain a longitudinal view of SCV. Because of the clavicle, the probe may need to be moved laterally to visualize the SCV as it becomes the axillary vein distal to the 1st rib.

 Use color flow and/or Doppler to distinguish the vein from artery (FIGURE 24.4)

 Maintain a longitudinal view of the SCV (stabilize the hand holding the probe on the patient’s chest to keep the probe in position)

 Insert the introducer needle at a 30- to 45-degree angle to the skin in line with the long axis of the ultrasound probe

 Note that the probe marker is facing the needle entry site and the needle should enter the skin directly next to the probe (FIGURE 24.5)

 The needle must be parallel to the long axis of the ultrasound probe to be visualized

 This in-plane approach allows direct visualization of the entire needle shaft and tip as it enters the vein and decreases the risk of pneumothorax and arterial puncture

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