Central Venous Catheter Placement

Daniel E. Melville, MD, ABFM
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Subject: Central Venous Catheter Placement

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Introduction

Central venous catheters are often inserted for a variety of clinical indications. In 1953, Sven-Ivar Seldinger introduced the technique of placing a central venous catheter by threading the catheter over a guidewire. This process, known as the Seldinger technique, is currently the most common and accepted method of facilitating cannulation of large vessels. Several advantages to using the Seldinger technique include the use of a smaller and safer needle for insertion, the ability to use a venodilator to establish large-bore catheters if higher flow rates are needed, the flexibility to exchange different catheters without repeated punctures, and the use of a J-wire, reducing risk of perforation. 
Central venous catheters can be inserted into the internal jugular, external jugular, subclavian, femoral, or brachial veins. The optimal site of insertion is influenced by operator preference, experience, patient anatomy, and clinical circumstances. The subclavian vein is the most commonly used site for central venous access. The femoral vein is the second most commonly used site and is used when access is required distally from an injury, during resuscitative measures so that cardiopulmonary resuscitative measures do not need to be stopped while venous access is established, or when the vessels of the upper body are not suitable for cannulation. Therefore, subclavian and femoral venous line placements are discussed in further detail later in this chapter. 
An important concept to establishing vascular access lines is to understand the indication. At times a large-caliber peripheral intravenous catheter is preferred. For example, when a rapid bolus of large quantities of fluids is required to correct a hypovolemic shock state, a shorter length of a peripheral catheter with a large-bore radius is imperative. This concept follows the Poiseuille law, which can be summarized to state that the rate of flow is proportional to the fourth power of the radius of the cannula and inversely related to its length. Simply stated, short catheters with large diameters are more appropriate for rapid infusion rates. 
Of note, ultrasound visualization of the central vein while puncture is attempted is becoming more readily available to ease cannulation. Ultrasound assistance reduces the number of punctures necessary for cannulation to establish central access and reduces the incidence of complications. It should be considered particularly if vascular anomalies or body habitus impede identification of traditional landmarks. 
Standard precautions and preparation should be followed universally by all operators to prevent complications and reduce risk of infection. All providers should use an alcohol-based hand sanitizer or antimicrobial soap immediately prior to donning sterile gloves. The skin of the patient should be properly prepped with a chlorhexidine solution by rubbing back and forth with a sponge or gauze for a minimum of 30 seconds (see Appendix E). Once applied, the chlorhexidine solution should be allowed to air dry for at least 2 minutes and should not be wiped or blotted. If chlorhexidine cannot be applied because of an allergy or unavailability, a povidone-iodine solution can be applied in a similar fashion. Ideally, a sterile full-body drape should be placed on the patient. The Centers for Disease Control and Prevention recommend abiding by standard precautions of wearing a face mask, eye protection, cap, sterile and water-impervious gown, and sterile gloves prior to beginning procedures. 

Equipment

  • One multilumen indwelling catheter: size varies depending on location and reason

  • One spring-wire guide: straight soft tip on one end with a J-tip on the other end

  • One fastener: catheter clamp

  • One introducer needle: 18-gauge with a 12-mL syringe

  • One injection needle: 22-gauge with a 5-mL syringe

  • One injection needle: 25-guage with a 3-mL syringe

  • Skin prep materials (see Appendix E)

  • One 5-mL ampule of HCL, 1% lidocaine solution

  • One tissue dilator

  • One drape: 24 × 36 inches with 4-inch fenestration

  • Two gauze pads: 2 × 2 inches

  • Five gauze pads: 4 × 4 inches

  • One no. 11 scalpel

  • One suture: 3-0 silk with cutting needle

The instruments can be ordered individually or in a prepackaged sterile kit from companies such as Arrow International, Inc., Reading, Pennsylvania. 

Indications

  • To allow administration of numerous medications simultaneously, such as total parenteral nutrition, chemotherapy, and pressor agents

  • To administer drugs that have a higher risk of causing phlebitis when given through a peripheral intravenous catheter

  • To establish access to the central circulation if a pulmonary artery catheter or pacemaker placement is necessary

  • To gain access to central circulation if peripheral veins cannot be cannulated

  • To gain access for hemodynamic monitoring, such as to facilitate measurement of central venous pressure and venous oxyhemoglobin saturation

  • To facilitate plasmapheresis, apheresis, hemodialysis, or continuous renal replacement therapy

Contraindications

  • Injury distal to the vessel to be cannulated

  • Wounds directly over the cannulation site

  • Infection or overlying cellulitis in area around vessel to be cannulated

  • If the vessel to be cannulated has a known thrombus

Caution should be used when establishing a central venous access site in an area in which hygiene or a clean field would be compromised. For instance, avoid femoral line placement in a patient with fecal or urinary incontinence to avoid potential contamination and subsequent infection, or if a patient has a poor body habitus and excess pannus could potentially cover the cannulation site, again raising concerns of infection. 
A patient who is on warfarin (Coumadin), or other blood-thinning agents, or has a known coagulopathy can still have a central line established, although the patient should be approached cautiously, recognizing the potential complications of excessive bleeding. 

The Procedure

Subclavian Venipuncture (Infraclavicular Approach) using the Seldinger Technique

Step 1
Place the patient in a supine position. Prep the skin with povidone-iodine or chlorhexidine solution well around the venipuncture site and drape the area (see Appendix E). Standard precautions of sterile gloves, sterile gown, mask, cap, and eye protection should be followed. 
  • Pearl: Place the patient in a Trendelenburg position of at least 15 degrees down to distend the neck veins and reduce the risk of an air embolism.

Step 2
Apply a local anesthetic subcutaneously and deep at the venipuncture site. Usually 1% lidocaine without epinephrine is the anesthetic agent used. 
Step 3
Identify your landmarks, remembering that the subclavian vein is a continuation of the axillary vein and typically runs a fixed course along the undersurface of the clavicle. The insertion site should be at the bisection of the middle and medial thirds of the clavicle. 
  • Pearl: The subclavian artery usually lies deeper than the vein; to reduce risk of subclavian artery puncture, avoid deep penetration by the probe needle.

Step 4
Use a 12-mL syringe filled with 0.5 to 1.0 mL of normal saline attached to a large-caliber needle to puncture the skin at the junction of the middle and medial thirds of the clavicle. Once the skin is punctured, with the bevel of the needle upward, expel the skin plug that may occlude the needle. Holding the needle and syringe parallel to the frontal plane, direct the needle medially, slightly cephalad, and posteriorly behind the clavicle toward the posterior, superior angle to the sternal end of the clavicle (toward the finger placed in the suprasternal notch). 
Step 5
Slowly advance the needle while gently withdrawing the plunger of the syringe. When a free flow of blood appears in the syringe, remove the syringe. 
  • Pearl: To lessen risk of air embolism, occlude the needle with a finger.

Step 6
While holding the tip of the needle in the vessel, pass the guidewire through the needle, and then remove the needle. 
Step 7
With a scalpel (no. 11 blade), puncture the skin at the insertion point of the guidewire to facilitate cannulation and lessen resistance when dilating the vessel. Thread the dilator catheter over the guidewire, creating a larger tract for catheter placement. Remove the dilator, keeping the guidewire in place. 
Step 8
Advance the catheter over the guidewire into the blood vessel, and if possible, monitor for rhythm abnormalities with an electrocardiogram. Insert the catheter over the guidewire to a predetermined depth (the tip of the catheter should be above the right atrium for fluid administration). 
Step 9
Remove the guidewire and connect the catheter to the intravenous tubing. 
Step 10
Affix the catheter in place with a suture, apply an antibiotic ointment, and dress the area with a hydrocolloid dressing (Tegaderm) transparent seal to reduce risk of infection and to allow monitoring for potential bleeding. 
  • Pearl: For extra security, tape the intravenous tubing in place.

  • PITFALL: Obtain a chest x-ray to identify the position and placement of the intravenous catheter and a possible pneumothorax.

Step 10
Step 10

Femoral Venipuncture using the Seldinger Technique

Step 1
Place the patient in a supine position. The ipsilateral hip should be in a neutral or slightly externally rotated position. Then cleanse the skin well around the venipuncture site and drape the area. Standard precautions of sterile gloves, sterile gown, mask, cap, and eye protection should be followed. 
Step 2
Palpate the femoral artery as your primary landmark. The femoral vein typically lies directly medial to the femoral artery (nerve, artery, vein, empty space, lymphatics). The insertion site should be approximately 1.5 cm medial to a palpable femoral pulse and approximately 1.5 cm below the inguinal ligament. To lessen risk of cannulation of the femoral artery, keep a finger on the artery to verify anatomical location during the procedure. 
Step 3
Apply a local anesthetic subcutaneously and deep at the venipuncture site. Usually 1% lidocaine without epinephrine is the anesthetic agent used. 
Step 4
Use a 12-mL syringe filled with 0.5 to 1.0 mL of normal saline attached to a large-caliber needle to puncture skin directly over the femoral vein. Direct the needle toward the patient’s head and attempt to keep the needle and syringe parallel to the frontal plane. 
Step 5
Slowly advance the needle in a cephalad and posterior direction while gently withdrawing the plunger of the syringe. When a free flow of blood appears in the syringe, remove the syringe. 
  • PEARL: To lessen risk of air embolism, occlude the needle with a finger.

Step 6
Pass the guidewire through the needle, and then remove the needle. With a scalpel (no. 11 blade), puncture the skin at the insertion point of the guidewire to facilitate cannulation and lessen resistance when dilating the vessel. Thread the dilator catheter over the guidewire, creating a larger tract for catheter placement. Remove the dilator, keeping the guidewire in place. 
Step 7
Advance the catheter over the guidewire into the blood vessel. 
Step 8
Remove the guidewire and connect the catheter to the intravenous tubing. 
Step 9
Affix the catheter in place with a suture, apply an antibiotic ointment, and dress the area with a hydrocolloid dressing (Tegaderm) transparent seal to reduce the risk of infection and to allow monitoring for potential bleeding. 
  • Pearl: For extra security, tape the intravenous tubing in place.

  • PITFALL: Obtain chest and abdominal x-rays to identify the position and placement of the intravenous catheter.

  • PITFALL: Remember that the catheter should be changed as soon as practical to reduce complications of infection and thrombosis.

Complications

Subclavian Venous Access

  • Pneumothorax or hemothorax

  • Venous thrombosis

  • Arterial or neurologic injury

  • Arteriovenous fistula

  • Chylothorax

  • Infection

  • Air embolism

  • Malpositioning

Femoral Venous Access

  • Deep venous thrombosis

  • Arterial and neurologic injury

  • Infection

  • Arteriovenous fistula

  • Malpositioning

Pediatric Considerations

Pediatric patients may not cooperate with placement of the catheter. Because of the risks of damage to vessels, nerves, etc., consider conscious sedation with intramuscular injections or oral administration of sedating medications, such as midazolam (Versed) or ketamine

Postprocedure Instructions

The central venous catheter should be removed as soon as possible to avoid potential complications. When removing the catheter, use a 4- × 4-inch piece of gauze and apply it directly over the catheter site. Cut and remove all securing devices and then pull gently on the catheter. It should come out easily. Once removed, firm pressure should be applied directly to the area for at least 1 minute, longer if bleeding is still appreciable. Dress the wound with a dry, sterile gauze. 
A potential serious complication during removal of a catheter is a venous air embolism; it can occur during insertion, while the catheter is in place, and during removal of the catheter. To decrease risk of an air embolism, the patient should be placed in a supine position and the catheter should be removed during exhalation or during a Valsalva maneuver. This is believed to be better because during exhalation, the intrathoracic pressure is greater than the atmospheric pressure, lowering the risk of air entering the venous circulation. 
If there is clinical suspicion of a catheter or bloodstream infection, the tip of the catheter should be removed sterilely and sent for culture. 
The patient should be instructed to monitor the bleeding of the area and to return if any abnormal bleeding is noted. The patient should also be educated to call with questions or concerns regarding pain, numbness, or discomfort in the area. The patient should also monitor for evidence of infection. Lastly, the patient should be advised to clean the area with warm soap and water and to pat the area dry. 

Coding Information and Supply Sources

Supplies may be purchased from these companies: 
  • American Hospital Supply. Phone: 407-475-1168. Web site: http://www.americanhospitalsupply.com/.

  • Arrow Medical Products Ltd., 2400 Bernville Road, Reading, PA 19605. Phone: 800-233-3187. Web site: http://www.arrowintl.com/.

  • Baxter, 1 Baxter Pkwy., Deerfield, IL, 60015-4625. Phone: 847-948-2000. Fax: 847-948-3642. Web site: http://www.baxter.com.

  • Cardinal Health, Inc., 7000 Cardinal Place, Dublin, OH 43017. Phone: 800-234-8701. Web site: http://www.cardinal.com/.

  • Owens and Minor, 4800 Cox Road, Glen Allen, VA 23060-6292. Phone: 804-747-9794. Fax: 804-270-7281.

Bibliography

American College of Surgeons Committee on Trauma: Advanced Trauma Life Support, Student Course Manual . 7th ed. Chicago; American College of Surgeons, 2004.
Marino PL. The ICU Book . 3rd ed. Philadelphia: Lippincott Williams & Wilkins;  2007:107–128.
Merrer J, Jonghe BD, Golliot F, et al. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA.  2001; 286:700. [View Abstract]
McGee WT, Gould MK. Preventing complications of central venous catheterization. N Engl J Med .  2003;348:1123. [View Abstract]
Seneff MG. Central venous catherization: a comprehensive review. Intensive Care Med.  1987;2:163–175,218–232.
Tintinalli JE, Kelen GD, Stapczynski JS. Emergency Medicine: A Comprehensive Study Guide . 6th ed. New York: McGraw-Hill;  2004:124–131.
2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
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