Indications

• IV access (especially if difficult peripheral access)
• CVP monitoring
• ScvO2 monitoring/sampling
• Infusions of irritant substances (e.g. vasoactive agents, chemotherapy, or TPN administration)
• Renal replacement therapy, plasmapheresis, and apheresis
• Transvenous pacing

Site Choice

Internal Jugular

• Advantages
• • Reliable anatomy-right IJ also has direct access to SVC
  • Accessible, compressible
  • Low complication rates
• Disadvantages
  • Difficult to access if pt in C-spine
  • Potential impairment cerebral blood flow

Subclavian

• Advantages
  • Lower rates of thrombus and infection
  • Comfortable
  • Can access while patient in C-spine
• Disadvantages
  • Higher risk of pneumothorax
  • Higher risk of damage to nearby structures: eg. nerve, artery thoracic duct
  • Non compressible location
  • Difficult location to USS

Femoral

• Advantages
  • Compressible
  • Supine/Trendelenburg not required
  • Can access while patient having concurrent procedures on the chest/airway
• Disadvantages
  • Higher risk of thrombus and infection
  • No accurate CVP measurement
  • Highest rate of inadvertent arterial puncture

Preparation

• Aseptic technique with full gown, mask, hat, and gloves.

• The patient, machine, and operator position as above but can vary depending on circumstances/ space.
• Pre scanning of the IJV area is the key.
• Different lumen number and sizes are available but usually triple lumen and above is used.
• Arrange parts of the CVC kit in the sequence that they will be used.

Procedure-Skin Puncture and Seldinger Technique.

• CVC placement is a sterile procedure; ensure sterile glove, gown, and wear appropriate mask and hat.
• Position yourself and patient with inline vision with USG screen. Place patient in Trendelenburg position (head down 15-30deg) and pre scan to identify IJV, carotid artery, Sternocleidomastoid, and lung tissue area.
• Skin Preparation with chlorhexidine or iodine solution. Sterile drape to create a procedural field. Use ultrasound probe cover with a long sleeve to keep conditions sterile.
• Scan again and ensure you are comfortable with structure orientation.
• Local anesthetic infiltration under the skin under direct vision.
• Insert CVC needle OR cannula provided attached with a syringe and puncture IJV as you slowly go down, you will get give away feeling and will aspirate blood. At this point hold the base of the needle with the left hand and detach the needle.
• Insert Seldinger wire gently and slowly until it reaches 15 cm ie. 3 dots on the wire.
• At this point take the needle out. DO NOT let go of the wire, as inadvertent wire loss into patient can have catastrophic consequences.
• Use Scalpel to make a small incision along the line of the guidewire.
• Use dilator over the guidewire, push forwards and keep moving the wire to and fro to ensure that the wire is not kinked
• Once dilated, thread the CVC line over it till the wire comes out of brown lumen, grab the wire and then advance the line.
• Fix the catheter with suture on the skin and dress accordingly.
• Confirm position by CXR.

Complications

Immediate
Pneumothorax (highest for SCV)
Accidental arterial puncture
Haemothorax
Haematoma
Arrhythmia
Thoracic duct injury
Guide wire embolus
Air embolus

Early
Haemopericardium and tamponade.
Pneumothorax
Catheter blockage
Chylothorax

Late
Infection
Catheter fracture
Vascular erosion
Vessel stenosis
Thrombosis
Osteomyelitis of clavicle

Author of this lesson-

Dr. Sara Clements, FACEM

Dr. Hassan Zahoor, FACEM