Central Line Placement

Central Venous Catheters and Central Venous Access

Central Lines

IJ Lines

Go straight through medial portion of lateral head of SCM muscle. (J. Cardio Vasc Anes 8:6)

Femorals

Higher Infection Rate, Higher Thrombosis Rate than subclavian (French, Prospective Trial JAMA 286:6, 2001 JB )

Study of cath related infection shows Subclav<IJ<Femoral (Intensive Care Medicine Volume 30, Number 8 August 2004)

SVC access superior to IVC access in codes Ann Emerg Med 1984: 13, 881-884

Central superior to peripheral Am J Emerg Med 1984:2, 385-390 Ann Emerg Med. 1981 Aug;10(8):417-9.

right sided lines 16-19 cm

left sided 19-21

chlorhexidine is clearly superior to povidine-iodine

Finger in fossa technique to prevent guidewire malposition in subclavians (Ambesh SP, Dubey PK, Matreja P, et al. Manual Occlusion of the Internal Jugular Vein During Subclavian Vein Catheterization: A Maneuver to Prevent Misplacement of Catheter into Internal Jugular Vein. Anesthesiology. 2002; 97(2): 528-529.)

IJ Location confirmed by numerous CT scans (Khatri VP A Safer Technique of IJ Puncture. J Cardio and Vasc Anesthesis 1994;8(6))

Keep head in neutral not rotated for IJ (Journal of Emergency Medicine Volume 31, Issue 3 , October 2006, Pages 283-286)

Subclavians and IJs were safe during resuscitations (Scalea Acad Emerg Med. 1994 Nov-Dec;1(6):525-31.)

Supraclav is safe in mech vent pts (

Anesthesiology:2009 – Volume 111 – Issue 2 – pp 334-339

shoulder position for subclavian

(anes 2004;101:1306) use lower shoulder position puncture site just lateral to midclavicular line

Shoulder retraction (padding behind the back) was not helpful (Br. J. Anaesth. (2013) 111 (2): 191-196.)

Thoracic trauma: neck line on same side or femoral line

Mediastinal Trauma: neck line on contralateral side or femoral

Abdominal: neck line, no femorals (Scalea et al: Percutaneous central venous access for resuscitation in trauma Academy of Emerg Med 1994 6:525-31

Westfall et al: Intravenous access in the critically ill trauma patient: Ann Emerg Med 1994 23(3):541-5

Femoral Lines

nerve, artery, vein, yin-yang (NAVY);

Inflammation at CVC insertion site is not indicative of bloodstream infection (Crit Care Med 2002 30:12, 2632)

Get the veins real fat with IV fluid, try putting the patient head down, try pulling down on the ipsilateral arm, try turning the j-wire through 90 degrees four times, try turning the patients neck one way and if that doesn’t work — the other way, try using the other (non j-shaped) end of the wire — in the 21st century this is equally flexible as the j-end — it was not always so.

Preventing cvc complications (NEJM 2003;348(12):1123) Use subclavian site Use maximal barrier precautions avoid antibiotic ointments. promotes resistance and fungus disinfect cath hubs no routine changes

One programs intervention (NEJM 2006;355:2725)

List of references as to why it works

Backwalling of Subclavian with guidewire (Br J Anaesthesia 2005;95(4):472)

Zone A represents the lower SVC and upper RA. In this zone CVCs placed from the left side are likely to lie parallel to the vessel walls. However, a part of this zone lies within the RA and therefore within the pericardial reflection. This may represent a necessary compromise for left-sided CVCs to ensure they lie parallel to the vessel wall. Right-sided CVCs in this zone, however, should be pulled back to zone B. The azygous vein junction with the SVC lies within this zone and catheters may pass into this system. Zone B represents the area around the junction of the left and right innominate veins and the upper SVC. This is a suitable area for CVCs placed from the right side, however left-sided CVCs will enter this area at a steep angle (see Fig. 4) and are at risk of abutting the lateral wall of the SVC and should ideally be advanced into zone A. Zone C represents the left innominate vein proximal to the SVC. CVCs in zone C are probably suitable for short-term fluid therapy and CVP monitoring, but not for inotrope infusions or long-term use. The safety of this site has been questioned.14 Instructions accompanying the packaging of CVCs state that it is negligent to site the CVC with the tip in the RA. This is because of the potential risk of pericardial tamponade if the CVC tip erodes through the vessel wall below the pericardial reflection. The upper limit of the pericardial reflection cannot be seen on CXR, but anatomical studies have shown that it is very unlikely to extend above the level of the carina

There is literature out there to support you (especially supporting the notion when experienced clinicians use good technique, good clinical judgment, and discrimination- Puls LE.; Twed C; Hunter J; Langan E, Crane M. Confirmatory Chest Radiographs after Central Line Placement: Are They Warranted? Southern Medical Journal 2003; 96(11):1138-1141.). However a relatively recent reviews point out the relatively high rate of catheter tip malposition (Catheter tip malposition occurs in up to 14% of cases of IJ insertion and 11% of subclavian vein (Ruesch S, Walder B, Tramer M. Complications of Central Venous Catheters: Internal Jugular versus Subclavian access-A Systematic Review. Crit Care Med. 2002;30:454-60;Slo nim A, Landucci DL, et al. Cannulation of the Internal Jugular Vein: Is Postprocedural Chest Radiography Always Necessary? Crit Care Med. 1999; 27: 1819-1823). As far as pneumothorax, unless the patient is on positive pressure ventilation the presentation can be delayed (Tyburski, JG., Joseph, A.Thomas, G. Delayed pneumothorax after central venous access: a potential hazard. American Surgery 1993; 59(9), 587-589.).

Trendelenberg for Line Placement

(Emergency Medicine Journal 2005;22:867-868) Conclusion: Increasing the degree of Trendelenburg tilt increases the lateral diameter of the IJV. Even a 10° tilt is effective. The cumulative effect of tilt (that is, the effect of the previous angle) is not significant. Ultrasound guided cannulation is ideal, but in its absence Trendelenburg tilt will increase IJV diameter and improve the chance of successful cannulation. While 25° achieved optimum distension, this may not be practical and may be detrimental (for example, risk of raised intracranial pressure).

Subclavian is 3 times less infection prone than IJ and much lower than femoral (CAn J Anesth 2006;53(5):524)

A persistent left superior vena cava (LSVC) that is not associated with other congenital heart defects is found in 0.30.5% of the population. During embryological development, venous return from the head and arms occurs via the left and right cardinal veins. At 8 weeks gestation, the caudal portion of the left cardinal vein degenerates, leaving the right cardinal vein to develop into the right superior vena cava. Failure of regression of the left cardinal vein results in a persistent LSVC (2). The LSVC courses in the anterior aspect of the aortic arch draining into the right atrium via the coronary sinus, which becomes dilatated (3). Unless associated with other anomalies, this condition does not cause any harmful hemodynamic effects (1). The existence of a persistent left superior vena cava is suggested by an X-ray that implies aortic cannulation in the face of an uncomplicated venous puncture and no evidence to support arterial cannulation.

Trendelenberg increases diameter (Emerg Med J 2005;22:867)

Humming is as effective (Ann Emerg Med 2007;50:73)

Neck extension and palpation of artery decreases size (Acta Anaes Scand 1994;38:229) Head rotation decreases it as well (Anesth Analg 1996;82:125)

Alternative sites for HD access

(Crit Care 2006;10:230)

placement of rapid infusion sheathes in separate veins, either side ported or not

Femoral lines are fine for HD caths as long as the pt is not a fatty (

Femoral vs Jugular Venous Catheterization and Risk of Nosocomial Events in Adults Requiring Acute Renal Replacement Therapy

JAMA. 2008;299(20):2413-2422.)

Ultrasound Guidance

Ann Emerg Med Volume 48, Issue 5, Pages 540-547 (November 2006) Ultrasonographically guided internal jugular vein catheterization in the ED setting was associated with a higher successful insertion rate and a lower complications rate.

Ultrasound for Subclavian

(Crit Care Med 2011;39:1)

Ambesh Maneuvers

IJ occlusion test (Anesthesiology 2001;95(6):1377)

After subclav line placement, if you push on IJ and CVP increases 3-5 mmHg then the lumen is in the IJ instead of the SVC

(Anesthesiology 2002;97(2):528)

manual compression of the IJ during wire passage

(Michelle Lin)

Validation Study (Anesthesiology 2006;105(5):1062-1063)

Similarly-

J Neurosurg Anesthesiol. 2006 Oct;18(4):268-9. Flush test–a new technique to assess the malposition of subclavian central venous catheter position in the internal jugular vein.

Biopatch

J Antimicrob Chemother. 2006 Aug;58(2):281-7. Epub 2006 Jun 6. Links meta-analysis. Chlorhexidine-impregnated dressing is effective in reducing vascular and epidural catheter bacterial colonization and is also associated with a trend towards reduction in catheter-related bloodstream or CNS infections. A large randomized controlled trial is needed to confirm whether chlorhexidine-impregnated dressing is cost-effective in preventing bacterial infection related to vascular and epidural catheters.

The Wire

Safe use and handling of guidewires for central venous cannulation requires an understanding of the structure and physical characteristics of the wires. Monaca et al.6 have recently described the structure of a commonly used guidewire. According to their detailed description the guidewire consists of an inner single filament wire core and a surrounding coiled wire-cover. The latter is designed as a helix of stainless steel to form a tunnel for the inner wire and provides elastic properties. Apart from the two ends of the guidewire where the outer spiral is welded to the inner wire, there is no further point of attachment between the core and the outer wire. The typical J-shaped curvature is achieved by flattening the round core to a thickness of 0.1 mm wire at approximately 2.5 cm from the tip. This structure provides increased flexibility at the J-shaped tip. However it becomes an area of structural weakness at the junction of the rounded and flattened segments, which can lead to potential breakage.

Alternative approach to supraclavicular

Proposed (left) and traditional (right) supraclavicular approach techniques. Place a needle tip at the clavisternomastoid angle, then direct the needle 10° medially from the sagittal plane and 35° posteriorly from the coronal plane (that is to say, physician’s hand moves 10° laterally and 35° anteriorly from the skin entry point). Keep the bevel of an introducer needle and the J-tip of a guidewire heading to the medial side (arrow) to prevent ipsilateral axillary vein placement of catheter. In the original description of the supraclavicular approach by Yoffa (6), the needle directs at an angle of 45° from the sagittal plane and 15° anteriorly from the coronal plane. SCM: the sternocleidomastoid muscle, IJV: the internal jugular vein, SCV: the subclavian vein, IV: the innominate vein.

(Anesthesia & Analgesia Volume 105(1), July 2007, pp 200-204)

in a pinch, use the packaging that the wire came in to transduce the central line catheter

Acceptable LIJ/subclav locations

Proper Position For Femoral Vein Access If you are attempting to cannulate the femoral vein without the aid of an ultrasound machine, proper positioning of the leg can greatly enhance your chance of success. A recent study of health volunteers revealed that the femoral vein cannulation in adults is increased by placing the leg in abduction and external rotation.The mean percentage of the femoral vein accessible with the leg in external rotation/abduction was greater than with the leg straight. This simple position change not only increased the mean diameter of the vein, it prevented the vein from being directly posterior to the artery.

References: (1) Werner SL, et al. Effect of hip abduction and external rotation on femoral vein exposure for possible cannulation J Emerg Med 2008;35: 73-5. (2) Roberts JR, Hedges JR. Clinical Procedures in Emergency. Medicine, 4th edn. Saunders, Philidelphia,. 2003.

Ski lift approach to long axis use (Acad Emerg Med. 2010 Jul;17(7):e83-4)

Venous vs. Arterial Placement

J Clin Anesth Volume 21, Issue 5, Page 387 (August 2009)

Can use ultrasound visualization of guidewire (Scand J Trauma, Resus 2010;18:39)

bubble test works with non-agitated saline (Acad Emerg Med. 2010 Jul;17(7):e85)

Oblique Approach to UTS Placement

Article

US for Subclavian

(Ann Emerg Med 2010;56(5):492) ED central line infection rate was same as ICU

Central line insertion while anti-coagulated seems safe and complications probably correlate with skill of physician (emerg med j 2011;28(6):536)

Arterial Placement of Venous Lines

The article on arterial injection of medications was Mayo Clin Proc. 2005;80(6):783-795
The article on what to do once you have placed a big line in an artery is J Vasc Surg 2008;48:918-25

Placement of arterial closure devices for inadvertent placement (Vasc and Endovasc Surg 2008;42(5):471))

People who think they can see the guidwire probably can’t (American Journal of Emergency Medicine (2011) 29, 432436)

Patients with high ICP can herniate if you lay them flat

Cerebral herniation associated with central venous catheter insertion: risk assessement J Crit Care, 28 (2013), pp. 189–195

Guidewire Change may be Safe from Infection Perspective

Guide-wire exchange seems safe (Crit Care 2013;17:R184) GWX-CVC’s and NI-CVC’s had similar rates of tip colonization at removal, CA-BSI and mortality. If the CVC removed by GWX is colonized, a new CVC must then be inserted at another site. In selected ICU patients at higher central vein puncture risk receiving AST CVC’s GWX may be an acceptable initial approach to line insertion.