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  1. Approach To Medicine
  2. ICU
  3. Lines

Lines

Modified 20:41, 31 Oct 2015 by apavel | Page History
    Table of Contents
    1. 1. General Notes
    2. 2. Types of Lines
      1. 2.1. Internal Jugular (IJ)
      2. 2.2. Subclavian
      3. 2.3. Femoral Vein
    3. 3. Complications

    .

    Source: Paul Marino's Little ICU book

    CVC: Central Venous Catheter

     

    General Notes

    • Coagulopathy is not a contraindication to central venous cannulation.
    • LineTypes.jpg
    • tripleLumen.pngdialysisCatheter.png

    Types of Lines

    Internal Jugular (IJ)

    • Common type of line used
    • Right IJ should use catheter no longer than 15cm (14 usually)
    • Left IJ should use catheter no longer than 
    • IJ runs obliquely from pinna of ear to the sterno-clavicular joint, lateral to carotid in the lower region of neck.
    • Anterior Approach (most popular, higher risk of puncturing carotid)
      • Insert at the apex where sternocleidomastoid splits into two heads ---> advance to ipsilateral nipple.
    • Posterior Approach:
      • Identify where external jugular vein crosses lateral edge of SCM muscle.
      • Insert just cm superior to that point under the belly of SCM.  Advance toward suprasternal notch.
    • Benefits:
      • Popularized as a way to reduce risk of pneumothorax over subclavian (but shown to be false, risk is same).
        • Lung apex protrudes to the neck
    • Drawbacks:
      • High risk of carotid puncture (3%)

     

    Subclavian

    • Subclavian vein runs along underside of clavicle.
    • Distance to R-atrium is 14.5 R side and 18.5 L side. (don't use longer than 15cm catheter)
    • Landmarking:
      • Find insertion of SCM muscle on clavicle --> subclavian vein is right underneath clavicle at this point.
      • Approach vein above or below clavicle --> 2-3cm from skin insertion site.
      • Keep probe needle just underneath catheter to avoid hitting artery (artery is deep to the vein).
    • Benefits:
      • Large vessel, predictable anatomically
      • Better patient tolerance
      • Major bleeding is rare, coagulopathy does not increase risk.
    • Drawbacks:
      • Historically high concern for pneumothorax (but rare if performed by experienced person)
      • Cannot localize with ultrasound. (some techniques exist though)
      • (Some risk of subclavian thrombosis?  --> one arm will be edematous)
    • SubclavianLandmarking.png

     

    Femoral Vein

    • Femoral artery + vein within few centimeters of skin in inguinal crease.
    • Location:
      • If artery palpable:
        • Just below inguinal crease, palpate femoral artery pulse --> femral vein medial to palpated pulse.
        • Insert probe needle within 2cm of palpable pulse (2-4cm deep)
      • If artery not palpable:
        • Draw imaginary line from ASIS to pubic tubercle, divide line into 3 segments, femoral artery should be at junction of medial and middle segments.
        • Vein is 1-2cm medial to this point.
        • 90% success rate
    • Benefits:
      • Vein is large, far from thorax
    • Drawbacks:
      • Risk of arterial damage
      • Risk of femoral vein thrombosis
      • IJ and Subclavian PREFERRED over femoral (avoid femoral veins, remove as soon as possible)
    • FemoralLandmarking.png

     

    Complications

    • ComplicationRates.jpg
    • (Source: "The Little ICU Book" by Paul Marino 2008)
    • Venous Air Embolism
      • Can cause pulmonary embolism, and if pt has intracardiac shunts can cause ischemic strokes.
      • Highest risk when patient takes deep breath in (can suck air in)
      • Avoid by palcing in Trendelenburg position, head 15° below horizontal.
        • Don't have to do this if patient is vented (no negative thoracic pressures).
      • Should get patient to hum when changing CVC connections.
      • If suspected, then position patient Left side Down.  May even need RV needle aspiration.
    • Pneumothorax
      • Obtain post-line Xrays:
        • Should be EXPIRATION Xrays increases volume of pleural space.
        • If film is supine, hard to see pneumo.
      • Many pneumothoraces are delayed
    • Catheter position
      • Proper Placement:
        • Should run parallel to shadow of SVC.
        • Tip of catheter should be slightly above 3rd ant. intercostal space (Where SVC meets right atrium (RA)).
        • If anterior 3rd rib cannot be visualized:
          • Look at carina (below carina = inside heart)
        • Should withdraw, risk of cardiac perforation (extremely rare)
      • Left-IJ placement:
        • Tip should not be against the lateral wall of SVC (do not make the down-ward turn) can perforate SVC.  
        • Either withdraw into innominate vein or advance further.
    • Thrombosis:
      • Highest risk in lower limbs (femorals)
      • Small risk in subclavians --> one arm edematous
        • Can extend to SVC causing SVC syndrome
        • Ultrasound has low detection rate of subclavian thrombosi (Sn 56%, Sp 69%)
        • If suspect thrombus --> remove catheter, anticoagulate (unproven), elevate arm
      • High risk in femorals (6%!!!)
        • U/S is >90% sensitive/specific in detecting thrombosis.
        • Treatment: catheter removal and anticoagulate.
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