Table of contents
- 1. General Notes
- 2. Types of Lines
- 2.1. Internal Jugular (IJ)
- 2.2. Subclavian
- 2.3. Femoral Vein
- 3. Complications
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Source: Paul Marino's Little ICU book
CVC: Central Venous Catheter
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
- Popularized as a way to reduce risk of pneumothorax over subclavian (but shown to be false, risk is same).
- 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)
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
- If artery palpable:
- 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)
Complications
- (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
- Obtain post-line Xrays:
- 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.
- Proper Placement:
- 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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