Transcript Central Venous Access

Central Venous Access:
Approach and Complications
Introduction
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Options
– Peripheral venous catheters
– Central venous catheters
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Central Venous access: Internal Jugular,
Subclavian, Femoral
 Arterial Line access: Radial artery, Femoral
artery, Axillary artery.
Catheter choice
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Single lumen short term
– IVF, TPN, Simple drug regimens
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Multilumen short term
– Complicated drug regimens, added TPN, frequent blood
draws, CVP monitoring
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Long term (PICC):
-Prolonged (>4 weeks) need for IV access
Current uses/Indications
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Vascular access
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Fluids*
Transfusion*
Medications, Vasopressor agents, Inotropic agents
Parenteral nutrition
Hemodialysis
Hemodynamic resuscitation
– Large bore 14G peripheral line preferred - if rapid volume
administration needed, Introducer catheter preferred.
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Hemodynamic monitoring
– Measurement of CVP
– Pulmonary artery catheterization
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Transvenous cardiac pacing
Temporary central venous
catheters
Procedures and Monitoring for the Critically Ill, Saunders, 2002
Temporary central venous
catheters
Internal Jugular Vein Anatomy
Descends in the carotid sheath to the medial end of the
clavicle where it ends by uniting with the subclavian vein
to form the innominate (brachiocephalic) vein.
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Internal Jugular Vein Anatomy
The carotid artery and internal jugular vein are well seen.
The IJV is much larger than the artery.
Variable relationship of Internal Jugular Vein and
Carotid Artery
Internal Jugular Vein Anatomy
Coronal view through the thoracic inlet and thorax.
Note that the most direct approach to the superior vena cava is via the right internal
jugular vein.
Right IJ is preferred site for all IJ catheters initially whenever possible.
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Subclavian Vein Anatomy
Coronal view through the thoracic inlet and thorax.
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Subclavian Vein Approach
The needle is inserted in the mid-clavicular line ~ 2 cms below the
clavicle. Note that the index finger of the left hand is placed in the
suprasternal notch.
Procedures and Monitoring for the Critically Ill, Saunders, 2004
Relation to thoracic duct
The confluence of the thoracic duct
and the left subclavian vein is
shown in this diagram.
The duct loops behind the internal
jugular vein to enter the
subclavian vein in the region of
its joining with the internal
jugular vein. Thus it can be
injured in left sided approach.
Femoral Vein Anatomy
The point of insertion should be 1 cm medial to the
artery and 2 cm inferior to the inguinal ligament.
Procedures and Monitoring for the Critically Ill, Saunders, 2002
Femoral Vein/
Artery variants
But…
-Vein may directly overlie
the artery, or vice versa
-Femoral artery may overlie
the vein in up to 13% of
normal patients
Journal of Surgical Anatomy…May 1984
COMPLICATIONS
Up to 15% of patients who get central venous
catheters have complications
 Mechanical complications 5-19% of patients
 Infectious complications 5-26% of patients
 Thrombotic complications 2-26% of patients
McGee DC, Gould MK. Preventing Complications of Central Venous Catheterizations.
N Engl J Med. 2003; 348 (12): 1123-33
Factors associated with
Mechanical complications
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Extremes of BMI (very low or high)
Multiple prior catheterizations
Advanced age
Time needed to place catheter (multiple attempts)
Prior radiotherapy, known history of vascular
disease
NEJM…2003;348;1123
Intensive care Med…2002;28:1036
Patient assessment
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History:
– Bleeding history, Previous access, Radiation, Peripheral vascular disease,
Existing catheters in place: PICC, HD access, AICD, Pacemaker, etc.
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Medications:
– Anticoagulants
Physical:
– Clavicular anatomy, Flexibility, Trendelenberg positioning
-- Can the patient be properly positioned?
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Labs:
– Platelets, PTT/PT INR
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Ultrasound:
– Vein compressible? Too close to the artery? Too small? Clot within the
vessel?
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Proper Site Selection
Thrombus within the Femoral
Vein
Vein overlying the Artery
Site Advantages & Disadvantages
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Internal jugular
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Large vessel, less complications
Ultrasound guidance is used
Uncomfortable, difficult to maintain dressings and catheter
Poor landmarks in obese pts
Vein collapses with hypovolemia
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Prone to exposure to patients oral secretions.
Subclavian
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Large vessel with high flow rate
Easy to dress and maintain, lower infection rate.
Vein less collapsible with hypovolemia
Pneumothorax, and Hematoma risk
Difficult to control bleeding,
Higher risk in ventilated patients, esp with high levels of PEEP.
Femoral
– Easy access, Large vessel, Advantageous during code situations, can be placed
emergently, easier for inexperienced operators.
– Uncomfortable, high rate of infection, thrombosis, phlebitis
– More anatomic variations
Common Insertion Mistakes
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Multiple attempts at the same site
– Max 3 attempts. Greater than 3 attempts is associated with
increased complication rates, regardless of operator skill.
– Use Ultrasound when experienced operator available
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Pushing the guidewire in too far
 Pushing the guidewire or catheter against resistance
– False passage can be created
– Vessel can be torn
– Guidewire can become entrapped
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Pulling the guidewire or catheter against resistance
– Entangled by other intravenous devices- AICD, PM, Vascath, etc
– Knot formation
How much guidewire is too much?
Average Distance of atrio-caval junction from
skin puncture site:
Right Internal Jugular Vein to Atrio-caval junction
16.0 cms
Right Subclavian Vein to Atrio-caval Junction
18.4 cms
Left Internal Jugular Vein to Atrio-caval Junction
19.1 cms
Left Subclavian Vein to Atrio-caval Junction
20 cm
16.5 cm should be considered the upper limit for most neck lines
Crit Care Med 2000 Jan;28(1):138-42
Is the needle in the vein?
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Visual inspection of the color of the aspirated
blood.
Observation of the blood flow characteristics
(pulsatility and volume)
Measurement of the pressure within the vessel by
either a pressure transducer (CVP measurement)
The use of ultrasound.
Pulsatility and color may not be reliable indicators
of arterial vs venous placement in hypotensive or
hypoxemic patients. Connect to CVP when in
doubt.
Catheter complications: Early
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Injuries
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Cardiac - arrhythmia
Lymphatic - Chylothorax
Great vessel perforation,
Vessel perforation or tears due to dilator or stiff catheter
Malposition
– 5% on post procedure CXR
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Air embolism
– Occurs during Insertion and removal
– Cardiovascular collapse, wheel mill murmur
– Rx: Left lateral decubitus positioning, air aspiration if
possible.
Catheter complications: Early
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Catheter embolism
– Needs Radiologic retrieval
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Guidewire complications
– IVC filter entrapment
– Guidewire entrapment on existing hardware
– Loss of Guidewire
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Pneumothorax
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2-10% with subclavian cannulation
1-2% with internal jugular
Post procedure CXR mandatory
CXR needed before bilateral attempts!!
Mechanical Complications- Prevention
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Recognize risk factors for difficult catheterization
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Use ultrasound guidance during internal jugular catheterization;
reduces the rates of unsuccessful catheterization, carotid artery
puncture and hematoma formation
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Do not schedule routine catheter changes; Insertion at a new site
increases the risk of mechanical complications for the patient
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A physician should only make 3 attempts; The incidence of mechanical
complications after three or more attempts is six times the rate after
one attempt
N Engl J Med. 2003; 348 (12): 1123-33
McGee DC, Gould MK. Preventing Complications of Central Venous Catherizations
Pneumothorax/Hemothorax
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Serious and life threatening complication
Reported incidence ranges from 0-6%
Higher with Subclavian approach
Pts may have Desaturation/hypotension after
placement, but 1/3 of pts are asymptomatic.
CXR insensitive in making diagnosis early
Presence of Pneumothorax must be ruled out after
any failed line attempt- esp prior to attempt on the
opposite side.
Prevention
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Optimal position
Operator skill
Alternate approach to subclavian site in high risk
patients- COPD, bullous disease, PEEP.
Avoid multiple attempts
Tredelenberg position
Bowyer MW, Bonar JP. Non-infectious complications of invasive hemodynamic monitering
in the intensive care unit. In Complications in the ICU: recognition, prevention and
management . 1997
Arterial Puncture
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Incidence ranges from 1-19%
 Easy to identify in pts with normal BP and
paO2. More obscure in hypoxemic,
hypotensive pts.
 Results in hematoma formation. Large
hematoma formation in the neck can
potentially cause airway compromise.
Prevention
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Avoid multiple attempts
Ultrasound guidance
Correction of coagulopathies
Use of small finder needle
Do not use dilator when in doubt
CVP/ABG for confirmation
Bowyer MW, Bonar JP. Non-infectious complications of invasive hemodynamic monitering
in the intensive care unit. In Complications in the ICU: recognition, prevention and
management . 1997
Arrhythmias
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Atrial and ventricular arrhythmias frequently
accompany the insertion of CVP lines
 These arrhythmias occur as a direct result of
myocardial stimulation by the guidewire or
catheter that has been advanced too far
 Can be minimized by using the shortest catheter
that will place the tip of the CVP catheter into the
SVC just above the right atrium;
Bowyer MW, Bonar JP. Non-infectious complications of invasive hemodynamic monitering in the
intensive care unit. In Complications in the ICU: recognition, prevention and management . 1997
Air Embolism
 Air
may enter the great vessels
directly when a needle is inserted
 Most cases occur during use or
catheter maintenance
 Negative intrathoracic pressure in a
spontaneously breathing pt can
draw air into the vein
Prevention
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Occlude hubs at all times
 Clear air bubbless
 Flush all catheter ports!!
 Trendelenberg postion increases CVP and
reduces likelihood of air entry
Thoracic duct injury
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The thoracic duct arches over the dome of
the left lung lateral to the left internal
jugular vein and joins the subclavian vein at
the internal jugular-subclavian angle
 Reported incidence of injury is 1%
 Most commonly occurs with left sided
subclavian cannulation
Catheter malposition
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CXR confirms malposition
 Repeat CXR can show migration of catheter
Radiographic assessment of
implanted catheter
Tip of subclavian
catheter at atriocaval junction
Central Venous Catheter Tip Position
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In the distal tip in the SVC for routine
applications
 In the upper right atrium, to achieve optimal
performance of a hemodialysis or
plasmapheresis catheter
 The right tracheobronchial angle
landmark
Journal Of Intensive Care..Feb 1999
Other Complications
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Loss of Guidewire
Guidewire perforation of vessel
Guidewire kinking
Dislodgement of IVC filters
Guidewire fragmentation/embolization
Rx: Management of most of these complications will
require interventional radiology or vascular
surgery intervention.
Catheter Infection
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Common (10%) and expensive (7 hospital
days per infection, $6000-10,000)
 10 to 20% mortality.
 Exit site, tunnel, catheter related sepsis,
septic thrombophebitis, metastatic
bacteremia
Catheter infections: Sources
Infection prevention
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Strict Sterile technique
 Removal when no longer needed
 Catheter care teams
– Gauze dressing change Q48 hrs, transparent dressings Q7
days, intravenous tubing Q48-72 hrs, after blood
transfusion or lipid infusion change with in 24 hrs
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Scheduled Catheter replacements
– Every 72-96 hrs for peripheral venous lines
– No recommendations for peripheral arterial lines
– No clear advantage to routine catheter change without sign
of infection.
Indications for Catheter Removal*
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Bacteremia and/or clinical symptoms persisting beyond 48-72 hours
despite appropriate IV antibiotic therapy through the catheter
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Progressive exit site, insertion site, or subcutaneous tunnel infections
(especially Pseudomonas)
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Reproducible chills or hypotension following irrigation of the catheter
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Clinically unstable condition with line sepsis suspected
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Evidence of septic emboli or endocarditis
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When catheter is no longer functional or required for
therapy
Removal of Central Catheters
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Neck Lines
– Trendelenberg position advised
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Risk of air embolism is highest during removal
– Pressure
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Limb lines
– Reverse Trendenlenburg for femoral lines
– Pressure
– Occlusive dressing