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Central Venous Access

Central Venous Access

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Published by charlenetan18

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Published by: charlenetan18 on Dec 18, 2008
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09/07/2012

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APPENDIX
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APPENDIX: ITITLE: CENTRAL VENOUS ACCESS PROCEDURESREVISED: 15 April 2006
I. BACKGROUND
Placement of central intravenous lines allows for rapid access to the centralcirculation.
II. INDICATIONS:
1. Rapid fluid replacement for traumatic exsanguination2. To gain venous access in the presence of symptomatichypotension and venous collapse
CENTRAL LINE PLACEMENT SHALL ONLY BE ATTEMPTED WHENPERIPHERAL VENOUS ACCESS IS NOT POSSIBLE, OR WHEN THEANTICIPATED DELAY IN ESTABLISHING A PERIPHERAL ROUTE MAYRESULT IN INCREASED MORTALITY OR MORBIDITY.
III. CONTRAINDICATIONS:
None
IV. COMPLICATIONS:
1. Hemotoma with airway compromise2. Inadvertent extravenous placement causing:
pneumothorax
hemothorax
hydrothorax
hydromediastinum3. Major vessel laceration of the:
femoral artery
subclavian artery
carotid artery4. Air embolus5. Sepsis
V. PROCEDURE:
Physician Comments
: The medical director preference is that the femoralsite be considered before the internal jugular, and the internal jugular sitebefore the subclavian.
 
 
APPENDIX
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Femoral approach
Special Considerations:
Medications given via the femoral route in secondand third trimester may not be distributed effectively. Consider other sites.
Procedure
1. Prepare equipment in advance.2. Identify the anatomical landmarks
Locate the femoral arterial pulse 1 cm caudad of the inguinalfold. The puncture site for femoral vein catheterization is just
MEDIAL
and parallel to the artery.3. Using aseptic technique, prepare the insertion site.4. Palpate the femoral pulse. Using a long 14 or 16-gauge over-the-needle catheter with an attached 10-12 cc syringe, insert the needleand advance cranially at a
45 
angle to the skin, parallel to the arterialpulse. Continually aspirate the syringe during insertion.5. Upon free aspiration of blood, advance the catheter over the needle.6. Attach the infusion set to the catheter, observe for free flow of solutionand blood return when the infusion set is lowered below the level ofthe patient’s heart.7. Secure the catheter and place an occlusive dressing over theinsertion site.
Internal Jugular approach
Special Considerations
Care should be taken when accessing the internal jugular vein because of theproximity of adjacent structures.
Procedure
1. Prepare equipment in advance.2. Place the patient in the Trendelenburg position with the face rotatedaway from the side of insertion.3. Identify the anatomical landmarks:
Locate the triangle formed by the sternal and clavicular headof the sternocleidomastoid muscle.4. Using aseptic technique, prepare the insertion site.5. Using a long 14 or 16-gauge over-the-needle catheter with anattached 10-12 cc syringe, insert the needle into the apex of thetriangle formed by the three heads of the sternocleidomastoid muscle.Direct the needle on a 45-60 degree angle, laterally toward theipsilateral nipple. Continually aspirate the syringe during insertion.6. Upon free aspiration of blood, advance the catheter over the needle.7. Remove the stylet
on exhalation
and immediately occlude thecatheter with a gloved finger to reduce the risk of air embolism.
 
 
APPENDIX
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8. Attach the infusion set to the catheter
during exhalation
, observe forfree flow of solution and blood return when the infusion set is loweredbelow the level of the patient’s heart.9. Confirm equal breath sounds and observe for respiratory difficulty.10. Secure the catheter and place an occlusive dressing over theinsertion site.11. Secure site well.
Subclavian approach
1. Prepare equipment in advance.2. Place the patient in the Trendelenburg position with the face rotatedaway from the side of insertion.3. Identify the anatomical landmarks, specifically the clavicle and thesuprasternal notch.4. Using aseptic technique, prepare the insertion site.5. Establish a point of reference by placing a fingertip into thesuprasternal notch to locate the deep side of the superior aspect ofthe clavicle.6. Using a long 14 or 16-gauge over-the-needle catheter with anattached 10-12 cc syringe, introduce the needle approximately 1 cmbelow the junction of the middle and medial thirds of the clavicle.7. Apply negative pressure to the syringe and direct the insertionmedially and slightly cephalad toward the posterior and superioraspect of the sternal end of the clavicle, aiming slightly behind thefingertip in the suprasternal notch.8. Upon free aspiration of blood, advance the catheter over the needle.9. Remove the stylet and immediately occlude the catheterwith a gloved finger to reduce the risk of air embolism.10. Attach the infusion set to the catheter during exhalation,observe for free flow of solution and blood return when theinfusion set is dropped below the level of the patient’sheart.11. Confirm equal breath sounds and observe for respiratorydifficulty.Secure the catheter and infusion device and place an occlusive dressing overthe insertion site.
 
Central Venous Access Device (CVAD)
 
Special Considerations
Arterial bleeding will result if the needle is dislodged from a dialysis graft orfistula.Dialysis fistulas and grafts (located under skin of arm) may have high backpressure and require positive pressure to infuse.When attempting to insert a needle into a dialysis fistula, avoid the scar lineor any lumpy areas in the graft or fistula. Follow the track marks that arepresent from previous use of the site for dialysis.
When in doubt, aspirate first PRIOR TO FLUSHING the line. The heparinin some catheters is an extremely high concentration that will beharmful if it enters central circulation.

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