Thammasat Medical Journal, Vol. 14 No.

1, January-March 2014

79

hemodynamics


: , internal jugular, subclavian
:

80

Hemodynamic monitoring ,

.
,

superior vena cava

internal jugular
(internal jugular vein) subclavian
(subclavian vein)
inferior vena cava femoral,


internal jugular subclavian

Internal jugular vein

Subclavian vein

Trendelenburg



Cardiopulmonary


resuscitation (CPR)






(ambulatory)
venous thrombosis

(Anatomy)

internal jugular
subclavian

. internal jugular

internal jugular
jugular foramen anteromedial mastoid
process subclavian

Femoral vein

Congestive heart failure
(CHF)
CPR

lateral head clavicle

medial clavicle
sternal head
clavicular head sternocleidomastoid
carotid



cricoid cartilage, ,

Thammasat Medical Journal, Vol. 14 No. 1, January-March 2014

81

internal jugular
. subclavian

subclavian
axillary
lateral
anterior scalene subclavian
subclavian subclavian
internal jugular
brachiocephalic trunk superior vena
cava

subclavian

thoracic duct subclavian
internal jugular
subclavian

(apex)
subclavian medial anterior scalene
subclavian
subclavian

subclavian

82

internal jugular
subclavian


hematoma
, subclavian

(landmark)

internal
jugular central, anterior
posterior
subclavian
infraclavicular supraclavicular

internal jugular

Central

Anterior

Landmark

medial


sternocleidomastoid

heads
thyroid cartilage

sternocleidomastoid




skin






(Aim toward)

Posterior
lateral
sternocleidomastoid

mastoid process

sternocleidomastoid
Sternal notch

Thammasat Medical Journal, Vol. 14 No. 1, January-March 2014

internal jugular

central approach

83

internal jugular

anterior approach

internal jugular posterior approach

84

subclavian

Infraclavicular approach

Supraclavicular approach

Landmark lateral

midclavicular line
clavicular head

sternocleidomastoid

coronal plane



coronal
bevel
medially and caudally
medially

J-wire

sternal notch

(Aim toward)

sternal head

sternocleidomastoid

subclavian infraclavicular approach

Thammasat Medical Journal, Vol. 14 No. 1, January-March 2014

85

subclavian supraclavicular approach

(Indication), , ,

. (caustic)

. central venous pressure

. pulmonary artery catheter
transvenous pacing
(absolute contraindication), , ,

.

. (thrombosis)

(relative contraindication), , ,

. (coagulopathy)


partial thromboplastin time (PT)
activated thromboplastin time (aPTT) / International
Normalized Ratio (INR)
(platelet)

fresh frozen plasma (FFP)

platelet count ,
, INR .

,

.


(sedation)

peripheral line

.
(deformities) (hematoma)

86

subclavian
anterior
landmark

subclavian

subclavian

internal jugular carotid

atherosclerosis
plaque
stroke


(penetrating injury)

. left bundle branch block
(guidewire) right
ventricle complete heart block

, ,

- Povidone iodine solution chlorhexidine

- sterile

-

-

- 5 ml syringe

- Finder needle ( )

- Introducer needle or catheter over-the-needle

- (guidewire)

-

- sterile

- central venous line

- Dilator

-

- Suture material needle holder

- Normal saline

- dressing

Thammasat Medical Journal, Vol. 14 No. 1, January-March 2014

central line

central line single lumen, multiple lumen
percutaneous sheath multiple lumen

central venous pressure
multiple lumen
lumen
lumen catheter
single lumen
lumen
(French)


percutaneous sheath

pulmonary artery catheter transvenous pacing

wire

(hypotensive hypovolemia), ,

Trendelenburg
internal jugular
air embolism


subclavian

deltoid

ECG pulse oximetry noninvasive
blood pressure monitoring

ventricular ectopy
right ventricle

87

sterile
mask sterile

sterile

landmark

(clavicular area) povidone iodine
chlorhexidine

sterile

(pneumothorax)

portable , , ,

superior vena cava
internal
jugular (internal jugular vein)
subclavian (subclavian vein)
inferior vena cava
femoral,
internal jugular subclavian

internal jugular
central approach
landmark approach
landmark
landmark
approach
ultrasound-guidance
ultrasound central
approach
carotid posterior approach
internal jugular lateral
carotid

variation
internal jugular carotid
approach
ultrasound-guidance

88

internal
jugular central approach, ,

. sterile

.

. flush normal saline
lumen

. finder needle syringe normal
saline negative
pressure
sternocleidomastoid



internal jugular

.
finder needle

. introducer needle syringe
finder needle
carotid medial
lateral
negative pressure

negative pressure
pressure

pressure


medial

. introducer
needle syringe
carotid

syringe
(free flow)
fix

. syringe introducer needle
(needle hub)
air embolism

. (sleeve)
J

. introducer needle

.
ventricular ectopy

. introducer
needle fix



.

Thammasat Medical Journal, Vol. 14 No. 1, January-March 2014

. dilator

. catheter
catheter multiplelumen catheter lumen distal
lumen hub catheter

. catheter
hub
catheter
Peres formular



right atrium proximal
inferior vena cava (IVC)
right subclavian
right internal jugular
left subclavian
left internal jugular

catheter


Right internal jugular
Left internal jugular
Right infraclavicular subclavian
Left infraclavicular subclavian

central venous

H/10
(H/10) + 4
(H/10) - 2
(H/10) + 2

*H =

.
catheter
catheter

. syringe normal saline
catheter
flush

. heparin lock
catheter multiple-lumen catheter
lumen

. fix
silk nylon

89

. sterile

.
superior vena cava
superior vena cava right atrium


subclavian infraclavicular approach,

internal jugular

medial lateral

lateral
medial

bevel introducer
needle (caudal)
coronal plane
suprasternal notch
guide

internal jugular
Seldinger technique
J
superior vena cava
internal jugular
ultrasound guidance


ultrasound guidance


hematoma (hemothorax)

ultrasound probe

internal jugular carotid
echogenic

subclavian color flow

subclavian ,

90

internal jugular

mechanical

mechanical
(thrombotic)

.



colonize hub
lumen hematogenous
seeding catheter The Institute for Healthcare
Improvement

chlorhexidine

mechanical
antiseptic ointment
, ,

. mechanical

mechanical
hematoma
(arrhythmia)

internal jugular subclavian

ultrasound guidance,

(venous thromboembolism)

Internal jugular
Subclavian
Femoral

Pneumothorax (%)
< .
Hemothorax (%)
NA*
Infection
.
(rate per 1,000 catheter-days)
Thrombosis
.
(rate per 1,000 catheter-days)
Arterial puncture (%)

Malposition

*NA = (Not applicable)

. .
. .

NA*
NA*
.

Thammasat Medical Journal, Vol. 14 No. 1, January-March 2014

superior
vena cava inferior vena cava
(atrium)

cardiac tamponade
,
right tracheobronchial angle

hemodynamics

landmark

.

.


.

Hanson CW. Procedures in critical care. New York:

McGraw Hill; 2009.
Feldman R. Central venous access. In: Richman E,
Simon M, editors. Emergency medicine procedure.
United States: McGrawHill; 2002.
Fraenkel DJ, Rickard C, Lipman J. Can we achieve
consensus on central venous catheter-related infections?
Anaesth Intensive Care 2000;28:475-90.

91
. Raad I. Intravascular-catheter-related infections. Lancet
1998;351:893-8.
. Graham AS, Ozment C, Tegtmeyer K, Lai S,
Braner DAV. Central venous catheterization. N Engl J
Med. 2007;356:e21.
. Braner DAV, Lai S, Eman S, Tegtmeyer K. Central
venous catheterization subclavian vein. N Engl J
Med 2007;357:e26.
. Haas B, Chittams JL, Trerotola SO. Large-bore tunneled
central venous catheter insertion in patients with
coagulopathy. J Vasc Interv Radiol 2010;21:212-7.
. Foster PF, Moore LR, Sankary HN, Hart ME, Ashmann
MK, Williams JW. Central venous catheterization in
patients with coagulopathy. Arch Surg 1992;127:273-5.
. Gomella LG, SA H. Bedside procedures. Clinician's
pockets reference: McGraw Hill; 2007.
. Murray MJ. Critical care medicine: perioperative
management. Philadelphia:Lippincott Williams &
Wilkins; 2002.
. Bannon MP, Heller SF, Rivera M. Anatomic
considerations for central venous cannulation. Risk
Manag Healthc Policy 2011;4:27-39.
. Peres PW. Positioning central venous catheters--a
prospective survey. Anaesth Intensive Care 1990;
18:536-9.
. Kim WY, Lee CW, Sohn CH, Seo DW, Yoon JC,
Koh JW, et al. Optimal insertion depth of central
venous catheters--is a formula required? A prospective
cohort study. Injury 2012;43:38-41.
. Ray BR, Mohan VK, Kashyap L, Shende D, Darlong
VM, Pandey RK. Internal jugular vein cannulation: A
comparison of three techniques. J Anaesthesiol Clin
Pharmacol 2013;29:367-71.
. Agarwal A, Singh DK, Singh AP. Ultrasonography: a
novel approach to central venous cannulation. Indian J
Crit Care Med 2009;13:213-6.

92

Abstract
Central venous catheterization
Yajai Apibunyopas
Emergency Department, Faculty of Medicine, Thammasat University

Central venous catheterization has variety of indications. It is indicated for emergency patients, critical patients and
chronically ill patients. The utilization of central line includes providing route for administration of large volume resuscitation
and caustic agents, and hemodynamics monitoring. Apart from indications, to learn about contraindications, appropriate sites
for placement, preparation, procedure and all possible complications, is very crucial for practitioner. In order to achieve the
maximum benefit and the most safety result from central venous catheterization, one must learn all before attempting to
do the procedure.
Key words: Central venous catheter, Internal jugular vein, Subclavian vein