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Surgery Essay

Discuss the indications for setting up a CVP line. Outline


briefly the potential sites and hazards associated
with such sites.

Placement of a central venous catheter is indicated for


monitoring central venous pressure and at the same time give
the clinician secure access for the rapid administration of large
volumes of fluid. A CVP line is not essential in the early stages
of resuscitation, since it is a thin long catheter and that hinders
high flow rates as indicated by Poiseulle’s law. However, after
the initial resuscitation, CVP measurements can help the
clinician decide if further measurements are required and can
aid in the identification of patients who may appear to be
clinically normo-volemic but remain volume depleted, such as
in stages 1 and 2 shock.

There are two approaches. The first is known as an


infraclavicular approach, which targets the subclavian vein. The
patient is supine with his head down at 15 degrees. This will
distend the neck veins and prevents an air embolism. A needle
attached to a saline-filled syringe is inserted 1cm below the
junction of the middle and inner thirds of the clavicle. The
needle is aimed medially and upwards, aiming to the sterna
notch. The plunger is pulled to make sure the needle is in the
vein. The syringe is detached from the needle and a guide wire
is inserted through the needle. The needle is removed, and the
central line is inserted over the guide wire. The tip of the
catheter is placed in the SVC.

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Surgery Essay

The other approach targets the internal jugular and a Seldinger


technique is used, like the one above. There are two methods
to reach this artery. The high approach includes feeling for the
carotid pulse anterior to the sternocleidomastoid. The needle is
pointed lateral to the pulse aiming posteroinferiorly towards the
nipple of the same side. The low approach targets the internal
jugular between the two heads of the sternocleidomastoid.

Complications include pneumothorax and haemothorax, the


latter especially in the subclavian approach. An arterial
puncture is possible in both approaches; however it is easier to
apply pressure to the internal carotid than the subclavian
artery, which is hidden deeply. Haematoma formation and
infection are common to both approaches. Finally, in the
infraclavicular approach a component of the brachial plexus
can be damaged, as this runs close to the subclavian artery and
in the internal jugular approach, the vagus nerve can be
damaged as the nerve lies between the artery and vein and on
the left side, the thoracic duct may be damaged.

07/02/09