PROCEDURES IN THE ICU 0749-070492 $0.00+.20 CENTRAL VENOUS CATHETERIZATION IN THE CRITICALLY ILL PATIENT Kim R. Agee, MD, and Robert A. Balk, MD ‘The central venous catheter is one of the most commonly used invasive tools in the management of critically ill patients. Indications vary from routine ‘access to emergent situations in which the central venous catiteter is a vital ‘component of resuscitative efforts (Table 1). Perhaps the most frequent reason given for insertion is lack of adequate peripheral veins for patient care needs Other uses for the central venous catheter include delivery Of parenteral nutri tion, infusion of medications that would be toxic or iritating to salle peripheral veins, vasopressor therapy, simultaneous infusion of multiple incompatible ‘medications through different ports of multilumen catheters, and rapid delivery of lifesaving medications in an emergent situation, Central venous access certainly is a positive addition to patient care in many situations, but itis a tool that may hurt as well as help the patient. The presence of a centnl line does not guarantee adequate care; in fact it may well be an impediment to if the operator s inexperienced in placement techniques or n idenvifying complications such as pneumothorax, extravascular placement, or infection. ‘Table 4. INDICATIONS FOR CENTRAL VENOUS ACCESS {Lack of peripheral venous ats or inability 1 cannulae peripheral vane ‘Administration of caus, exe, o tating solutions ‘Avoitance of medication iniruplons and o allow administration of incompatible medications using mulipe lumen catheters Deter of parenteral nuttin Cental venous access for hemodynamic monitoring or temporary Iwansvenous cardiac pacing rom the Division of Pulmonary and Critical Care Medicine, Department of Medicine, ‘Rush Medical College, Rush-Presbyteran St. Luke's Medical Center, Chiago, Tinos CRITICAL CARE CLINICS —_———“ VOLUME 8 NUMBER 4 OCTORER 12 oF678 AGBE & BALK “Table 2, SELECTED CHARACTERISTICS OF DIFFERENT CENTRAL LINE SITES Ziioote Ewiernl jugar Internal uguler _Subslavan_ Femorl peor aa Mrinal ‘sacs ‘aananced deat Suoewse te 70 s os °° e vantages Salty Low kof pneu: Cormtatancomy Doesnt terre mora wi oe ea Cleatartges Lower cucu Lantradmay Ask of noize. Oil Resp ‘aie, cbealy © becbecurein forex ofan cea gues hor nek ace orabese compass # ray be ardte ‘mates ven ator Seedy occurs pass asco uo visuals provers Compbontne Minimal Cart aney ——Prewmoharac Fema ary parce "abeavan puree hems iter puree toma Jn this article, we review the indications for and various anatomic approaches ‘used in obtaining central venous access, pertinent landmarks, and advantages Jind disadvantages inherent to each site. ‘The technigue of venous cannulation snd insertion of the catheter over a flexible guidewire is described in detail, We then provide guidelines for using various sites, and discuss potential compl- cations peculiar to each site. APPROACH TO CENTRAL VENOUS CATHETERIZATION “The four most commonly used sites for central venous access are the external jugular (E}), internal jugular (J), subclavian (SC), and femoral veins. In order odeal with the variety of situations encountered in the jntensive care unit, the Critical care physician must be proficient at insertion of catheters at each site, because each has its specific atsibutes and associated complications (Tables 2 and 3). The] site is preferred by many because ofits ease of insertion, high success rate (90°95, and relatively low complication rate, Many clinicians also prefer “Table 3. RELATIVE INDICATIONS AND CONTRAINDICATIONS FOR DIFFERENT (GENTAAL VENOUS CATHETER SITES (CENTRAL VENOUS CATHETER SITES Sue Tnaoations Contraindications ‘Exeral jgular Coagiopathy. operator inexpe- _PreWous neck suger Ona rience. iy fo wsualze vein Intemal jugular (W)_n'genera, any incication for Coagulpay, Previous neck Genial venous access ‘surgery, shor or obese neck, Uuvozable landmarks Subclavian (80) ably to tain LU access __Coagulopathy, claweular defor ‘my, mechanical vetiaton, Tow florence for preuno- thorax, iyprocooosis Femoral Inability to obtain N er S__Obese patient. urinary incon acess sme cates where nie, local of lower exter Soaguiopahy precles Ler fy fseton or thrombosis SSC atlompt cardiac arrest 5 atop eae areet(CENTRAL VENOUS CATHETERIZATION IN THE CRITICALLY 1 PATIENT 679) See ae Set erie REE Pence vores SS ae ay eaten a eee TT ny fees mayne at Seon Settee ESTOS sagt Tome the I approach over the SC approach because it caries a lower risk of pneu mothorr Together, I and ates acount forte majority of ene Hes ‘ost medial intensive care unis The proximity of the carotid artery may serve to dampen the physician's entiusin fr the I ste, however Te dof cold ay peslaoe es insllehands, may approach Racy Css than of tine), anton variants may make cthetezaton dif in hese instances an cessoure Guided, vessel-finding needle may prove to be of woe Subchivian vein catheterization, although assoated with a success rate similar fo attempts, is associated witha significant rik of pneamothorse os high as 28.5%, Additonal complistions of SC attempls incude sebchvoe artery purcue, thoracic ductlnceration, and inequeni damages the phen or recurrent laryngeal nerve. Advantages of the SC sis includevelateey con, Sant anatomy (with respect to the clavicle) anda catheter thats perhaps coors physically stable and less prone to become contaminated than onto the Ione, "The H require the lest operator sll and ws aseeated wilted ce Blcatons The main complication i hematoma in paints with bleeding dat esis, Unfortunately, the EJ vein may be impossible to identify in obese oF short necked individuals, and of a 2 yena cava (SVC) catheter placement is considerably I Wi insertion Some operators choose to avoid the femoral veins, primarily because of problems with infection and in situ thrombosis that may complicate long, term ‘use. During an emergency situation, however, the femoral route may present the fewest roadblocks to quick central venous access? because it is physically ‘more accessible during cardiopulmonary resuscitation. GENERAL TECHNIQUE __// After identification of the vessel or pertinent landmarks and assembly of the necessary equipment (Table 4), the site is prepared by scrubbing widely with fan antiseptic solution (povidone-iodine or other). The physician should then, don sterile gown, gloves, mask, cap, and eye protection. The patient is draped to providea sterile working environment. A small amount (1-5 mL) of 1% lidocaine is injected into the superficial skin foran€] attempt. For]. SC, and femoral attempts, the deeper subeutaneous tissues are also anesthetized with lidocaine, Using a modification ofthe Seldinger Nv 2 °660 ACHES BALK Tea nak aging poe nee Tisat goers aap perme Trig aay ain age Do ‘tho garare meinen oo Fey ano gos, Shins mance ‘gare The Seldingortochrigue for cameo ineortin. irom Siteman JV The techie Fietstasing conta venous bnes,Joumal Ine Cea I! 50-56; 1887: wih permssion) technique, the vein is cannulated with an 18-gauge thin-walled needle (Fig. 1) Ihfter the nevdle has entered the vein (confirmed by easy aspiration of blood), the syringe is removed from the needle hub and the hub is occluded (to prevent ir embolism) uni a 0,035-inch J tip guidewire can be inserted through the ‘needle into the vein. The wire is then advanced into the SVC (lige vein for a Femoral attempt). The guidewire should pass effortlessly and never be forced. ‘While the wires inside the patient, the éleetrocacdiogram should be monitored for signs of eclopy. If arrhythmias are noted, the wire should be withdrawn @ few centimeters, The rare ventricular agrhythmia that does not cease following uidevite withdrawal may require lidocaine thers. After the wire is satisc~ Grily inserted, the introducer needle is removed while the wire is stabilized. A. small skin nick with a #11 scalpel blade may failitate passage of the dilator, ‘The dilator is then advanced with a twisting motion through the skin and sub- Cutaneous lissue into #he vessel. The operator or an assistant should always: (CENTRAL VENOUS CATHETERIZATION INTHE CRITICALLY ILL PATIENT 681 Figure 2. Anatomic relationships among the large vemns of te arm and nee ang the superior vena ‘cava, (From Quan SF" Technical aspects of vas. ‘ular tines. n Bone RC, George FI, Hudson LH (ed): Acute Respatory Fabre. New York, Churcil LUvingstone, 1967, p 34; wih permission) hold the guldewire fo ensure against migration into or out ofthe vessel. The allator is then withdrawn and the catheter is threaded over the guidewire (again, continuously holding the wire) into the vein. When the catheter is in place, it is stabilized by holding itat the skin site, and the guidewire is withdrawn, ‘Venous blood is aspirated from each port of the catheter, after which the Jumens are flushed with heparin or saline solution. Aspiration and flush should be performed easily. If difficulty is encountered aspirating blood, sight manip- tation of the catheter (rolation or retraction) may move the port away from the vessel wall or a valve. The catheter is then secured with suture and a sterile 's applied. pele, and SC cathe placement rtp, hn neck and chat should be examined for evidence of subcutaneous emphysema, Wacheal shi o unilateral diminution of breath sounds. The absence ofthese findings docs ot rule oat a pneumothorax, and a chest radiograph should alas be obtained to ule out barotrauma and confirm catheter positon INSERTION TECHNIQUES FOR SPECIFIC SITES External Jugular Vein ‘The patient is placed in 20 to 30 degres of Trendelenbur poston and the head is tamed 45 legres avcay from the side of intended plceanent, One oe two EJ veins ae identified coursing from the submenta ares tothe midponton of the caicle (Figs. 2 and 3). Gene supraclavicular pesoue can sometimes ic i distinguishing the vein: Dilly sometimes i'encountered in passing682 AGRE A BALK sania OO] ‘Cavicular Hood Figure 3. Location ofthe intemal and extemal jugular veins in relationship to the caratié Sry and stemocricomastond misce, (Fm Quan SF: Tacnica aspects of vascular ines. iBone RC, George AB, Husson LM (eds: Acute Respiratory Faure. New York, Churchill Livingstone, 1987, p 350; wih permission) the guidewire into the thorax. Allowing the patient to return his or her head to the midline may facilitate intrathoracic placement. Generally, the dilator is not needed for insertion of an E} catheter, Internal Jugular Vein ‘The patient is placed in 20 to 30 degrees of Trendelenburg and the head is tuyned 43 dagrees away frm the side of insertion. The following landmarks are identified (see Fig 3): sternocleidomastoid muscle (medial and lateral heads), Carotid pulse, suprasternal notch, and dlavicle, Landmarks may be accentuated by placing a tolled-up towel between the seapulze or by asking the patient to raise his or her head, ‘The vein ies deep to the sternocleidomastoid muscle, posterior and lateral to the carotid artery within the carotid sheath. The most superficial portion of the vessel lies between the sternal and clavicular neads of the sternocleidomas- toid muscle. The vein may be cannulated either at chs site (tne middle approach) for at a more cephalad site (the posterior approach). Both approaches are widely practiced; the posterior may have a slightly higher risk of carotid puncture, and fhe middle may have a greater incidence of pheumothorax. Middle Approach ‘After positioning, preparing, and draping te patient, the skin and sub- utara ance are akestetoed with 1 Moone. The insertion siti he' i | CENTRAL VENOUS CATHETERIZATION IN THE CRITICALLY ILL PATIENT 683, x of a triangle formed by the sternal and clavicular heads of the sternoctei- jomastoid muscle. A 22-gauge needle is used for the anesthesia and is directed in a posterolateral fashion toward the ipsilateral nipple, The needle should enter the skin at about a 30- to 45-degree angle, and its path should be guided by the ‘carotid pulse as well as the other landmarks. Vessel entry is confirmed by aspi- tation of venous blood. Ifthe vein is not located initially, the needle should be directed more laterally. ‘ter the vessel is entered, the syringe is removed from the needle to confirm ‘venous pressures. Any suspicion of arterial puncture may be evaluated by attach ing a pressure transducer tothe needle or by blood gas analysis ofthe aspirated ‘ood: If arterial puncture has occured the needle should be withdrawn and compression applied for 10 minutes. If venous entry is confirmed, the finder ‘needle should be left in place (with the hub occluded) and the introducer needle inserted slongside it, using the tip ofthe finder needle as a target. Posterior Approach After positioning, preparing, and draping the patient, the skin and sub- cutaneous issues ae anesthetized with 1 lidocaine. The insertion sts the Posterior edge ofthe cephalad portion ofthe steroclidomastond muscle ime: Siatly cephalad to te area where the muscle crossed by an Evin The skin and subcitancous taoues are anesthetized, withthe 22-gmuge hinder nee being dreted beneath the muace from the posterior magi almang for he Supesteal notch: When the blood retum is encountered, is venous origin Confirmed es described eater. The finder needles lf h place and te Spi ued as target forthe intoducer needle ‘Subclavian Vein ‘The patient spaced in 29 to 30 degrees of Trendelenburg and the head is fumed 49 degrees away from the side of intended placement. A rolled-up towel is placed longitudinally between the scapulae. The pertinent landmarks are the clavicle, the acromiocavicular joint, and the suprasternal notch (Fig. 4). The SC vein enters the thorax posterior to the clavicle and passes over the anterolateral aspect ofthe first rib. The SC artery lies posterior tothe vein and the two vessels are separated by the anterior scalene muscle, The cupola of the lung, is thus ‘medial and posterior to the SC vein. After the patient is prepared and draped, the skin and subcutaneous tissues are anesthetized. The insertion site is 1 em beneath the inferior margin of the clavicle atthe junction of its medial and distal thirds, Lidocaine is also injected into the periosteum of the clavide at this point. No attempt is made to use the anesthesia needle asa finder needle (asin J placement), because its generally too short 0 reach the vessel With an index finger in the suprasternal notch, the introducer needle is inserted into the skin ¥ to 2 em inferior to the clavicle at the juncture of the ‘medial and distal thirds. The needle tip is aimed atthe suprasternal notch and, when the clavicle is encountered, the needle is withdrawn slightly and gently “walked down” the davicle until the inferior margin is encountered, When the needle slips beneath the clavicle, it continues to be advanced toward the supra- stemal notch, keeping the tip flush with the posterior border of the clavicle This may be facilitated by having ar assistant hold the patients ipsilateral shoul=684 AGEE & BALK Figure 4, Anatomic elatonshins among the subclavian ven, subclavian atten, and superior ‘ra cava, (From Guan SF: Technical aspects of vascular lines. Bone AC. George RB, Hisdson LH (eos) Acute Respiratory Fale. Now York, Church Livingstone, #967, p 351: ‘wh permission) der down, The introducer needle is inserted into the patient with the bevel facing cephalad; when the vessel is entered, the evel is rotated 180 degrees. ‘This facilitates thoracic (gather than cervical) guidewire placement. Femoral Vein ‘The inguinal ligament is deep to an imaginary line projecting from the symphysis pubis to the anterior superior ihac crest These structures, along with the femoral arterial pulse, comprise the landmarks of importance in femoral vein cannulation (Fig. 5). "The patient is placed supine with the knee extended and the foot rotated ‘outward 15 to 30 degrees, The insertion point is 2 3 cm inferior to the inguinal Tigament, 1 #0 2 cm medial to the femoral pulse. The area is often shaved prior seni, The vin may be oad with the Zrgmge ner neds desea previously. COMPLICATIONS Complications of central venous catheters are listed in Table 5. In general, these may’ be divided into issues that require immediate action—such as prew- tmothorax and arterial puncture—and those with more delayed effects, stich as infection, Preumothorax is frequently (but not always) heralded by aspiration of ait inio the syringe, respiratory distress, and decreased ipsilateral breath Sounds, Tracheal shift and hypotension may octur as the collection of intra- pleural air nereases. A chest radiograph contirins the diagnosis, and most patientsFomor. _~ fina Lig ~ Gast Sephora Figur 5. anaiomy of he femevat wang for frnral von caneitizaion (From Quon SF: “Technical aspects of vasestar lite. in Bone Ae, Gangs FS, Hodson Li (ees). Reule Fespiraior Fallre. New York, Ghurchil Livingstone, 1987,» 24% an pormssion) (especially hose with pre-existing respiratory compromise requiring mechanical ventilation) require evacuation of the ait ‘Arterial puncture is obvious when the syringe fills easily with bright red blood or when biood under systemic pressurcs pulses from ihe need hub after the syringe is removed. fn hypotensive, hyporie patients, entry of the needle into an artery may not be so obvious. Any question may be resolved by either ‘connecting the needle hub lo a pressuse transducer with analysis ofthe waveform, ur by analyzing a blood sample for oxyhemoglabin saturation ariesal panciare, pressure should be held { intermittent release in the case of carotid artery puncture) “spar frm arterial puncuie and preunothras, the most severe (and st frequently encountered) complication of central venous catheters is infection, Infections may occur in up to 40% ofall central lines," but the rate af dactimentect bbacteremin is substantially fess. Most cases of catheter infection are believed to be associated with inward migration of skin bacteria, The addition ov a silver impregnated subcutaneous cuff to the eathoter seems to reduce the mfection, tate Ifan infection is suspected, either because of recurrent fever or local signs, the cathater should be removed and the tip sent for quantiative catures, Rein: 125. COMP VENOUS CATHETERLZATION Pheu Bleoding Infection Arenal ciate ‘Yonous "arnbsie- pmonary sit fe try Cather malostion Hemoineaepioua of Nowe tiury—plreric, brah pl Ferlearcel puncte and afusion —soveee teriponace686 AGEE& BALK. troducing @ new catheter into the same site over 2 guidewire should generally bbe avoided because the tract may also be infected, CONCLUSIONS In this article ge have discussed the indians echrigues, and compl cations aiprited ith conta venous eatheteriaton, Te must be stressed that iia atthe segue’ through supervised mameson ard egoct ftiton.apare so many ofthe process sspocated wih the practice of cia Gare meticine. Although we hope we have ghuon the reader" base overview Of this topic thee Is ne subsite foe nical experience. References 1. Bozzett F, Teme G, Camerinl , etal Pathogenesis and predictability of ental venous fatheter sepsis. Surgery 91:385, 1982 2, Denys BG, Uretsy BF. Anatomical variations of inte-al jugular vein location: Impact fn central venous acess. Crit Care Med 1951516, 191 23, Gore JM, Alpert J, Benot J, «ta: Handbook of Hemodynamic Monitoring, Boston, ile, Bown, 1988, pp 8, 77 4, Mala’DG, Cobb L, Carman JK, et al: An attachable silve-impregnated cull for pre ‘Yention of infection with central venous catheters a prospective randomized mule center tial, An | Med 85:207, 1966, 5. Moki DG, Goldman DA, Rhame FS: Infection contol in intravenous therepy. Ann Inter Med 79387, 1973 6. Quan 8! Technical aspects of vasculay lines, Bone RC, George RB, Hudson LIT (Gas), Acute Respiratory Fase. New York, Chorchll Lvingstone, 1987, p 35 7, Pun VK. Carlson RW, Bander Ij, etal: Complcaics of vascular eathettization in thay ts pcepcive say. Col Cte Med 5,168) 8, Rosen Mi, Lato IP Ng Ws: Handbook of Percutancous Cental Venous Catheterization London, WB Saunders, 1887 «9, Sansom RS, Unig PN, Gross PL, et al: Emergency intravenous access through the femoral vein, Ann Emerg Med 13288, 1961 Adress reprint requests 9 Rabect A Bol, MD ‘Section of Pulmonary and Caitial Care Medicine Th58 West Congress Parkway ‘Chicago, IL 60612