The most impo tant advancement in mode n CVC came
C H A P T E R 2 2 in 1953 when the Swedish adiologist Sven Seldinge had the
Salim R. Rezaie, E.C. Co ey, and Christopher R. McNeil
C ent al venous access emains a co ne stone o esuscitation
and c itical ca e in both the eme gency depa tment (ED)
and intensive ca e unit. Advanced hemodynamic monito ing,
apid in usion o uid, placement o t ansvenous pacemake s,
and administ ation o selected medications all e ui e eliable
cent al venous access. Cent al venous cathete ization has also
gained acceptance in the esuscitation and t eatment o c itically
ill child en (see Chapte 19). T aditionally, the subclavian vein
(SV), inte nal jugula (IJ) vein, and emo al vein have p ovided
eliable and easily obtainable vascula access th ough the use
o identifable anatomic landma ks. Ove the past decade the
inc eased availability o , and t aining and p ovide competence
in bedside ult asonog aphy have had a signifcant impact on
the standa d app oach to both pe iphe al and cent al venous
cathete ization. Ult asound-guided cent al venous cathete iza-
tion has imp oved success ates, educed complication ates,
dec eased the time e ui ed to pe o m the p ocedu e, and
esulted in ove all cost savings.
The va ious techni ues desc ibed in this chapte each have
inhe ent advantages and disadvantages, but all have a place in
the p actice o eme gency medicine. F e uently, a clinician’s
p evious expe ience with a pa ticula techni ue dete mines
the p e e ed app oach, but clinicians esponsible o acute
esuscitation o the ill and inju ed should maste seve al o
these techni ues (Videos 22.1-22.8).
HISTORICAL PERSPECTIVE
In 1667, Lowe placed the f st known cent al venous cathete
(CVC) into a human IJ vein o a blood t ans usion om the
ca otid a te y o a sheep.1 Mode n cent al venous cathete ization
he alds back to at least 1928 when We ne Fo ssmann, a
25-yea -old Ge man su geon, pe o med a venous cutdown
on his own le t antecubital vein, inse ted a u ete al cathete
to a distance o 65 cm, and then climbed seve al ights o
stai s to the adiology suite to conf m that it te minated in
the ight at ium. Although the hospital f ed D . Fo ssmann
o not obtaining pe mission, he went on to win the 1956
Nobel P ize o his pionee ing e o ts.1,2
Du y epo ted a la ge se ies o emo al, jugula , and
antecubital vein cathete izations in 1949.3 Aubaniac developed
subclavian venipunctu e while wo king on F ench A my
casualties between 1942 and 1952.4 His in aclavicula SV
app oach was efned by Kee i-Szanto in 1956, and the
sup aclavicula app oach to the vein was f st desc ibed by
Yo a in 1965.5,6 Aside om Du y’s ea lie wo k, He mosu a
(1966) and English (1969) a e gene ally c edited with the
scientifc development o the pe cutaneous IJ app oach.7
booksmedicos.org
idea o advancing la ge cathete s ove a exible wi e that was
inse ted th ough a pe cutaneous needle.8,9 The ole o cent al
venous p essu e (CVP) monito ing in the maintenance o
optimal blood volume helped popula ize cent al cathete ization
in the United States.10 This was accele ated by the advent o
the pulmona y a te y cathete , which was developed by Je emy
Swan and William Ganz in 1968.11 Swan, who was inspi ed
by his obse vations o a sailing boat du ing a picnic with his
child en, developed a ow-di ected balloon that allowed
measu ement o pulmona y a te y p essu e.12
ANATOMY
SV System
The SV begins as a continuation o the axilla y vein at the
oute edge o the f st ib. It joins the IJ vein to become the
innominate (sometimes e e ed to as the b achiocephalic) vein
3 to 4 cm p oximally. The SV has a diamete o 10 to 20 mm,
is app oximately 3 to 4 cm long, and is valveless. A te c ossing
ove the f st ib, the vein lies poste io to the medial thi d o
the clavicle. It is only in this a ea that the e is an intimate
association between the clavicle and the SV. The costoclavicula
ligament lies ante io and in e io to the SV, and the ascia
contiguous to this ligament invests the vessel. Poste io to the
vein and sepa ating it om the subclavian a te y is the ante io
scalene muscle, which has a thickness o 10 to 15 mm. The
ph enic ne ve passes ove the ante io su ace o the scalene
muscle late ally and uns immediately behind the junction o
the SV and the IJ vein. The la ge tho acic duct (on the le t)
and the smalle lymphatic duct (on the ight) pass ove the
ante io scalene muscle and ente the SV nea its junction
with the IJ vein. Supe io and poste io to the subclavian a te y
lies the b achial plexus. The dome o the le t lung may extend
above the f st ib, but the ight lung a ely extends this high
(Fig. 22.1).
IJ Vein
The IJ vein begins just medial to the mastoid p ocess in the
jugula o amen at the base o the skull and is o med by the
in e io pet osal sinus and the sigmoid sinus. It uns in e io ly
and passes unde the ste nal end o the clavicle to join the SV
and o m the innominate o b achiocephalic vein. At the level
o the thy oid ca tilage, the IJ vein, the inte nal ca otid a te y,
and the vagus ne ve cou se togethe in the ca otid sheath just
deep to the ste nocleidomastoid (SCM) muscle. Within the
ca otid sheath, the IJ vein typically occupies the ante io late al
position and the ca otid a te y lies medial and slightly poste io
to the vein. This elationship is elatively constant, but studies
have ound that the ca otid a te y may ove lap the IJ vein.
Note that no mally the IJ vein mig ates medially as it nea s
the clavicle, whe e it may lie di ectly ove the ca otid a te y.
When using the most common (cent al) app oach, the IJ vein
tends to be mo e late al than expected.13,14 Fu the mo e, in
5.5% o those studied, the IJ vein may even be medial to the
ca otid a te y.14–17 The elationship between the IJ vein and
the ca otid a te y also depends on head position. Excessive
head otation can cause the ca otid a te y to otate ove the
IJ vein.18,19
405
406 SECTION IV VASCULAr TECHNIqUES AND VOLUME SUPPOrT

Central Venous Catheterization

Indications Complications
Central venous pressure monitoring Arterial puncture and hematoma
High-volume/flow resuscitation Pneumothorax (subclavian and internal jugular approach)
Emergency venous access Hemothorax (subclavian and internal jugular approach)
Inability to obtain peripheral venous access Vessel injury
Repetitive blood sampling Air embolism
Administering hyperalimentation, caustic Cardiac dysrhythmia
agents, or other concentrated fluids Nerve injury
Insertion of transvenous cardiac pacemakers Infection
Hemodialysis or plasmapheresis Thrombosis
Insertion of pulmonary artery catheters Catheter misplacement

Contraindications
Infection over the placement site
Distortion of landmarks by trauma or congenital anomalies
Coagulopathies, including anticoagulation and thrombolytic therapy
Pathologic conditions, including superior vena cava syndrome
Current venous thrombosis in the target vessel
Prior vessel injury or procedures
Morbid obesity
Uncooperative patients

Equipment (contents of a typical central venous catheterization kit)

1% lidocaine
without epinephrine
5-mL syringe
(for venipuncture)

5-mL syringe
(for anesthetic)

18-gauge needle
(for venipuncture)
25- and 22-gauge needles
(for anesthetic)

chlorhexidine
Dilator
Sterile drape
Scalpel with a No.11 blade

Triple-lumen catheter

Catheter clamp
Guidewire Silk suture

Review Box 22.1 Cent al venous cathete ization: indications, cont aindications, complications, and e uipment.

booksmedicos.org
 CHAPTEr 22 Cent al Venous Cathete ization and Cent al Venous P essu e Monito ing
Internal
jugular vein
Subclavian
vein
Subclavian
artery
First rib
Lung
Figure 22.1 Subclavian vein anatomy. The subclavian vein uns pa allel
to the clavicle and ante io to the subclavian a te y. The cupula o
the lung lies just caudad to these st uctu es. I the int oduce needle
is kept almost pa allel to the clavicle, the a te y and lung should not
be encounte ed.
Anatomic landma ks o locating the vein include the ste nal
notch, the medial thi d o the clavicle, and the SCM. The two
heads o the SCM and the clavicle o m a t iangle that is key
to unde standing the unde lying vascula anatomy. The IJ vein
can be located at the apex o the t iangle as it cou ses along
the medial head o the SCM and occupies a position in the
middle o the t iangle at the level o the clavicle be o e it
joins the SV and o ms the innominate vein. At the level
o the thy oid ca tilage, the IJ vein can be ound just deep to
the SCM.
Gene ally, the ight IJ vein is bigge than the le t IJ vein
because o its connection to the SV and the ight at ium. The
IJ vein can be pulsatile, but in cont ast to the ao ta, these
pulsations a e not palpable. When visualized, howeve , the
p esence o venous pulsations can give an indication o patency
o the IJ vein to the ight at ium. The IJ vein also changes
size with espi ation. Because o the negative int atho acic
p essu e at end-inspi ation, blood in the IJ vein is actually
d awn into the ight at ium and the diamete o the IJ vein
sh inks. In cont ast, at end-expi ation the inc eased int atho acic
p essu e will limit etu n o blood to the ight at ium and the
diamete o the IJ vein will inc ease. Anothe uni ue cha ac-
te istic o the IJ vein is its distensibility. The IJ vein will enla ge
when p essu e in the vein is inc eased, such as when ow o
blood back to the ight at ium is obst ucted, as with th ombosis.
This distensibility can be advantageous o the placement o
cent al venous access. Use o a head-down (T endelenbu g)
position o a Valsalva maneuve will inc ease the diamete o
the IJ vein and the eby inc ease the likelihood o success ul
punctu e (Fig. 22.2).
Femoral Vein
The emo al anatomy is less complex than that o the neck
and shoulde and contains ewe vital st uctu es. The emo al
vein is most easily cannulated pe cutaneously in patients with
a palpable emo al pulse. The emo al vein begins at the
adducto canal (also known as Hunte ’s canal) and ends at the
booksmedicos.org
407
External
jugular vein
Internal
jugular vein
Carotid
artery
Figure 22.2 Inte nal jugula anatomy. The inte nal jugula vein uns
pa allel and late al to the ca otid a te y but lies almost di ectly above
the ca otid a te y at the level o the clavicle.
in e io ma gin o the inguinal ligament, whe e it becomes
the exte nal iliac vein. It is contained within the emo al t iangle
(inguinal ligament, medial bo de o the adducto longus, and
late al bo de o the sa to ius muscle). Medially, the emo al
vein abuts a obust system o lymphatics. Late ally, the vein
is intimately associated with the emo al a te y. The emo al
ne ve cou ses down into the leg just late al to the emo al
a te y. These elationships om late al to medial can be
emembe ed with the mnemonic NAVEL (ne ve, a te y, vein,
empty space, lymphatics). Note that as the emo al a te y and
vein cou se down the leg within the emo al sheath, thei
side-by-side elationship e uently otates such that the emo al
a te y may lie on top o the vein. The e o e to avoid a te ial
punctu e, keep cannulation attempts just unde the inguinal
ligament. When cannulating this vessel distal to the inguinal
ligament, ult asound guidance can be help ul to avoid a te ial
punctu e (Fig. 22.3).
INDICATIONS
Cent al venous access has seve al clinical indications (see review
Box 22.1). I necessa y, any cent al venous app oach could be
used o each o these situations. Howeve , ce tain app oaches
o e advantages ove othe s in specifc clinical settings. The
clinical indications a e discussed in detail in the ollowing
sections.20–22
CVP Monitoring and Oximetry
Fo a pe iod, pulmona y a te y cathete ization somewhat
supplanted CVP monito ing; howeve , the e is little evidence
that this p actice has any beneft with ega d to patient mo tality
o uality o li e. In the specifc setting o esuscitation o
patients in septic shock, CVP monito ing is an impo tant
component o “ea ly goal-di ected the apy” (EGDT).23,24
Continuous o episodic measu ements o cent al venous oxygen
satu ation (ScvO2) also have a p ominent ole in EGDT
p otocols o the agg essive t eatment o septic shock.23,24 Mo e
ecent evidence, howeve , does not demonst ate imp ovements
408 SECTION IV VASCULAr TECHNIqUES AND VOLUME SUPPOrT
Inguinal
ligament
Sartorius
muscle
Femoral
nerve
Femoral
artery
Femoral
vein
Adductor
longus
muscle
Figure 22.3 Femo al vein anatomy. The emo al vital st uctu es a e
located in the emo al t iangle: inguinal ligament supe io ly, sa to ius
muscle late ally, and adducto longus muscle medially. The t iangle
can be emembe ed by the mnemonic “SAIL” (sa to ius, adducto
longus, and inguinal ligament). Note the emo al st uctu es om
late al to medial: ne ve, a te y, vein, empty canal, and lymphatics
(mnemonic—NAVEL). The emo al vein lies medial to the emo al
a te y. Important anatomic note: at sites mo e distal to the inguinal
ligament, the vein lies di ectly above the a te y.
in patient-cente ed outcomes with the use o CVP monito ing
o volume esponsiveness and ScvO2 monito ing in patients
with seve e sepsis o septic shock.25–27 As a esult, the e has
been a de-emphasis on CVP monito ing in septic shock.
Cent al venous cathete ization is widely used as a vehicle
o apid volume esuscitation. Notwithstanding, sho t, la ge-
calibe pe iphe al cathete s can be as e ective as cent al access
because o the p ope ties o Poiseuille’s law, which states that
the ate o ow is p opo tional to the adius o the cathete
and inve sely p opo tional to its length.3 To illust ate, the
g avity ow ate o saline th ough a pe iphe al 5-cm, 14-gauge
cathete is oughly twice that th ough a 20-cm, 16-gauge CVC.
Conse uently, placement o la ge-bo e pe iphe al cathete s is
gene ally the astest method o volume loading.
Delivery of High-Flow Fluid Boluses
and Blood Products
The advent o the mo egulating high-volume apid in use s
a o ds the advantage o using cent al venous cathete ization
in the setting o seve e hemo hagic shock o hypothe mia.
The available systems can in use blood wa med to 37°C th ough
an 8.5-F int oduce sheath 25% mo e apidly than th ough
a 14-gauge pe iphe al int avenous (IV) line and up to 50%
aste than th ough an 18-gauge pe iphe al IV line.28 The
Level 1 rapid In use (Smiths Medical, St. Paul, MN) and the
Belmont FMS 2000 (Belmont Inst ument Co po ation, Bille ica,
MA) a e examples o mode n systems with in usion ates as
high as 1500 mL/min. 28 Massive ai embolism was a conce n
booksmedicos.org
with ea ly apid in use s, but sa ety p ecautions have now been
enginee ed to p event this. Howeve , i the cathete is misplaced,
uid o blood can be apidly in used into the tho ax, medias-
tinum, o pe itoneum with se ious conse uences.
Emergency Venous Access and Inability
to Achieve Peripheral Access
The p edictable anatomic locations o the subclavian and
emo al veins and the speed with which they can be cannulated
have p ompted thei use in ca diac a est and othe eme gency
situations. The need o a cent al line du ing ca diopulmona y
esuscitation (CPr) is cont ove sial.29–31 When achieved easily,
cent al venous cannulation, especially via the IJ vein o SV
oute, is p e e ed ove pe iphe al venous access because it
p ovides a apid and eliable oute o the administ ation o
d ugs to the cent al ci culation o patients in ca diac a est.
With esuscitation o ao tic catast ophes o tho acoabdominal
t auma, two CVCs, “one above and one below” the diaph agm,
a e o ten used.
Patients with a histo y o IV d ug use, majo bu ns, ch onic
disease, dehyd ation, o mo bid obesity and those who e ui e
long-te m access may have inade uate pe iphe al IV sites.
Cent al venous cannulation may be indicated as a means o
venous access in these patients even unde noneme gency
conditions.32 Mo e ecently with the use o ult asound, deep
b achial, axilla y, and basilic vein cannulation may be attempted
be o e cent al venous cathete ization. This app oach avoids
the complications that can be associated with cent al venous
access.
Routine Serial Blood Drawing
The potential complications o CVCs make them inapp op iate
solely o outine blood sampling. Howeve , lines al eady in
place may be used o this pu pose i they a e p ope ly clea ed
o IV uid. A 20-cm, 16-gauge cathete contains 0.3 mL o
uid, so at least this much must be withd awn to avoid dilution
o blood samples. Mo eove , to avoid aspi ation o c ystalloid-
diluted blood om the pe iphe al vein, it is advised that the
IV line be tu ned o o at least 2 to 3 minutes be o e using
the cathete o a blood d aw. Because o the inc eased isk
o in ectious complications, ai embolism, and venous back-
bleeding, the IV tubing should not be epeatedly disconnected
om the cathete hub. Inte position o a th ee-way stopcock
in the IV tubing simplifes access and is an acceptable method
o sampling blood in the intensive ca e setting, ega dless o
the IV site. The oxygen level in blood om the SV can be
dete mined o guidance in EGDT o sepsis i one chooses
not to place a continuous oximet ic monito .
Additionally, se ial lactate levels may help guide ea ly goal-
di ected esuscitation. With an imbalance in oxygen supply
and consumption, tissue hypope usion and hypoxia lead to
anae obic metabolism. The fnal p oduct o this p ocess is
lactate. A te ial lactate levels would best ep esent ove all
pe usion because such samples contain blood coming om
the pulmona y veins, supe io vena cava (SVC), and in e io
vena cava (IVC). Pe iphe al lactate p e e entially e ects
pe usion and metabolism in the compa tment om which
the blood was d awn, but not ove all pe usion. A te ial and
cent al venous lactate co elate closely mo e than 96% o the
time, whe eas pe iphe al venous lactate and a te ial lactate
co elate only 87% o the time.33
 CHAPTEr 22 Cent al Venous Cathete ization and Cent al Venous P essu e Monito ing
Infusion of Hyperalimentation and Other
Concentrated Solutions
Cent al venous hype alimentation is sa e and eliable. Use o
the in aclavicula subclavian techni ue ees the patient’s
ext emities and neck; this p ocedu e is the e o e well suited
o long-te m applications. Hype osmola o i itating solutions
with the potential to cause th ombophlebitis i given th ough
small pe iphe al vessels a e e uently in used th ough cent al
veins. Examples a e potassium chlo ide (>40 mmol/L), hype -
osmola saline, 10% calcium chlo ide (but not calcium gluconate,
which can sa ely be given pe iphe ally), 10% dext ose in usions,
chemothe apeutic agents, and acidi ying solutions such as
ammonium chlo ide. Vasoactive substances (e.g., dopamine,
no epineph ine) a e best administe ed th ough a CVC because
they may cause so t tissue nec osis i ext avasation occu s in
pe iphe al sites.
Cent al cathete s, though sa e than pe iphe al IV lines,
a e not immune to ext avasation; indeed, atal cases have been
epo ted i the cathete becomes wedged up against the vessel
wall, valves, o endoca dium.34 St ategies to avoid this complica-
tion include delive ing vesicant d ugs only th ough the distal
po ts o econf ming that the p oximal po t is sa ely in the
vein by aspi ating blood th ough it.34
Other Indications
Othe indications o cent al venous access include inse tion
o a pulmona y a te y cathete o t ansvenous pacemake ,
ca diac cathete ization, pulmona y angiog aphy, and hemodi-
alysis. A pulmona y a te y cathete can be valuable o dete min-
ing uid and hemodynamic status in the c itically ill. Its
widesp ead use in the 1980s and 1990s d ew heavy c iticism
because data showing a beneft in patient-o iented outcomes
TABLE 22.1 Advantages and Disadvantages of Central Venous Access Techniques
TECHNIQUE ADVANTAGES
IJ Good exte nal landma ks
Imp oved success with ult asound
Less isk o pneumotho ax than with SV access
Can ecognize and cont ol bleeding
Malposition o the cathete is a e
Almost a st aight cou se to the supe io vena
cava on the ight side
Ca otid a te y easily identifed
Femo al Good exte nal landma ks
Use ul alte native with coagulopathy
SV, in aclavicula Good exte nal landma ks
SV, sup aclavicula Good exte nal landma ks
P actical method o inse ting a cent al line in
ca dio espi ato y a est
CVP, Cent al venous p essu e; IJ, inte nal jugula ; SV, subclavian vein.
booksmedicos.org
409
we e lacking. Pulmona y a te y cathete s have subse uently
lost popula ity and should be used only when the diagnostic
benefts outweigh the potential isks.35,36 Cathete s such as the
Uldall and quinton devices can be inse ted within minutes,
the eby pe mitting eme gency o sho t-te m hemodialysis.
Howeve , these cathete s a e ve y la ge and elatively sti
and have been known to pe o ate the vena cava o at ial
walls, with atal outcomes. 37,38 Ext a caution should be applied
du ing thei inse tion, possibly unde ult asound o uo oscopic
guidance.
CONTRAINDICATIONS
Gene al cont aindications to the va ious techni ues o cent al
venous access a e p esented in review Box 22.1. Table 22.1 lists
the gene al advantages and disadvantages with each app oach.
Most cont aindications listed a e elative and should be viewed
in the context o the patient’s ove all condition, u gency o
need, and availability o alte native options o vascula access.
Pe haps the only t ue absolute cont aindication is inse tion
o cathete s imp egnated with antibiotics (most commonly
tet acycline, i ampin, o chlo hexidine) i the patient has a
se ious alle gy to the d ug. 39,40 Local cellulitis and disto ted
local anatomy o landma ks p eventing sa e inse tion a e elative
cont aindications to any access oute. Inse tion o cathete s
th ough eshly bu ned egions, though somewhat challenging,
is not associated with a highe incidence o in ection until
app oximately 3 days a te the bu n, when bacte ial colonization
accele ates.41,42 One o the mo e commonly encounte ed impedi-
ments to CVC placement is mo bid obesity.43 Su ace landma ks
in the neck a e o ten obscu ed, and an abdominal pannus
can block the emo al access site and conse uently e ui e
deepe inse tions and steepe angles. An ult asound-guided
DISADVANTAGES
Mo e di fcult and inconvenient to secu e
Possibly highe in ectious isk than with SV access
Possibly highe isk o th ombosis than with SV
access
Di fcult to secu e in ambulato y patients
Not eliable o CVP measu ement
Highest isk o in ection
Highe isk o th ombus
Unable to comp ess bleeding vessels
“Blind” p ocedu e
Should not be attempted in child en younge than 2 y
“Blind” p ocedu e
Unable to comp ess bleeding vessels
410 SECTION IV VASCULAr TECHNIqUES AND VOLUME SUPPOrT
IJ app oach is sa e unde these ci cumstances.43 Inse tion o
anothe cathete on the same side as a p eexisting one isks the
complication o ent apment.44 Combativeness is an impo tant
acto in the decision to place a CVC because the isk o
mechanical complications g eatly inc eases in uncoope ative
patients. Sometimes it is best to sedate and intubate c itically ill
patients be o e attempting cent al venous cathete ization. Othe
elative cont aindications include conditions p edisposing to
scle osis o th ombosis o the cent al veins, such as vasculitis,
p evious long-te m cannulation, o illicit IV d ug use via any
o the deep venous systems.
Coagulopathy is a e uent conce n su ounding inse tion
o a CVC, with the ove all isk o clinically signifcant hemo -
hage in these patients app oximating 2%.45 A t ans usion o
esh ozen plasma is commonly used to co ect any existing
coagulopathy. Howeve , a 2005 eview concluded that i good
techni ue is used, co ection o coagulopathy is not gene ally
e ui ed be o e o du ing the p ocedu e.46 Mumtaz and
cowo ke s ound that even in th ombocytopenic patients
(platelet count <50 × 109/L), bleeding complications occu ed
app oximately 3% o the time and we e limited to bleeding
at the inse tion site47; these complications we e managed with
additional sutu es. Although the occasional patient may e ui e
a blood t ans usion o eplacement o clotting acto s i a
hemo hagic complication a ises, p ophylactic co ection o
an abno mal inte national no malized atio o platelet count
be o e the p ocedu e is not outinely necessa y.46–48 risk can
be u the educed in coagulopathic patients with the use o
ult asound-guided placement techni ues.14,49–52
SV Approach
SV access is cont aindicated in patients who have p eviously
unde gone su ge y o sustained t auma involving the clavicle,
the f st ib, o the subclavian vessels; those with p evious
adiation the apy involving the clavicula a ea; those with
signifcant chest wall de o mities; and those with ma ked
cachexia o obesity. Patients with unilate al de o mities not
associated with pneumotho ax (e.g., actu ed clavicle) should
be cathete ized on the opposite side. Subclavian venipunctu e
is not cont aindicated in patients with penet ating tho acic
wounds unless the inju ies a e known o suspected to involve
the subclavian vessels o SVC. Gene ally, cannulate the vein
on the same side as the chest wound to avoid the possibility
o bilate al pneumotho aces. When (p eexisting) SV inju y is
suspected, cannulate on the opposite side. Exe cise g eate
caution when placing a CVC in the SV in coagulopathic patients
because this vessel is not comp essible. Fo me ly, subclavian
venipunctu e was not ecommended o use in small child en,
but in expe ienced hands it has been demonst ated to be sa e.53–55
IJ Approach
Ce vical t auma with swelling o anatomic disto tion at the
intended site o IJ venipunctu e is the most impo tant con-
t aindication to the IJ app oach. Likewise, the p esence o a
ce vical colla is p oblematic. Although bleeding diso de s a e
elative cont aindications to cent al venous cannulation, the
ult asound-guided IJ app oach is p e e ed ove the SV oute
because the IJ site is comp essible. Howeve , p olonged
comp ession o the a te y to cont ol bleeding could impai
the ce eb al ci culation i collate al blood ow is comp omised.
In a study by Oguzku t and colleagues, only mino bleeding
booksmedicos.org
complications occu ed in less than 2% o patients a te
ult asound-guided IJ vein cathete ization.50 In the setting o
seve e bleeding diatheses, the ult asound-guided emo al
app oach is an acceptable alte native. Ult asound-guided IJ
vein cathete placement is p e e ed in patients with abno mal
anatomy om p evious IJ vein t auma, small IJ vessels, and
mo bid obesity. Histo ically, ca otid a te y disease (obst uction
o athe oscle otic pla ue) is a elative cont aindication to IJ
vein cannulation because inadve tent punctu e o manipulation
o the a te y could dislodge a pla ue. I a p eceding SV
cathete ization has been unsuccess ul, the ipsilate al IJ oute
is gene ally p e e ed o a subse uent attempt. In this manne ,
bilate al iat ogenic complications can be avoided.
Femoral Approach
Cont aindications to emo al cannulation include known o
suspected int aabdominal hemo hage o inju y to the pelvis,
g oin, iliac vessels, o IVC. Additionally, avoid the emo al
app oach when known o suspected deep venous th ombosis
is p esent. Palpation o emo al pulsations du ing CPr is
di fcult and the pulsations a e o ten venous athe than a te-
ial.31,56 Ult asound-guided cathete ization o the emo al vein
du ing CPr is mo e success ul, and it is less likely to incu
inadve tent a te ial punctu e than the standa d landma k-
o iented app oach.31
PROCEDURE
The most commonly used method o cent al venous cannula-
tion is the Seldinge (guidewi e) techni ue, in which a thin-
walled needle is used to int oduce a guidewi e into the
vessel lumen. Seldinge o iginally desc ibed this techni ue in
1953 as a method o placing a cathete o pe cutaneous
a te iog aphy.17 The Seldinge techni ue is illust ated in
Fig. 22.9. To obtain vascula access, inse t a small needle into
the intended vessel. Once the int oduce needle is positioned
within the lumen o the vessel, th ead a wi e th ough the
needle and then emove the needle. The wi e, now within the
vessel, se ves as a guide ove which the cathete is inse ted.
Although the Seldinge techni ue involves seve al steps, it
can be pe o med uickly once maste ed. Mo e impo tantly,
this techni ue b oadens the application o cent al venous
cannulation by pe mitting the inse tion o standa d in usion
cathete s, multilumen cathete s, la ge-bo e apid in usion
systems, int oduce devices, hemodialysis devices, and even
pe iphe al ca diopulmona y bypass cannulas. Given this ex-
ibility, the use o Seldinge -type systems is advantageous despite
thei g eate cost.
Ult asound guidance has evolutionized the cannulation o
cent al veins. As with all anatomic st uctu es in the human
body, veins a e highly va iable in thei location. Not su p isingly,
esea ch has demonst ated that the ability to see the inte nal
st uctu e’s location and p oximity to othe st uctu es g eatly
inc eases the sa ety and success ate while dec easing the
time e ui ed to pe o m the p ocedu e.49–52,57–59 These advan-
tages have been ecognized by national o ganizations. In a
epo t om the Agency o Healthca e resea ch and quality
(AHrq), use o ult asound guidance was listed as one o the
top 10 ways to educe mo bidity and mo tality.60 Many hospitals
now e ui e the use o ult asound guidance o the placement
o all CVCs.
 CHAPTEr 22 Cent al Venous Cathete ization and Cent al Venous P essu e Monito ing
The basic mate ials e ui ed o cent al venous cannulation
a e shown in review Box 22.1 and a e discussed he e in u the
detail. The cathete may be a component in a guidewi e system
o may be o the ove -the-needle va iety (the othe widely
used method o cathete placement). Seve al types o CVC
Seldinge -type p epackaged kits a e comme cially available
and the va iations in each kit a e discussed in the next section.
EQUIPMENT
P epa ation and o ganization o e uipment ahead o time a e
impe ative o a success ul p ocedu e. Most cathete s now
come om the manu actu e in convenient ste ile kits. We
st ongly ecommend stocking all additional e uipment such
as ste ile gowns, gloves, and d apes in a dedicated “cent al
line ca t.” This is a undamental pa t o the “bundling” p actice
that has been shown to educe the sea ch o supplies, imp ove
compliance with ull-ba ie techni ue, and subse uently
dec ease cathete - elated in ections.61–66 Ste ile ba ie p ecau-
tions with cap, ace mask, ste ile gown, and gloves should be
used at all times du ing inse tion o CVCs.64,67,68
Ultrasound
Histo ically, many clinicians p e e ed to f st locate the position
o a cent al vein with a small explo ato y o “fnde ” needle
athe than di ectly cannulating the vein with a la ge needle
to accommodate a guidewi e o cathete . This p actice is less
p actical o the SV app oach and has la gely been eplaced
with the use o bedside ult asound. Ult asound-guided CVC
placement allows the p ovide to su vey the anatomy be o e
the p ocedu e, guide inse tion o the needle into the co ect
vessel, and conf m placement o the cathete in the vessel14,50–52
(see Ult asound Box 22.1).
Needle
Vi tually any needle o cathete can be used to int oduce a
guidewi e into a vessel, but the e a e advantages to using needles
specifcally designed o passage o a guidewi e. These needles
must be la ge enough to accommodate the desi ed wi e, yet
be as small as possible to minimize bleeding complications.
The int oduce needles p ovided with CVCs o int oduce
devices a e usually thin walled to maximize lumen size elative
to the ove all needle diamete . I a needle that is not thin
walled is used, choose a size that is 1 gauge smalle (la ge
bo e) than that listed in Table 22.2. I unsu e, simply test the
e uipment f st to ensu e compatibility.
Standa d needles may have a uni o mly st aight-bo e lumen
th oughout thei length. A wi e passing into a st aight needle
may encounte an obstacle at the p oximal end. The p oximal
end o a Seldinge needle inco po ates a unnel-shaped tape
that guides the wi e di ectly into the needle (Fig. 22.4). It is
advisable to use a non–Lue -Lok o slip-tip type o sy inge
because the added twisting that is e ui ed to emove a Lue -
Lok sy inge om the int oduce needle may dislodge a tenu-
ously placed needle. Sa ety sy inge systems exist that pe mit
passage o the wi e without emoval o the aspi ating sy inge
by using a cent al tunnel in the ba el. This device inco po ates
a hollow sy inge th ough which the guidewi e can pass di ectly
into the int oducing needle without detachment. It also educes
the isk o ai embolism, which can occu when the needle
booksmedicos.org
411
TABLE 22.2 Needle Sizes for Venous and
Arterial Cathetersa
STANDARD FULL-LENGTH COIL
GUIDEWIRE CATHETER SIZE (Fr) NEEDLE GAUGEb
3 21
4–4.5 20
5–6.0 20–19
6–8.5 19–18
a
Any size o cathete om 3.0 to 8.5 F may be int oduced with a 22-gauge
needle i a solid wi e (e.g., Co -Flex, Cook C itical Ca e) is used.
b
All needle gauges a e o thin-walled needles only, the type supplied in cent al
line kits.
A Straight-bore lumen
B Tapered lumen
Figure 22.4 Int oducing needles. A, O dina y needle with a st aight-
bo e lumen. B, Seldinge needle with a tape ed lumen, which allows
easy ent y o the guidewi e.
is open to ai . It is not uncommon o the wi e to become
snagged at the junction o the sa ety sy inge and the needle
hub. In this case, simply emove the sy inge and inse t the
wi e di ectly.
Guidewire
Two basic types o guidewi es a e used: st aight and J-shaped.
St aight wi es a e o use in vessels with a linea confgu ation,
whe eas J-wi es a e o use in to tuous vessels. Both wi es
have essentially the same inte nal design (Fig. 22.5). The
exibility o the wi e is the esult o a stainless steel coil o
helix that o ms the bulk o the guidewi e. Within the cent al
lumen o the helix is a st aight cent al co e wi e, called a
mand el, that adds igidity to the steel coil. The mand el is
usually fxed at one end o the helix and te minates 0.5 and
3.0 cm om the othe end to c eate a exible o oppy tip.
Wi es a e also available with two exible ends, one st aight
and the othe J-shaped. The exible end o the guidewi e
allows the wi e to ex on contact with the wall o a vessel. I
the contact is tangential, as with an in aclavicula app oach
to the SV, a st aight wi e is gene ally p e e ed. I the angle
is mo e acute, as with an exte nal jugula app oach to the SV,
o i the vessel is pa ticula ly to tuous o valves must be t a-
ve sed, a J-shaped wi e may be used. The mo e ounded leading
edge o the J-wi e p ovides a b oade su ace to manipulate
within the vessel and dec eases the isk o pe o ation. This
is especially advantageous when attempting to th ead a wi e
th ough a vessel with valves. Many guidewi es also contain a
st aight sa ety wi e that uns pa allel to the mand el to keep
the wi e om kinking o shea ing.
412 SECTION IV VASCULAr TECHNIqUES AND VOLUME SUPPOrT

Sleeve

J-tip
A

Straightened
tip
B
Sleeve and straightened
tip inserted into needle hub

C A
Figure 22.5 J-wi e. A, Plastic sleeve in the et acted position
demonst ating the J-tip. B, Plastic sleeve advanced to st aighten the
cu ve o easy int oduction into the needle hub. C, Plastic sleeve
inse ted into needle hub. In an eme gency, take ca e to not misplace
o th ow the sleeve away. Without it, placing the J-wi e into the hub
o the needle is ve y di fcult. Some wi es may have a “so t-tipped”
st aight end on the opposite end o the wi e. These wi es a e enginee ed
to be exible (to avoid vessel inju y) and may be used i the e is
di fculty passing the J end.
B

Figure 22.6 A and B, Although newe guidewi es a e mo e esistant

The standa d size o guidewi es is 0.025 to 0.035 inch
(0.064 to 0.089 cm) in diamete , which pe mits int oduction
th ough an 18-gauge thin-walled needle. A modifcation o
this standa d wi e uses a ba e mand el with the exible coil
solde ed to its end. This const uction p ovides a wi e with a
diamete o just 0.018 inch (0.047 cm) but with the same igidity
as the la ge wi es. The manu actu e states that such a wi e
can be int oduced th ough a 22-gauge thin-walled needle yet
still guide an 8.5-F cathete (Mic opunctu e Int oduce Sets
and T ays with Co -Flex Wi e Guides, Cook C itical Ca e,
Inc., Bloomington, IN).
It is impo tant to emphasize that guidewi es a e delicate
and may bend, kink, o unwind. A o ce o 4 to 6 lb may cause
a wi e to uptu e. Wi es should th ead easily and smoothly
and neve be o ced; the wo st complications o CVC placement
a e associated with the application o excessive o ce ac oss
pa ts o the appa atus that a e not th eading smoothly.69 I a
wi e is not passing easily, withd aw the wi e and the int oduce
needle as a single unit. Embolization o po tions o the guidewi e
is possible, and sha p de ects in the wi e may pe o ate vessel
walls (Fig. 22.6). I one encounte s a good ash o blood but
cannot eadily manipulate the wi e, this may indicate that the
oute wi e coils a e ent apped against the p oximal sha p edge
o the needle bevel. The J-shape can be st aightened emotely
by applying gentle o ce on the wi e in each di ection, which
may allow et ieval o the wi e.58 Wi es should be inspected
o small de ects such as kinks, sha p ends, o spu s be o e use
and especially a te a ailed attempt. Wi es may be th eaded
into the int oduce needle hub mo e easily by using the plastic
sleeve attached to the wi e as shown in Fig. 22.5C.
Catheters
A numbe o di e ent cathete and int oduce devices have
been developed, and the method o passage into the vessel
va ies acco dingly. The unctions o cathete s have become
mo e sophisticated as well, most notably o continuous
monito ing o SCVO2 and ca diac output. Gene ally, one can
to shea ing, i a guidewi e will not advance, withd aw both the needle
and the wi e in one motion. These pictu es demonst ate a pe manently
de o med guidewi e that could not be advanced. Withd awing the wi e
with the indwelling int oduce needle in place within a vessel may
shea o a po tion o the wi e and esult in systemic embolization.
place single-, double-, and t iple-lumen cathete s by sliding
the cathete di ectly ove a guidewi e into the intended vessel
(Fig. 22.7A). Cathete inse tion lengths a e listed in Table
22.3. La ge cathete s o devices without lumens can be
int oduced with a sheath-int oduce system. Ove -the-needle
cathete s can be int oduced once int avascula placement is
attained.
The Desilets-Ho man–type sheath int oduce became
available in 1965 to aid in a te iog aphy p ocedu es that e ui e
many cathete changes. This device is commonly but inco ectly
te med a Cordis, which is a p op ieta y t ade name. The sheath-
int oduce unit includes two pa ts, an inne dilato and an
oute sheath, as shown in Fig. 22.7B. The dilato is igid with
a na ow lumen to accommodate the guidewi e. It is longe
and thinne than its sheath and has a tape ed end that dilates
the subcutaneous tissue and vessel de ect c eated by the needle.
The sheath (o int oduce cathete when used as a cannula
o inse ting Swan-Ganz cathete s, t ansvenous pacemake s,
o othe devices) has a blunt end and is simply a la ge-diamete
cathete .
Many modifcations o the sheath exist, such as side a ms
and diaph agms to aid in the placement o devices without
lumens. Ca e must be taken when using side-a m sets o apid
administ ation o uid because some cathete s a e 8.5 F in
diamete but have only a 5-F side a m. Some sets have a
“single-lumen in usion cathete ,” which pe o ms the same
unction but is mo e easily secu ed to the sheath int oduce .
Selection o the app op iate diamete o int oduce cathete
should co espond to the indication o placement o a CVC.
Gene ally, an 8.5-F cathete is used to acilitate placement

booksmedicos.org
 CHAPTEr 22 Cent al Venous Cathete ization and Cent al Venous P essu e Monito ing 413

and chlo hexidine) o antibiotics (minocycline, i ampin,

o ce azolin) to educe bacte ial colonization and mic obial
g owth. Hepa in-coated cathete s a e also available that p event
fb onectin binding, the eby inhibiting the o mation o bacte ial
bioflm on the cathete ’s su ace. These cathete s can dec ease
cathete -associated in ection (CAI) signifcantly and a e cost-
Infusion ports e ective when the p evalence o CAI is g eate than 2%.45 They
should be avoided in patients with a histo y o hepa in-induced
th ombocytopenia.72 Minocycline- and i ampin-imp egnated
cathete s a e cu ently conside ed to be the most e ective.40,70
Othe inte ventions that dec ease cent al line in ections include
the use o ull ste ile ba ie p ecautions,64,68 skin p epa ation
A with chlo hexidine solution,64–66,73 and placement by expe ienced
physicians.68,74–76
Many di e ent cathete s a e cu ently manu actu ed.
Dilator Although this leads to g eat exibility in choice and cost, it
Side-arm o ten esults in con usion when a clinician is handed an
infusion port un amilia cathete du ing an eme gency. It is best to use one
b and outinely and to ensu e that all medical pe sonnel a e
tho oughly amilia with its use.77

One-way
valve
TECHNIQUE
B Preprocedure Preparation
Figure 22.7 A, T iple-lumen cathete . The cathete po ts a e used o When possible, discuss the p ocedu e with the patient and
in usion o uids, administ ation o medications, and monito ing o obtain w itten in o med consent. Place the patient and you sel
cent al venous p essu e and a e typically labeled as p oximal, medial, in an app op iate position o the specifc vessel being accessed.
and distal. The distal o b own po t, typically 16 gauge, acilitates I available, pe o m an ult asound su vey to identi y the patient’s
passage o the guidewi e. Note that the end cap o the distal po t anatomy, ensu e vessel patency, and conf m the punctu e
(arrow) must be emoved be o e inse tion to allow passage o the site (Fig. 22.8). Ult asound-guided CVC placement has been
guidewi e. B, Sheath int oduce . This la ge-bo e device (8.5 F ) is used shown to dec ease p ocedu e times, as well as complication
as an int oduction cathete o devices such as Swan-Ganz cathete s ates.49–52 Additionally, compliance with a cent al line bundling
and t ansvenous pacemake s. Note that the dilato must be placed policy has been shown to signifcantly dec ease cent al line–
th ough the cathete be o e the device is inse ted into the patient.
associated bloodst eam in ections (CLABSIs).63–66 P epa e and
d ape the punctu e site while maintaining ste ile techni ue,
and obse ve unive sal p ecautions th oughout the p ocedu e
TABLE 22.3 Formulas for Catheter Insertion Length (Fig. 22.9, steps 1 and 2). A gown, su gical cap, mask, eye
Based on Patient Height and Approach p otection, and ste ile gloves should be wo n th oughout the
p ocedu e when possible. When pe o ming ult asound-guided
SITE FORMULA IN SVC (%) IN RA (%) placement o a CVC, ensu e that a ste ile t ansduce sheath
rSC (Ht/10) − 2 cm 96 4 and ste ile t ansduce gel a e used du ing the p ocedu e (see
Fig. 22.9, step 3). Using an assistant will p ove valuable in
LSC (Ht/10) + 2 cm 97 2 patient p epa ation, maintenance o ste ility, and handling o
rIJ Ht/10 90 10
the e uipment.

LIJ (Ht/10) + 4 cm 94 5 Guidewire Placement With

Ht, Patient height (in cm); LIJ, le t inte nal jugula ; LSC, le t subclavian; RA,
ight at ium; RIJ, ight inte nal jugula ; RSC, ight subclavian; SVC, supe io
vena cava.
F om Czepizak C, O’Callaghan JM, Venus B: Evaluation o o mulas o optimal
positioning o cent al venous cathete s, Chest 107:1662, 1995. rep oduced by
pe mission.
o a Swan-Ganz cathete and a 6.0-F cathete is used to
acilitate t ansvenous placement o a pacemake . I the int o-
duce cathete is la ge than e ui ed to suppo t the int aluminal
device, a leak may develop at the diaph agm inse tion point.
Special cathete s have been developed to p event bacte-
ial contamination and line sepsis. 40,70,71 These cathete s
a e imp egnated with eithe antiseptics (silve sul adiazine
the Seldinger Technique
When pe o ming ult asound-guided placement o a CVC,
begin with an ult asound su vey o the ta get vein, su ounding
st uctu es, and venipunctu e location, as shown in Fig. 22.8.
Veins can easily be distinguished om the nea by a te y by
applying exte nal p essu e with the t ansduce . Veins collapse
completely with p essu e, whe eas a te ies may de o m but
do not usually collapse. Occasionally, the vein does not collapse
with p essu e. I this occu s, a th ombus may be p esent in
the vein o the st uctu e has been misidentifed. I a suspected
vein does not collapse with p essu e, it is not an app op iate
vessel o cannulation. I available, Dopple unctions may also
be help ul in the di e entiation o veins and a te ies. Select a
venipunctu e location whe e b anching o the vein will allow

booksmedicos.org
414 SECTION IV VASCULAr TECHNIqUES AND VOLUME SUPPOrT

Vein

Artery

Compressed
vein

Artery

A C

Figure 22.8 A, Ult asound su vey. Pe o m an ult asound su vey to identi y the anatomy be o e
beginning the p ocedu e. B, C oss-sectional view o the a te y and noncomp essed vein. C, C oss-
sectional view o the a te y and comp essed vein.

the sho test path o the needle, will not obst uct passage o
the cathete , and will not allow inadve tent punctu e o othe
vital anatomic st uctu es. (See Chapte 66 o additional
in o mation and desc iptions o the ult asound techni ue.)
P epa e the cathete o inse tion by ushing each lumen
with ste ile no mal saline. Anesthetize the inse tion site with
lidocaine o bupivacaine (see Fig. 22.9, step 5). Attach a small
sy inge to an int oducing needle that is la ge enough to accom-
modate the guidewi e. Inse t the needle and sy inge togethe .
Slowly advance the needle into the vein and apply steady
negative p essu e on the sy inge (see Fig. 22.9, step 6). When
pe o ming ult asound-guided CVC placement, ollow the
needle t ajecto y in the so t tissue and obse ve penet ation o
the vessel. I the tip o the needle is not visualized at all times
with ult asound, the needle may be passed into st uctu es othe
than the vein. The key concept in using ult asound guidance
o venous access is to visualize the tip o the needle at all
times du ing cannulation (Fig. 22.10). Once the tip o the
needle ente s the vessel lumen, blood will be aspi ated eely.
Stabilize the needle hub to p event movement o the needle
and displacement o the tip om the vessel, and emove the
sy inge. This action can dislodge the needle tip and is the
activity most associated with ailu e to pass a wi e a te
the vein has initially been ente ed. The need to disconnect
the sy inge can be eliminated by use o the A ow Sa ety Sy inge
(Tele ex, Mo isville, NC). A te emoving the sy inge, cap
the needle hub with you thumb be o e passing the guidewi e
to minimize the potential o ai embolism.
Conf m that the blood ow is nonpulsatile. B ight ed
pulsatile blood is ve y suggestive o a te ial punctu e. Be awa e
that in shock states o ma ked a te ial desatu ation, da k,
nonpulsatile blood does not ule out a te ial cannulation. I
the e a e conce ns about possible a te ial punctu e, eithe
emove the int oduce needle and d aw a sample o blood
gas analysis om the needle to compa e with an a te ial blood
gas sample, o inse t an 18-gauge single-lumen cathete ove
the wi e and into the vessel because this step does not e ui e
the use o a dilato . The cathete can then be connected to a
p essu e t ansduce to conf m the p esence o venous wave-
o ms and venous p essu e.
Int oduce the exible end o the guidewi e into the hub o
the needle (see Fig. 22.9, step 7). It may be easie to int oduce
the J-wi e by advancing the plastic sleeve contained in the kit
onto the oppy end o the wi e to st aighten the J-shape. This
st aightened end is then int oduced into the needle hub. The
guidewi e should th ead smoothly th ough the needle into the
vessel without esistance. Do not o ce the wi e i esistance
is encounte ed, but emove it om the needle and eattach
the sy inge to aspi ate blood and econf m int avascula needle
placement. It is impo tant o the wi e to slip easily om the
needle du ing emoval. I esistance to emoval o the wi e is
elt, the wi e and needle should be emoved as a single unit
to p event shea ing o the wi e and esultant wi e embolism.
It has been ecommended by some that no wi e should eve
be withd awn th ough the int oducing needle.78 Although the e
a e no clinical data to suppo t this ecommendation and newe
wi es a e st onge and mo e esistant to shea ing, it ep esents
the sa est cou se o action. The ecommendation to emove
the needle and wi e as a unit is sometimes dis ega ded because
o eluctance to abandon a potentially success ul venipunctu e.
The clinician pe o ming the p ocedu e must use both caution
and good judgment to dete mine the best cou se o action but

booksmedicos.org
 CHAPTEr 22 Cent al Venous Cathete ization and Cent al Venous P essu e Monito ing 415

Ce n t r al V e no u s C a t h et er i z a t io n ( I n te rn a l J ug u la r A p pr o ac h )

1 2

Prepare the area with chlorhexidine solution. A gown, Apply a full-body, sterile drape. Meticulous attention must be
surgical cap, mask, eye protection, and sterile gloves should paid to sterile technique to avoid iatrogenic infection.
be worn throughout the procedure.

3 4

IJ
CA

Insert the ultrasound probe into a sterile sheath and use Identify the anatomic structures with ultrasound. The internal
sterile ultrasound gel during the procedure. Enlist the help of jugular vein (IJ) and carotid artery (CA) must be clearly
an assistant in patient preparation and maintenance of distinguished from each other (see text for more details).
sterility.

5 6

Anesthetize the tissues overlying the vein with local Insert the needle and syringe while slowly advancing and
anesthetic. Here, the operator is using ultrasound guidance applying negative pressure to the plunger. Follow the needle
to ensure a proper entry site. trajectory with ultrasound until the vein is entered and blood
enters the syringe (arrow).

7 8

Remove the syringe and advance the guidewire through the Once the wire has been inserted to the appropriate depth
needle. Use the straightener (arrow) to facilitate entry of the (see text for details), remove the needle (arrow). It is
J-wire into the hub. NEVER FORCE THE WIRE! essential to always maintain a grip on the wire throughout
the procedure (!).

Figure 22.9 Ult asound-guided inte nal jugula cent al venous cathete ization.
Continued

booksmedicos.org
416 SECTION IV VASCULAr TECHNIqUES AND VOLUME SUPPOrT

Cen t r al V e no u s C a t h et er i z a t io n ( I n te rn al J ug u lar A p pr o ac h )

9 10

Make an incision at the site of the wire to facilitate dilator Thread the dilator over the guidewire. The wire must always
and catheter passage. Make the incision the width of the be protruding from the end of the dilator and firmly in your
catheter and extend it completely through the dermis. grasp (!). Advance the dilator several centimeters into the
vessel and then remove.

11 12

Advance the catheter over the wire. It can be difficult to align Advance the catheter into the vessel. The guidewire will
the two pieces; hold the very end of the catheter and the emerge from the distal port. It is essential that the guidewire
wire to make this step easier. protrudes from the hub and is grasped before catheter
advancement (!).

13 14

Remove the wire. Cover the open port with your thumb Flush all ports with saline.
(arrow) until the end cap is screwed on.

15 16

Suture the catheter into place using nonabsorbable silk Clean the area around the catheter insertion site with
sutures. Several knots should be made to secure the line. chlorhexidine. Place a simple dressing, avoiding excessive
Avoid making knots that place excessive pressure on the amounts of gauze and tape.
skin.

Figure 22.9, cont’d

booksmedicos.org
 CHAPTEr 22 Cent al Venous Cathete ization and Cent al Venous P essu e Monito ing
A B
Figure 22.10 A, Ult asound-guided inse tion o the int oduce needle. B, C oss-sectional ult asound
image o the needle (arrow) within the vessel.
should not withd aw the guidewi e against esistance. Manipula-
tion o the wi e within an int oduce needle should be done
only with standa d coil guidewi es. Solid wi es (such as Co -Flex
Wi e Guides om Cook C itical Ca e) have a small lip at the
point at which the exible coil is solde ed to the wi e. This
lip can become caught on the edge o the tip o the needle
and shea o the coil po tion o the wi e. Solid wi es must
th ead eely on the f st attempt o the enti e wi e and needle
assembly must be emoved. Keep backup wi es on hand.
Occasionally, a wi e must be teased into the vessel; otating
the wi e o needle o ten helps in di fcult placements. I the
wi e does not th ead easily, pull back slightly on the needle
itsel just be o e advancing the wi e. This helps i the opening
o the needle is abutting the vessel’s inne wall and blocking
ent y o the wi e o i the vein is comp essed by int oduction
o the needle. Changing wi e tips om a st aight wi e to a
J-wi e o vice ve sa may also solve an advancement p oblem.
I the inne lumen o a vessel is smalle than the diamete o
the J, the wi e will be p evented om etu ning to its natu al
shape and the sp ing in the coil will gene ate esistance. Any
advantages o a J-wi e will be negated i the wi e ails to egain
its intended shape. In this instance, it should be possible to
int oduce a st aight tip without a p oblem. Alte natively, i
the angle o ent y o the needle into the vessel is mo e acute
than suspected, a st aight wi e may not be able to bend
app op iately as it encounte s the vessel’s a wall. A J-tipped
wi e may be used and th eaded in such a manne that the wi e
esumes its J-shape away om the a wall. All these maneuve s
a e pe o med with gentle ee motions o the wi e within the
needle. I at any time the wi e cannot be advanced eely,
suspect imp ope placement and eevaluate the attempt.
I th eading easily, advance the guidewi e until at least one
ua te o the wi e is within the vessel. The u the into the
vessel the wi e extends, the mo e stable its location when the
cathete is int oduced. Howeve , advancing the guidewi e too
a may esult in vent icula ectopy seconda y to endoca dial
i itation, myoca dial punctu e leading to tamponade, o
entanglement in a p eviously placed pacemake , inte nal
defb illato , o IVC flte . In both the le t and ight IJ vein
and in aclavicula SV app oaches, uo oscopic study du ing
passage o the guidewi e has dete mined the mean distance
om skin to the SVC-at ial junction to be 18 cm.78 This distance
has been ecommended as the g eatest depth o guidewi e
inse tion o these app oaches. It should be noted that 18 cm
booksmedicos.org
417
is not necessa ily the app op iate fnal depth o the cathete
being placed (see ollowing discussion).
Ca diac monito ing may be help ul du ing the inse tion o
cent al lines. Any inc ease in p ematu e vent icula cont actions
o a new vent icula dys hythmia should be inte p eted as
evidence that the guidewi e is inse ted too a and should be
emedied by withd awing the wi e until the hythm eve ts to
baseline. Usually, the p ocedu e can be continued a te a
moment, with ca e taken to not eadvance the wi e. Pe sistent
vent icula dys hythmias e ui e standa d advanced ca diac
li e suppo t t eatment and conside ation o a new vascula
app oach.
Occasionally, a wi e th eads easily past the tip o the needle
and then suddenly will not advance a the . I the int oduce
needle demonst ated ee etu n o blood at the time o wi e
ent y and the initial advancement o the wi e met no esistance,
the two options a e to halt the p ocedu e o seek conf mation
o the wi e position. The guidewi e within the lumen o the
vessel can be visualized and conf med via c oss-sectional and
longitudinal views on ult asound. Alte natively, the needle may
be emoved, the wi e fxed in place with a ste ile hemostat,
and a adiog aph taken to conf m the position o the wi e.78,79
A eely advancing wi e may suddenly stop once it is well
within a vessel i the vessel makes an unsuspected bend o is
being comp essed o deviated by anothe st uctu e, such as a
ib o muscle. This seems especially common with the in a-
clavicula app oach to the SV and can sometimes be emedied
by a mo e late al app oach.
Sheath Unit and Catheter Placement
Once the wi e is placed into the vessel, emove the needle in
p epa ation o passage o the cathete (see Fig. 22.9, step 8).
P ope positioning o the guidewi e within the vessel lumen
can be conf med by c oss-sectional and longitudinal ult asound
imaging (Fig. 22.11).79 This can be done at any point while
inse ting the wi e to ensu e that the co ect vessel has been
cannulated and that punctu e o the poste io wall has not
occu ed. This techni ue can be uite use ul when esistance
is encounte ed while eeding the guidewi e. A small skin incision
is e ui ed at the site o the wi e to widen the opening (see
Fig. 22.9, step 9). Make the incision app oximately the width
o the cathete to be int oduced and extend it completely
th ough the de mis.
418 SECTION IV VASCULAr TECHNIqUES AND VOLUME SUPPOrT
A B
Figure 22.11 A and B, C oss-sectional and longitudinal ult asound
images demonst ating a guidewi e (arrows) in the lumen o the ta geted
vein.
When placing so t multiple-lumen cathete s, the tissue must
be dilated om the skin to the vessel be o e placement o the
cathete . Th ead the guidewi e th ough the distal opening o
the igid dilato until it extends th ough the p oximal end o
the dilato (see Fig. 22.9, step 10). The wi e must always be
visibly p ot uding om the end o the dilato o cathete du ing
inse tion to avoid inadve tent advancement o the wi e into
the ci culation and potential loss o the wi e. While maintaining
cont ol o the guidewi e p oximally, th ead the dilato ove
the wi e into the skin with a twisting motion. Advance the
igid dilato only a ew centimete s into the vessel and then
emove it. Once the dilato is emoved, th ead the so t cathete
into position ove the wi e. Placement o multiple-lumen
cathete s e ui es identifcation o the distal lumen and its
co esponding hub. Find the distal lumen at the ve y tip o
the cathete . The co esponding hub is usually labeled “distal”
by the manu actu e . I the e is any con usion, inject a small
amount o ste ile saline th ough each hub until it is obse ved
exiting the distal lumen. Once the distal hub is identifed,
emove its cove cap to allow passage o the guidewi e. Place
the cathete by th eading the guidewi e into the distal lumen
and advancing it until it p ot udes om the identifed hub
(see Fig. 22.9, step 11). It is impe ative that the guidewi e
p ot ude om the cathete hub and that it be f mly g asped
as the wi e and cathete a e advanced. I the wi e does not
p ot ude om the p oximal end o the cathete , withd aw the
wi e at the skin ent y point until it p ot udes enough to be
g asped. While maintaining cont ol o the guidewi e p oximally,
advance the cathete into the vessel to the desi ed cathete
inse tion length (see Fig. 22.9, step 12). Ult asonog aphy can
be used to ve i y p ope cathete placement. A te inse tion
o the cathete , the wi e must be emoved (see Fig. 22.9, step
13) and the cathete must be ancho ed to the skin with sutu es.
When emoving the wi e om a cathete it must slip out
easily. I any esistance is met, emove both the wi e and the
cathete as a single unit and eattempt the p ocedu e. A common
cause o a “stuck wi e” is a small piece o adipose tissue wedged
between the wi e and the lumen o the cathete . Avoid this
p oblem by c eating a deep enough skin nick and ade uate
dilation o the t act be o e inse ting the cathete .
When placing a single-lumen, Desilets-Ho man sheath-
int oduce system, the dilato and la ge single-lumen cathete
a e inse ted simultaneously as a dilato -sheath unit. The
booksmedicos.org
dilato -sheath unit must f st be assembled by inse ting the
dilato th ough the cathete ’s diaph agm (Fig. 22.12, step 2).
When assembled co ectly, the dilato snaps into place within
the lumen o the sheath and p ot udes seve al centimete s
om the distal end o the cathete .
A te success ul guidewi e placement and a te the skin
incision is made, th ead the dilato -sheath assembly ove the
wi e (see Fig. 22.12, step 3). It is impe ative that the guidewi e
p ot ude om the p oximal end o the dilato -sheath assembly
and that it be f mly g asped as the wi e and unit is advanced.
I the wi e does not p ot ude om the p oximal end o the
assembly, withd aw the wi e at the skin ent y point until it
p ot udes enough to be g asped. While maintaining cont ol
o the guidewi e p oximally, advance the assembly th ough
the skin with a twisting motion until it is within the vessel.
G asp the unit at the junction o the sheath and dilato . This
p events the thinne sheath om kinking o bending at the
tip o om bunching up at the couple end. Keep the assembly
intact and advance it th ough the skin to the hub. Once the
cathete is placed, emove the wi e and dilato om the sheath
simultaneously (see Fig. 22.12, step 4). When emoving the
wi e and dilato , the dilato must “unsnap” om the sheath
unit and the wi e must slip out easily. Once the single-lumen
sheath-int oduce cathete is placed co ectly, it may be used
to acilitate the placement o additional int aluminal devices
such as a pulmona y a te y cathete , t ansvenous ca diac
pacemake , o an additional multiple-lumen cathete . At times,
c itically ill patients who e ui e initial la ge-volume esuscita-
tion will late e ui e multiple medications and the apies that
dictate the need o a multiple-lumen cathete . An alte native
method o placing a multiple-lumen cathete is to th ead the
cathete th ough a standa d Desilets-Ho man sheath-int oduce
system.
It is impo tant to conside the depth o inse tion o the
cathete (see Table 22.3). The p ope depth o cathete inse tion
is site specifc (see late ). A te success ul CVC placement, the
cathete should be ancho ed to the skin with sutu es (see Fig.
22.9, step 15). Each po t should be immediately capped and
ushed with a saline solution (see Fig. 22.9, step 14). The
cathete inse tion site should be d essed app op iately and all
sha p implements disposed o in app op iate eceptacles (see
Fig. 22.9, step 16).
Replacement of Existing Catheters
In addition to placing new cathete s, clinicians may use the
guidewi e techni ue to change existing cathete s. Many patients
with CVCs a e se iously ill and will e ui e subse uent monito -
ing o pulmona y a te y wedge p essu e, placement o a
t ansvenous pacemake , o inse tion o a di e ent cathete .
The CVC that is initially inse ted should have a lumen la ge
enough to accept a guidewi e and acilitate conve sion to a
di e ent cathete . Clinicians may use the guidewi e techni ue
to change a single-lumen CVC to a t iple-lumen cathete o
a sheath-int oduce set. Not all comme cially available CVCs
will accept a guidewi e.
replacement o an existing cathete begins with selecting
a guidewi e longe than eithe o the devices to be exchanged.
Use meticulous aseptic techni ue.73 Inse t the guidewi e into
the existing CVC until a ew centimete s o wi e p ot udes
om the p oximal end. With one hand holding the wi e secu ely,
emove the cathete and wi e as a single unit until the tip o
the cathete just clea s the patient’s skin. G asp the wi e at
 CHAPTEr 22 Cent al Venous Cathete ization and Cent al Venous P essu e Monito ing 419

I ns er t io n o f t h e S h ea th I nt r od u c er

1 2

Dilator
One-way
valve

Sheath
introducer

The sheath introducer and dilator must be assembled prior to Open the one-way valve (if so equipped), and fully insert the
insertion. Some sheaths have a one-way valve that must be dilator into the sheath.
opened (by rotating the valve) before insertion of the dilator.

3 4
Grasp the guidewire Remove the dilator
as it protrudes from and wire as a unit
the sheath-dilator
assembly
Advance the dilator and
sheath as a unit

Advance the dilator and sheath as a unit over the wire. It is After full insertion of the sheath, remove the dilator and guidewire
essential to grasp the guidewire as it protrudes from the dilator simultaneously, and close the one-way valve (if so equipped).
prior to advancing the catheter.

Figure 22.12 Inse tion o the sheath int oduce . Inse tion o a sheath int oduce va ies slightly om
that o a t iple-lumen cathete —the dilato and the cathete a e inse ted simultaneously as depicted.
The emainde o the steps a e analogous to those in Fig. 22.9. Once inse ted, sheath int oduce s
acilitate the placement o devices such as pulmona y a te y cathete s and t ansvenous pacemake s.

the point whe e it exits the skin and only then elease the wi e
at the othe end. Then slide the cathete o the wi e and
inse t the new device in the no mal ashion. Exe cise caution
with this techni ue because cathete embolization can occu ,
especially i a cathete is cut to allow use o a sho te guidewi e
o the exchange. In patients without evidence o line sepsis,
exchanging the guidewi e does not inc ease the incidence o
CAI i pe o med p ope ly.73
Over-the-Needle Technique
An optional method o cannulation is to place an ove -the-
needle cathete pe cutaneously. Ove -the-needle devices (such
as the Angiocath [Becton Dickinson, F anklin Lakes, NJ]) use
a tape ed plastic cathete that passes th ough the vessel wall
into the lumen, with the tip o the needle being used as a
guide. The e a e advantages with this system. The cathete
does not pass th ough a sha p needle and the e is less isk o
shea ing and esultant cathete embolization. Additionally, the
hole made by the needle in the vessel wall is smalle than the
cathete , thus p oducing a tighte seal. The IJ vein and SV via
the sup aclavicula app oach a e the most popula and app op i-
ate app oaches o this techni ue. These devices may be use ul
when apid cent al venous access is e ui ed (e.g., in ca diac
a est). These cathete s a e not suitable o high-volume uid
esuscitation and they a e too small o passage o a pacemake
lead. Once the clinical situation stabilizes, exchange this device
o a la ge cent al cathete via the Seldinge techni ue.
P epa e the skin with chlo hexidine solution. Use a longe
pe iphe al-type cathete (such as a 16-gauge, 5 1/4-inch
angiocathete ) in an adult. Smalle -diamete devices, such as
20-gauge cathete s, may be easie to pass but p ovide slowe
in usion ates. Attach the needle to a sy inge and slowly advance
it into the vein with steady negative p essu e applied to the
sy inge. This may be di fcult because o the longe length o
the needle elative to the cathete . When using bedside
ult asound, ollow the t ajecto y o the needle into the so t
tissues and visualize penet ation o the vessel. With ove -the-
needle cathete s, the needle extends a ew millimete s past the
tip o the cathete . retu n o blood will be obtained when the
tip o the needle is in the vein, although the cathete may
actually be outside the lumen. I the needle is withd awn be o e
the cathete is advanced, the tip o the cathete will emain
outside the vein. It is the e o e impo tant to advance the needle
a ew millimete s a te the venous ash is seen and then hold
it steadily while advancing the cathete into the vein. Secu e
the cathete and ve i y its placement as detailed late in this
chapte .

booksmedicos.org
420 SECTION IV VASCULAr TECHNIqUES AND VOLUME SUPPOrT
SITE SELECTION
Subclavian Approaches
Subclavian venipunctu e is the most e uently used means o
achieving cent al venous access. The in aclavicula SV app oach
was the f st popula means o cent al venous access and has
been used widely o nea ly hal a centu y. It is use ul in
many clinical situations and elatively easy to lea n. It is o ten
the best app oach in t auma because a ce vical colla can
inte e e with the IJ techni ue. The sup aclavicula SV app oach
may be p e e able du ing CPr because it minimizes physical
inte e ence in chest comp essions and ai way management.
In addition, the sup aclavicula SV techni ue has been pe -
o med in the sitting position in patients with seve e o thopnea.
The subclavian oute is associated with the lowest incidence
o cathete - elated in ections and deep vein th ombosis, but
is associated with the highest isk o pneumotho ax. Finally,
the le t SV p ovides a mo e di ect oute to the SVC and
is the p e e ed site o pacemake placement and CVP
monito ing.
IJ Approach
The IJ vein p ovides an excellent site o placement o a CVC.
Howeve , the e is a 5% to 10% isk o complications, with
se ious complications occu ing in app oximately 1% o
patients.49 Failu e ates have been ound to be 19.4% o
landma k-placed IJ cathete ization by a junio p actitione
and 5% to 10% by a clinician with extensive expe ience.80
Despite its potential complications, the IJ vein is in many cases
p e e ed ove othe options o cent al venous access. In
cont ast to the SV, a te ial punctu es a e easie to cont ol
because di ect p essu e can be used, and the incidence o
pneumotho ax is lowe . Hematoma o mation is easie to
diagnose because o the close p oximity o the IJ vein to the
skin. In addition, the ight IJ vein p ovides a st aight anatomic
path to the SVC and ight at ium. This is advantageous o
passage o cathete s o inte nal pacemake wi es to the hea t.
Disadvantages o IJ vein cannulation ove othe sites include
a elatively high ca otid a te y punctu e ate and poo landma ks
in obese o edematous patients.43,49
The IJ techni ue is use ul o outine cent al venous access
and o eme gency venous access du ing CPr because the site
is emoved om the a ea o chest comp essions. The di e ences
in mo bidity between the SV and the IJ vein app oaches have
p obably been ove stated.20,70,81,82 Cathete malposition is mo e
e uent in the SV, but the isk o in ection is p obably slightly
highe with IJ sites.20,22,45,68 The ate o a te ial punctu e is
highe with IJ vein attempts, but the SV is not a comp essible
site.20,45 Though counte intuitive, the evidence available does
not suppo t a signifcant di e ence in the ate o pneumotho ax
and hemotho ax.20,45 Although the e may be a slight di e ence
in complications between the two outes, in the absence o
specifc cont aindications clinicians should use the techni ue
with which they a e most amilia . The apid development o
eal-time ult asound guidance may tip the scales towa d the
IJ vein as the p e e ed site.14,50–52,83,84
Femoral Approach
Cannulation o the emo al vein o cent al venous access
has become inc easingly popula , especially o venous access,
booksmedicos.org
in usion po ts, passage o t ansvenous pacemake s, and place-
ment o p essu e measu ement cathete s in c itically ill
patients.84 The elatively simple and supe fcial anatomy
su ounding the emo al vein a o ds a apid app oach to the
cent al venous system and avoids many o the mo e signifcant
complications associated with cannulation o the IJ vein and
the SV. These benefts a e tempe ed somewhat by seve al
long-te m disadvantages, including highe in ection ates and
an inc eased isk o venous th ombosis. Othe indications o
ED emo al cannulation include eme gency ca diopulmona y
bypass o esuscitation pu poses, cha coal hemope usion o
seve e d ug ove doses, and dialysis access. The emo al a ea
is less congested with monito ing and ai way e uipment
than the head and neck a ea, and conscious patients who a e
still bed idden may tu n thei head and use thei a ms mo e
eely without moving the cent al line. The emo al site is
cont aindicated in ambulato y patients who e ui e cent al
access.
SPECIFIC VESSEL ACCESS TECHNIQUES
I SV o IJ vein app oaches a e planned, p epa e the skin in
the a ea, including punctu e sites o both the in aclavicula
and sup aclavicula SV and IJ vein app oaches. This pe mits
the clinician to change the site a te an unsuccess ul attempt
without epeating the p epa ation o having to obtain an inte val
chest adiog aph. P epa e the a ea, including the ipsilate al
ante io aspect o the neck, the sup aclavicula ossa, and the
ante io chest wall 3 to 5 cm past the midline and the same
distance above the nipple line. P epa e o emo al access by
t imming g oin hai s and applying chlo hexidine to cove an
a ea the b eadth o and extending 10 cm above and below the
inguinal ligament.
Each app oach to cent al venous cannulation is desc ibed
sepa ately in the ollowing sections. As with any invasive
p ocedu e, b ie y desc ibe the p ocedu e to awake patients,
and estate each step as it is about to be pe o med. A te
desc iptions o the common app oaches to the cent al veins,
punctu e site ca e, ve ifcation o placement, and othe adjuncts
to the p ocedu e a e summa ized.
Infraclavicular Subclavian Approach
Desc iptions o subclavian venipunctu e o ten ocus unduly
on angles and landma ks. Indeed, ecent studies have demon-
st ated that some t aditional positioning maneuve s may actually
hinde success ul cannulation e o ts.
Positioning
Place the patient supine on the st etche with the head in a
neut al position and the a m adducted at the side. Some autho s
have advocated va ious shoulde -, back-, head-, and a m-
positioning maneuve s, but they take ext a time and the help
o an assistant and a e o ten not help ul.85–95
We believe that the best position o almost all in aclavicula
SV attempts is the neut al shoulde position with the a m
adducted.85–96 Tu ning the head away may be help ul but is
ce tainly not e ui ed i ce vical inju ies a e suspected.86,88,93
Inte estingly, Jung and colleagues ound that in child en, tilting
the head towa d the cathete ization site imp oved cathete
malposition ates.97 This techni ue has not been studied in
adults.
 CHAPTEr 22 Cent al Venous Cathete ization and Cent al Venous P essu e Monito ing
In di fcult cases, placing a small towel oll unde the
ipsilate al shoulde 93 o having an assistant place caudal t action
o app oximately 5 cm on the ext emity may also be help ul.96
Placing the patient in a mode ate T endelenbu g position (10
to 20 deg ees) dec eases the isk o ai embolism.88,98 The
claim that this position distends the vein is cont ove sial, but
it may do so to a small avo able deg ee.86,88,90 I the T en-
delenbu g position is imp actical, the SV app oach is p obably
less a ected than the IJ vein app oach when eso ting to a
neut al o even an up ight position.86,88,90
Placing a pillow unde the back is commonly ecommended
to make the clavicle mo e p ominent, but as the shoulde alls
backwa d, the space between the clavicle and the f st ib
na ows, thus making the SV less accessible.95 Signifcant
comp ession o the subclavian vessels between these bony
st uctu es occu s as the shoulde s et act, which can cause a
“pinch o ” o the cathete as it slides th ough the SV between
the clavicle and the f st ib.95,99
Venipuncture Site
The ight SV is usually selected f st because o the lowe
pleu al dome on the ight and the need to avoid the le t-sided
tho acic duct. The mo e di ect oute between the le t SV and
the SVC is a theo etical advantage o le t-sided subclavian
venipunctu e; howeve , the e is no highe incidence o cathete
malposition when the ight in aclavicula SV app oach is used.
In conscious patients, anesthetize the point o needle ent y
with 1% lidocaine. I possible, inflt ate the pe iosteum o the
clavicle, ound by touching the bone with the needle, to make
the p ocedu e less pain ul. Opinions va y ega ding the best
point o needle ent y, mo e so than o the IJ o emo al
app oaches. With nonobese patients, look o the deltopecto al
t iangle, which is bounded by the clavicle supe io ly, the
pecto alis majo medially, and the deltoid muscle late ally.91,100
The junction o the middle and medial thi ds o the clavicle
lies just medial to this t iangle. Fu the medially, the vein lies
just poste io to the clavicle and above the f st ib, which acts
as a ba ie to penet ation o the pleu a. This p otective e ect
is theo etically diminished when a mo e late al location is
chosen. Howeve , when app oaching the vein mo e medially,
some clinicians have di fculty punctu ing the SV, dilating the
tissues, and passing the J-wi e. Othe ecommended sites o
app oach include late al and in e io to the junction o the
clavicle and the f st ib, with the needle aimed at this junction,
and ent y at the site o a small tube cle in the medial aspect
o the deltopecto al g oove. We ecommend punctu ing the
skin at the late al po tion o the deltopecto al t iangle via a
shallow angle o attack.91
Needle Orientation
O ient the bevel o the needle in e omedially to di ect the
wi e towa d the innominate vein athe than towa d the opposite
vessel wall o up into the IJ vein. Align the bevel o the needle
with the ma kings on the ba el o the sy inge to pe mit
awa eness o bevel o ientation a te skin punctu e.
Be o e inse ting the needle, place you le t index fnge in
the sup aste nal notch and you thumb at the costoclavicula
junction (Fig. 22.13). These landma ks se ve as e e ence points
o the di ection that the needle should t avel. Aim the needle
immediately above and poste io to you index fnge . Watch
o vessel ent y, signaled by ashback o da k venous blood,
which usually occu s at a depth o 3 to 4 cm. I the tip o the
needle is t uly int aluminal, the e will be ee- owing blood.
booksmedicos.org
421
Figure 22.13 In aclavicula subclavian app oach. Place you index
fnge in the sup aste nal notch and you thumb at the costoclavicula
junction; these landma ks will se ve as e e ence points o the
di ection that the needle should t avel. O ient the bevel o the needle
in e omedially and aim the needle above and poste io to you index
fnge . Note: to avoid punctu ing the lung o the subclavian a te y,
once the needle tip is unde the clavicle keep the needle pa allel to
the clavicle, NOT di ected poste io ly.
retu n o pulsatile ow signifes a te ial punctu e and the
needle should be withd awn immediately. A single a te ial
punctu e without lace ation a ely causes se ious ha m. Using
this techni ue eliminates the need to measu e angles, to “walk”
the clavicle, o to concent ate excessively on maintaining the
needle pa allel to the chest wall. Avoid using sweeping motions
o the tip o the needle to p event unseen inju ies.
Unsuccessful Attempts
Cannulation o the SV may not succeed on the f st attempt.
It is easonable to t y again, but a te th ee o ou unsuccess ul
attempts it is wise to move to a di e ent anatomic app oach
o to allow a colleague to attempt the p ocedu e. Use a new
setup each time that blood is obtained because clots and tissue
will clog the needle and mislead the clinician even i the vein
has been ente ed success ully on subse uent attempts. I seve al
attempts a e made, in o m the admitting clinician o anesthe-
siologist so that p ope p ecautions a e taken to identi y
subse uent complications. It is advisable to obtain adiog aphs
o the chest even a te unsuccess ul attempts. I the initial
punctu e site was placed p ope ly, use the same needle hole
o subse uent attempts i possible o aesthetic easons. I the
SV oute is unsuccess ul on one side, attempt IJ vein cathete iza-
tion on the same side athe than SV cannulation on the opposite
side to avoid bilate al complications.
Supraclavicular Subclavian Approach
Positioning
The goal o the sup aclavicula SV techni ue is to punctu e
the SV in its supe io aspect as it joins the IJ vein. Inse t the
needle above and behind the clavicle, late al to the clavicula
head o the SCM muscle. Advance it in an avascula plane
while di ecting it away om the subclavian a te y and the
dome o the pleu a (Fig. 22.14). The ight side is p e e ed
422 SECTION IV VASCULAr TECHNIqUES AND VOLUME SUPPOrT
IJ SV
SCM
ASM SA
A Subclavian Ultrasound Technique
SCM
(sternal head)
Clavicle
SCM
(clavicular head)
B is a the om the chest wall and pleu al su ace, thus dec easing
Figure 22.14 Sup aclavicula subclavian app oach. A, Anatomy.
As the subclavian vein passes ove the f st ib, it is sepa ated om
the subclavian a te y by the ante io scalene muscle. The dome o
the pleu a is poste olate al to the con uence o the g eat veins.
B, App oach. Inse t the needle 1 cm poste io to the clavicle and 1 cm
late al to the clavicula head o the ste nocleidomastoid muscle such
that the angle made by the clavicle and late al bo de o the muscle
is bisected. The needle t ave ses an avascula plane and punctu es
the junction o the subclavian and inte nal jugula veins behind the
ste noclavicula joint. The ight side is p e e ed because o a di ect
oute to the supe io vena cava and absence o the tho acic duct.
The needle is di ected 45 deg ees om the sagittal plane and 10 to
15 deg ees upwa d om the ho izontal plane and aimed towa d the
cont alate al nipple. Note that the vein is just poste io to the clavicle
at this junctu e. Arrow, Needle ta get; ASM, ante io scalene muscle;
IJ, inte nal jugula ; SA, subclavian a te y; SCM, ste nocleidomastoid
muscle; SV, subclavian vein.
because o the lowe pleu al dome, its mo e di ect oute to
the SVC, and location o the tho acic duct on the le t side.
The patient’s head may be tu ned to the opposite side to help
identi y the landma ks.
Needle Orientation
A te the a ea o the sup aclavicula ossa has been p epa ed
and d aped, identi y a point 1 cm late al to the clavicula head
o the SCM and 1 cm poste io to the clavicle. Alte natively,
use the junction o the middle and medial thi ds o the clavicle
as the landma k o needle ent y. Anesthetize the a ea with
1% lidocaine. I a 3-cm-long needle is used o anesthesia, it
may also be used to locate the vessel in a elatively at aumatic
booksmedicos.org
manne . The SV can almost always be located with this needle
because o its supe fcial location and the absence o bony
st uctu es in the path o the needle. Advance a 14-gauge
needle (o 18-gauge thin-walled needle) along the path o the
scout needle. Apply gentle negative p essu e with an attached
sy inge.
When seeking the SV, aim the needle so that it bisects the
clavicoste nomastoid angle and the tip points just caudal to
the cont alate al nipple. O ient the bevel medially to p event
the cathete om getting t apped against the in e io vessel
wall. Point the tip o the needle 10 deg ees above the ho izontal.
Success ul vessel punctu e gene ally occu s at a depth o
2 to 3 cm.
Typically, punctu e o the SV occu s at the point whe e the
vein is cou sing deep to the clavicle. Howeve , with ult asound,
visualization o the SV can be di fcult at this location because
o inte e ence with the ove lying bone. Fo tunately, mo e
distally the vein lies a the away om the clavicle and chest
wall. Hence, access to the SV typically occu s late al to the
cu ve o the clavicle bone, in the p oximal axilla y vein. As
the vein moves late ally, the mean depth om the skin inc eases
om 1.9 to 3.1 cm, whe eas the distance om the ib cage to
the vein inc eases om 1 to 2 cm. The a te iovenous distance
also inc eases om 0.3 to 0.8 cm and the e is less ove lap o
the a te y and vein.101 Because the vein is not in close p oximity
to the clavicle, i a hematoma develops, manual p essu e can
be used to stop the bleeding. Fu the mo e, the axilla y vein
the possibility o pleu al inju y and subse uent pneumotho ax.
In clinical studies, ult asound-guided axilla y vein access
had a f st–needle pass success ate o 76% with success ul
placement in 96% o cases. Despite the use o ult asound,
howeve , the cathete malposition ate was unchanged at
app oximately 15%.102
IJ Approach
Positioning
Position is c itical o maximizing the success o blind (landma k
techni ue) cannulation o the IJ vein. Place the patient in a
supine position with the head down and tu ned app oximately
15 to 30 deg ees away om the IJ vein to be cannulated. rotate
the head slightly away om the site o inse tion. rotating the
head mo e than 40 deg ees has been shown to inc ease the
isk o ove lapping the ca otid a te y ove the IJ vein.19
Occasionally, placing a towel oll unde the scapula helps extend
the neck and accentuate the landma ks. Stand at the head o
the bed with all e uipment within easy each. This may involve
moving the bed to the cente o the oom to allow a table o
wo k su ace to be placed at the head o the bed.
Ask the patient to pe o m a Valsalva maneuve just be o e
inse ting the needle to inc ease the diamete o the IJ vein.
Alte natively, the patient can be asked to hum. T endelenbu g
positioning, the Valsalva maneuve , and humming all inc ease
the a ea o the vessel by app oximately 30% to 40%.103 I the
patient is unable to coope ate, coo dinate the inse tion with
espi ation because the IJ vein is at its la gest diamete just
be o e inspi ation. In intubated patients this elationship is
eve sed because mechanical ventilation inc eases int atho acic
p essu e at end-inspi ation. Exte nal abdominal comp ession
also helps distend the IJ vein.
 CHAPTEr 22 Cent al Venous Cathete ization and Cent al Venous P essu e Monito ing 423

Anterior Approach
Insert needle along the medial edge of the
sternocleidomastoid, 2-3 fingerbreadths above
the clavicle.

Entry angle = 30° to 45°.

Aim toward the ipsilateral nipple.

Note: palpate the carotid artery during venipuncture.

The artery may be slightly retracted medially.

Central Approach
Insert needle at the apex of the triangle formed by
the heads of the sternocleidomastoid muscle and
the clavicle.

Entry angle = 30°.

Aim toward the ipsilateral nipple.

Note: estimate the course of the IJ vein by placing

three fingers lightly over the carotid artery as it runs
parallel to the vein. The vein lies just lateral to the
artery, albeit often minimally so.

Posterior Approach
Insert needle at the posterior (lateral) edge of the
sternocleidomastoid, midway between the mastoid
process and the clavicle.

Entry angle = 45°.

Aim toward the suprasternal notch.

Note: avoid the external jugular vein, which crosses

the posterior SCM border. During needle
advancement, apply pressure to the SCM to lift the
body of the muscle. The vein is usually reached at a
depth of 7 cm.

Figure 22.15 App oaches to the inte nal jugula vein. IJ, Inte nal jugula ; SCM, ste nocleidomastoid.

Venipuncture Site
The ight IJ vein p ovides a mo e di ect oute to the ight
at ium o t ansvenous pacing. The le t IJ vein is o ten mo e
to tuous and cathete s must negotiate two 90-deg ee tu ns at
the junction o the le t IJ vein with the SV and at the junction
o the SV with the SVC. Howeve , i the ight IJ vein is
obst ucted o sca ed by p evious access, the le t IJ vein may
be accessed with the same techni ue. O note, the ight IJ
vein has been obse ved to be twice the size o the le t IJ vein
in 34% o no mal adults.104
Aspi ate be o e injecting anesthetic so that it is not injected
into the ca otid a te y o IJ vein. Once inflt ation is completed,
use the needle to locate the IJ vein by aspi ating blood into
the sy inge. Note the depth and angle o needle ent y and use
this as a mental guide to fnding the IJ vein with the int oduce
needle. Typically, an 18-gauge 2.5-cm int oduce needle attached
to a sy inge is used initially to punctu e the IJ vein. Howeve ,
needle selection may va y depending on the cent al line kit
used. The ope ato may choose om th ee app oaches: cent al,
poste io , and ante io (Fig. 22.15).
Central Route
This app oach is avo ed by some who believe that the incidence
o cannulation o the ca otid a te y is dec eased and the cupula
o the lung is avoided.104 Fi st, palpate and identi y the t iangle
o med by the clavicle and the ste nal and clavicula heads o
the SCM. Use a ma king pen o a local anesthetic skin wheal
to ma k the late al bo de o the ca otid pulse, and pe o m
all subse uent needle punctu es late al to this point.
When using the scout needle techni ue, attach a 22-gauge,
3-cm needle to a 5- to 10-mL sy inge. Inse t the needle nea
the apex o the t iangle and di ect it caudally at an angle o
30 to 40 deg ees to the skin. Di ect the needle initially pa allel
and slightly late al to the cou se o the ca otid a te y. Estimate

booksmedicos.org
424 SECTION IV VASCULAr TECHNIqUES AND VOLUME SUPPOrT
the cou se o the IJ vein by placing th ee fnge s lightly ove
the cou se o the ca otid a te y as it uns pa allel to the vein,
using the fnge s as a guide o needle placement. The vein
consistently lies just late al to the ca otid a te y, albeit o ten
minimally so. P olonged deep palpation o the ca otid a te y
may dec ease the size o the vein, so use the th ee-fnge
techni ue lightly to identi y the cou se o the a te y.
Posterior and Anterior Routes
In the poste io app oach, make the punctu e at the poste io
(late al) edge o the SCM, app oximately midway between its
o igin at the mastoid p ocess and its inse tion at the clavicle.
The exte nal jugula vein cou ses in this a ea and can be used
as a landma k, with the punctu e occu ing whe e the exte nal
jugula vein c osses the poste olate al bo de o the SCM. Be
ca e ul to not st ike the exte nal jugula vein. Advance the
needle towa d the sup aste nal notch, just unde the belly o
the SCM, at an angle o app oximately 45 deg ees to the
t ansve se plane. Du ing advancement o the needle, apply
p essu e to the SCM in an e o t to li t the body o the muscle.
The vein is usually eached at a depth o 7 cm in an ave age-
sized adult. Because the poste io app oach occu s highe in
the neck, the e is less isk o hemotho ax, pneumotho ax, o
ca otid punctu e.105 The benefts o the poste io app oach
a e mo e d amatic in obese patients, with ca otid punctu e
occu ing in 3% o patients ve sus up to 17% with the ante io
app oach. 106
In the ante io app oach, needle punctu e occu s along the
ante io o medial edge o the SCM app oximately two to
th ee fnge b eadths above the clavicle. Inse t the needle at
an angle o 30 to 45 deg ees towa d the ipsilate al nipple, away
om the ca otid pulse. I cannulation is unsuccess ul, withd aw
the needle to the skin and edi ect it slightly towa d the ca otid
a te y.
Once the app oach is chosen, slowly advance the needle
towa d the IJ vein. C eate gentle negative p essu e with the
sy inge while advancing the needle. Once blood is seen, stop
advancing the sy inge. remove the sy inge om the needle
to dete mine whethe the vessel is pulsatile. Be ca e ul not to
allow negative int apleu al p essu e to d aw ai into the venous
system th ough the open needle. Because the tip o the
int oduce needle is beveled, late al motions o the needle tip
may cause lace ations o the deep st uctu es o the neck. It is
the e o e ve y impo tant to emove the needle om the neck
completely be o e any edi ection o the needle.
Once cannulation o the IJ vein has been conf med, emove
the sy inge om the needle and place a gloved digit ove the
needle hub to p event ai embolism. Inse t a guidewi e th ough
the needle into the IJ vein and place the cathete using the
Seldinge techni ue. Once the wi e is inse ted into the IJ vein,
educe the angle to the skin to make the needle nea ly pa allel
to the vein. This allows a g eate chance o di ecting the wi e
towa d the hea t. Do not let the guidewi e extend into the
ight at ium. The ave age distance om the inse tion site to
the junction o the SVC and ight at ium is 16 ± 2 cm o the
ight IJ vein and 19 ± 2 cm o the le t IJ vein. The sp ing
wi es supplied in kits a e o ten much longe , up to 60 cm in
length. I the ull length o the wi e is inse ted, the wi e could
ente the ight at ium o vent icle and cause myoca dial i itabil-
ity and subse uent dys hythmias. Monito ca diac hythm
du ing inse tion o the sp ing wi e to detect ca diac i itability.
The distance that the cathete is int oduced depends on the
distance om the site o int oduction to the junction o the
booksmedicos.org
SVC and ight at ium. This distance will be sho te with
the ight IJ vein than with the le t IJ vein.
IJ Ultrasound Technique
Cannulation o the IJ vein is an optimal location o the use
o ult asound guidance. Whe eas the landma k app oach is
associated with a complication ate o between 5% and 10%
i espective o the techni ue used o expe ience o the ope ato ,
with the use o ult asound, the complication ate is signifcantly
educed.104 Even with novice use s o ult asound o IJ vein
cannulation, f st-attempt success is signifcantly inc eased when
compa ed to the blind landma k techni ue (43% ve sus 26%).107
With expe ience, howeve , the f st-attempt success ate
imp oves to mo e than 75%.16,17,108 Use o ult asound o
placement o cent al lines in the IJ vein has also been shown
to dec ease ove all cathete placement ailu es by 64%, educe
complications by 78%, and dec ease the need o multiple
cathete placement attempts by 40% in compa ison to the
standa d landma k placement techni ue.109,110 The p ima y
eason o the inc eased success ate is the va iation in anatomy
o the IJ vein elative to the ca otid a te y. The anatomy o
the IJ vein has been shown to be abe ant in 9% to 19% o
cases.104,107,110 Fu the mo e, the IJ vein may be unusually small
(i.e., <0.5 cm) in up to 14% o patients. The IJ vein is th om-
bosed in up to 2.5% o some patient populations.107
With the use o ult asound the e is no need o eliance
on no mal anatomy o cannulation. The e o e the IJ vein
may be cannulated despite abno mal anatomy. Hence, can-
nulation may occu at the apex o the t iangle, nea the base
at the junction with the innominate vein, o anywhe e in
between.
Femoral Approach
Positioning and Needle Orientation
Place the patient in the supine position o the emo al vein
app oach. This app oach does not e ui e any special position-
ing o tilting o the bed. Fully expose and tho oughly cleanse
the a ea with a soapy washcloth o su gical sc ub b ush to
emove obvious soiling, which may be mo e common at this
site. Next, p epa e the skin at the site b oadly with chlo hexi-
dine, including the ante io supe io iliac spine late ally and
supe io ly, extending to the midline, and continuing 10 to
15 cm below the inguinal ligament. Tape a u eth al cathete
to the cont alate al leg. In an obese patient, have an assistant
et act the abdominal pannus manually o secu e it with
wide tape.
A te the instillation o local anesthetic, int oduce the needle
at a 45-deg ee angle in a cephalic di ection app oximately
1 cm medial to this point and towa d the umbilicus (Fig. 22.16).
Palpate the emo al pulse two fnge b eadths beneath the
inguinal ligament. Note that while palpating the a te y, p essu e
om the ope ato ’s fnge s can comp ess the adjacent vein and
impede cannulation. Avoid this anatomic disto tion by eleasing
digital p essu e while keeping the fnge s on the skin to se ve
as a visual e e ence to the unde lying anatomy. The depth o
the needle e ui ed to each the vein va ies with body habitus,
but in thin adults, the vein is uite supe fcial and is usually
eached at a depth o app oximately 2 to 3 cm, so advance the
needle slowly. retu n o da k, nonpulsatile blood signals suc-
cess ul venous penet ation.
Although using the emo al a te ial pulse as a guide is ideal,
it may not be palpable in an obese o hypotensive patient. A
 CHAPTEr 22 Cent al Venous Cathete ization and Cent al Venous P essu e Monito ing
Inguinal
ligament
Figure 22.16 Femo al app oach. Palpate the emo al a te y two
fnge b eadths beneath the inguinal ligament. Keep the fnge s on
the a te y to aid the emo al vein cannulation and to avoid the emo al
a te y. Int oduce the needle at a 45-deg ee angle in a cephalic di ection
1 cm medial to this point and towa d the umbilicus. Impo tantly,
mo e distally the vein lies ove the a te y, so place the cathete nea
the inguinal ligament, o use ult asound guidance.
mo e detailed unde standing o the emo al landma ks can be
used to guide cannulation attempts. On all but the most seve ely
inju ed t auma patients with a dis upted pelvis (in which case
a emo al app oach would be cont aindicated), the ante io
supe io iliac spine and the midpoint o the pubic symphysis
a e easily palpated. The line between these two bony e e ences
desc ibes the inguinal ligament. When this line is divided into
thi ds, the emo al a te y should unde lie the junction o the
medial and middle thi ds. The emo al vein will lie app oxi-
mately one fnge b eadth medial to this point. Alte natively,
the vascula anatomy o the egion can be evaluated and the
line placed via ult asound guidance.
Venipuncture
Du ing advancement o the needle, maintain gentle negative
p essu e on the sy inge at all times while the needle is unde
the skin. Di ect the needle poste io ly and advance it until the
vein is ente ed, as identifed by a ash o da k, nonpulsatile
blood. I the vessel is penet ated when the sy inge is not being
aspi ated, the ash o blood may be seen only as the needle
is being withd awn. The emo al vein lies just medial to the
emo al a te y at the level o the inguinal ligament. It is close
to the a te y than many clinicians app eciate. As the vein
p og esses distally in the leg, it uns close to and almost
behind the emo al a te y.
Femoral Ultrasound Technique
Cannulation o the emo al vein unde ult asound guidance
is ve y simila to that o the IJ vein. Using ult asound, the
common emo al vein, its junction with the saphenous
vein, and the b anches o the common emo al vein (i.e., the
booksmedicos.org
425
supe fcial and deep emo al veins) a e easily identifed. Typi-
cally, placement o the cathete should occu p oximal to the
bi u cation o the common emo al vein and p e e ably p oximal
to the junction with the saphenous vein.
ANCHORING THE CENTRAL LINE
A te the CVC is placed, it will need to be ancho ed in place
by one o th ee techni ues: StatLock (Ba d Medical, Covington,
GA), sutu e, o staple (Fig. 22.17). The StatLock may not
hold well in patients with oily skin but is excellent o olde
patients with thin skin. Fo sutu ing, one will need the ste ile,
nonabso bable sutu e mate ial (usually 2-0 silk) p ovided in
the CVC kit. The st aight sutu e needles ound in many sets
a e awkwa d o many clinicians, so a cu ved needle with a
d ive may be help ul. To avoid a needlestick with the st aight
needle, pass the blunt end o the needle th ough the ancho ing
devices and pull the sutu e o wa d manually. Place the sutu e
in the skin app oximately a hal centimete om the cathete
to ancho the cent al line in place. Seve al knots should be
made to secu e the line. Avoid making knots that place excessive
p essu e on the skin because this can lead to di fculty emoving
the knots and nec osis. Loose knots can lead to mig ation o
the cathete and loss o access. Stapling a cent al line into
place can be just as e ective as sutu ing; howeve , the staples
tend to all out a te a ew days.
Dressing
Clean the a ea a ound the cathete inse tion site with chlo hexi-
dine, and then use a clea d essing (such as Tegade m [3M,
St. Paul, MN]) to cove up the inse tion site o the cathete
once secu ed (see Fig. 22.9, step 16). Apply a chlo hexidine
patch (Biopatch [Ethicon, Some ville, NJ]) at the site whe e
the cathete ente s the skin (see Fig. 22.17E and F). Because
d essings a e inspected and changed pe iodically, place a simple
d essing and avoid excessive amounts o gauze and tape. Take
ca e to p otect the skin against mace ation.
Assessing Line Placement
Check all tubing and connections o tightness to p event ai
embolism, loss o uid, o bleeding. Be o e in using IV uids,
lowe the IV uid ese voi to below the level o the patient’s
ight at ium and check the line o back ow o blood. F ee
back ow o blood is suggestive but not diagnostic o int avas-
cula placement. Back ow could occu om a hematoma o
hemotho ax i the cathete is ee in the pleu al space. A pulsatile
blood column may be noted i the cathete has been inadve -
tently placed in an a te y. Less p onounced pulsations might
also occu i the cathete is advanced too a and eaches the
ight at ium o vent icle. In addition, pulsations may be noted
with changes in int atho acic p essu e as a esult o espi ations,
although these pulsations should occu at a much slowe ate
than the a te ial pulse. A fnal method o checking int avascula
placement is to attach a sy inge di ectly to the cathete hub
and aspi ate venous blood. It is also advisable to ensu e that
the cathete is easily ushed with a saline solution. This ca ies
the additional beneft o emoving ai om the system.
radiog aphs a e also always indicated to ve i y cathete location
and assess o potential complications, except a te outine
emo al line placements. In an awake patient, in using uids
426 SECTION IV VASCULAr TECHNIqUES AND VOLUME SUPPOrT

ULTRASOUND BOX 22.1: Central Venous Catheterization by Christine Butts, MD

IJ Vein Femoral Vein

When evaluating the internal jugular (IJ) vein, the transducer (7.5 to The emoral artery and vein lie together with the emoral nerve within
20 MHz) should be initially placed over the right or le t side o the a common sheath. They can be ound at the level o the inguinal
neck to evaluate the anatomy. An ideal initial location to begin is at crease on the medial aspect o the thigh. Palpating the emoral pulse
the apex o the triangle ormed by the two heads o the subclavian will also aid in localizing the vascular bundle. The transducer (7.5 to
muscle (Fig. 22.US1). Placing the transducer over this area in the 10 MHz) should be placed in a transverse or slightly oblique
transverse orientation will enable the vessels to be located in cross orientation overlying this area. Slightly rotating the thigh externally may
section, where they can best be evaluated. The internal carotid artery acilitate this step. Classically, the artery is described to lie lateral to the
and IJ vein will be seen as paired structures with anechoic central vein. However, this is o ten not the case and multiple variations may
areas (Fig. 22.US2). The position o one relative to the other can be be noted. The emoral artery and vein will appear as rounded
variable, but typically the IJ vein lies lateral and super cial to the anechoic structures (Fig. 22.US3). The emoral vein can be recognized
carotid artery. Several characteristics o the IJ vein serve to distinguish
it rom the carotid artery. The IJ vein is typically more oval in shape
(versus the rounded shape o the carotid artery), is thinner walled,
and will compress with gentle pressure. Additionally, the size o the IJ
vein will change with respiration and should be seen to increase in
size with a Valsalva maneuver.
Complications can be reduced by several methods. First, ensure
that the target vessel is indeed the vein and not the artery. Variant IJ
anatomy or variations in volume status (either depletion or overload)
may make the vessels di cult to distinguish rom one another. CA
Con rmation should be attempted by noting multiple characteristics o
the vessel (compressibility, shape, anatomic location, etc.). Once the
vessel has been con rmed as the vein, the operator must take great
care to ensure that the position o the tip o the needle is apparent at
all times. Most complications occur when the tip o the needle is
deeper or more medial than the operator realizes, thus placing it in
proximity to other structures (e.g., lung, carotid artery). An extensive
discussion o each approach can be ound in the basic ultrasound
chapter (see Chapter 66), and each approach has its drawbacks in Figure 22.US2 T ansve se image o the ca otid a te y and inte nal
determining position. In the transverse method, the angle o approach jugula (IJ) vein. The IJ vein can be ecognized by its oval o t iangula
can be di cult to ascertain and cause the tip o the needle to be shape and its thinne walls, and it will collapse with light p essu e.
deeper than the operator realizes. Additionally, the tip o the needle Although both a e ounded and contain anechoic (black) uid, the IJ
vein is slightly la ge and mo e oval in shape. Though not evident
may be di cult to ollow. In the longitudinal approach, the medial to
in this image, slight p essu e will cause collapse o the IJ vein. CA,
lateral orientation o the needle can be di cult to appreciate.
Ca otid a te y.
Additionally, slight movements o the transducer may result in loss o
the appropriate image. A combination o these two, or an oblique
approach, may minimize these di culties.

FA
FV

Figure 22.US3 T ansve se image o the emo al a te y and emo al

vein. Simila to vessels in the neck, the emo al vein is mo e oval
o t iangula in shape. Though not evident in this image, slight
Figure 22.US1 Placement o the ult asound t ansduce at the apex p essu e will cause collapse o the vessel. FA, Femo al a te y; FV,
o the t iangle o med by the heads o the ste nocleidomastoid. emo al vein.

booksmedicos.org
 CHAPTEr 22 Cent al Venous Cathete ization and Cent al Venous P essu e Monito ing 427

ULTRASOUND BOX 22.1: Central Venous Catheterization—cont’d

by its thinner walls and slightly more oval shape, and it will collapse
with gentle pressure. It will also typically increase in size when the
lower part o the leg is squeezed. The vascular bundle may need to
be ollowed in eriorly or superiorly to determine the most optimal
location or puncture.
Complications can be reduced by several methods. First, ensure
that the target vessel is indeed the vein and not the artery. Variant
anatomy or variations in volume status (either depletion or overload)
SV
may make the vessels di cult to distinguish rom one another.
Con rmation should be attempted by noting multiple characteristics o
the vessel (compressibility, shape, anatomic location, etc.). Once the
vessel has been con rmed as the vein, the operator must take great
care to ensure that the position o the tip o the needle is apparent at
all times. The tip o the needle may be di cult to ollow in the
transverse approach and result in an inadvertent puncture o the
posterior wall o the vessel. When the artery lies deep to the vein,
arterial puncture or cannulation may result. In the longitudinal
approach, the medial to lateral position o the needle may be di cult Figure 22.US5 Long-axis view o the subclavian vein. The subclavian
to appreciate and result in accidental arterial puncture. The oblique a te y, not seen in this image, will be seen as a simila -appea ing
approach may minimize these di culties. vessel deep to the vein. Colo ow and Dopple can be used to
distinguish between the two vessels. SV, Subclavian vein.
Subclavian Vein
The subclavian vessels can be imaged rom either a supraclavicular or
an in raclavicular approach. For the supraclavicular approach, the
transducer (7.5 to 10 MHz) is placed along the long axis o the
clavicle on the superior aspect (Fig. 22.US4). It should be angled
downward. In this view, the vessels should be seen in their long axis
(Fig. 22.US5). The vein can be identi ed by its variation with
respiration and change in size with the Valsalva maneuver. The vein
can also be ollowed to identi y the junction with the IJ vein, thereby
o ering urther con rmation. In the in raclavicular approach, the
transducer is placed beneath the clavicle at its most lateral aspect, in a
sagittal or slightly oblique orientation, ollowing the position o the
clavicle (Fig. 22.US6). In this view, the vessels will be seen in cross
section or a slightly oblique plane (Fig. 22.US7). The pleura may also
be seen deep to the vessels as an echogenic vertical line that slides
back and orth with respiration.
Figure 22.US6 Placement o the ult asound t ansduce in e io to
the clavicle to enable visualization o the subclavian vessels in sho t
axis. A sagittal (shown) o slightly obli ue o ientation should be used.

Figure 22.US4 Placement o the ult asound t ansduce supe io

to the clavicle to enable visualization o the subclavian vessels in Figure 22.US7 Sho t-axis view o the subclavian a te y (arrowhead)
the long axis. and vein (arrow) as seen om the in e io aspect o the clavicle.

Continued

booksmedicos.org
428 SECTION IV VASCULAr TECHNIqUES AND VOLUME SUPPOrT

ULTRASOUND BOX 22.1: Central Venous Catheterization—cont’d

A longitudinal approach should be used in which the needle is
introduced rom the end o the transducer in either the in raclavicular
or the supraclavicular approaches. This will enable a shallow angle to
be used and thereby minimize the chance o damaging deeper
structures such as the lung. Once a fash o blood has been obtained,
the ultrasound transducer can be set aside and the procedure
continued as described previously.
The subclavian artery and vein lie in close opposition to the pleura,
so pneumothorax is a more common complication. Using a long-axis
approach (in which the needle is introduced rom the end o the
transducer rather than rom the middle) o ers the advantage o
visualizing the entirety o the needle in its course toward the vein. A
shallow angle can be used, and the relationship o the needle to the
pleura can also be appreciated.

S e c u ri ng a C e n tr al V en ou s C a th e t e r

Rubber clamp Plastic fastener

Suture here
A B
A white rubber clamp is provided to secure the catheter when the The rubber clamp is covered with a blue plastic fastener, and both
full length is not needed. Twist open the pliable clamp and place the clamp and fastener are sutured to the skin to secure the
it over the catheter at a site a few centimeters from the insertion catheter. The hub of the catheter is also sutured to the skin.
site.

Stapler

Tent the skin

here and then
staple

C D
To avoid a needlestick, the blunt end of the needle is used to pass Alternatively, skin staples may be used. Tent the skin and pass the
the suture through the holes of the fastening devices. staples through the anchoring eyes.

E F
This Biopatch is a chlorhexidine-containing hydrophilic covering A simple Tegaderm clear covering is then applied.
placed at the site where the catheter enters the skin to deliver
local antisepsis for 7 days.

Figure 22.17 Methods to secu e a cent al venous t iple-lumen cathete .

booksmedicos.org
 CHAPTEr 22 Cent al Venous Cathete ization and Cent al Venous P essu e Monito ing 429

A B

Figure 22.18 Chest adiog aphs obtained a te placement o : A, ight inte nal jugula cent al venous
cathete , and B, le t subclavian cent al venous cathete . The tips o the cathete s a e app op iately
placed in the supe io vena cava (arrows). The tip should not lie within the ight at ium o the ight
vent icle.

via a cathete tip positioned in the IJ vein may p oduce an

audible gu gling o owing sound in the patient’s ea .111

Radiographs
Following placement o lines involving punctu e o the neck
o tho ax, listen to the lungs to detect any ine uality o lung
sounds suggestive o a pneumotho ax o hemotho ax. Obtain
a chest flm as soon as possible to check o hemotho ax,
pneumotho ax, and the position o the tip o the cathete (Fig.
22.18). Because small amounts o uid o ai may laye out
pa allel to the adiog aphic plate with the patient in the supine
position, take the flm in the up ight o semi-up ight position
wheneve possible. In ill patients, a otated o obli ue p ojection
on a chest adiog aph may be obtained, and the clinician may
be con used about the p ope position o the cathete . In such
cases, epeat the adiog aph. A misplaced cathete tip is usually
obvious on a p ope ly positioned standa d poste oante io chest
Figure 22.19 Chest adiog aph obtained a te le t inte nal jugula
adiog aph (Fig. 22.19), but occasionally, injection o cont ast cathete ization. Note that the cou se o the cathete (small arrows)
mate ial may be e ui ed. Fo example, a cathete in one o does not c oss the midline and that the tip (large arrow) p ojects to
the inte nal tho acic veins may simply appea mo e late al the le t o the midline nea the ao tic a ch. Although the cathete
than expected, but because o the close p oximity o these may have been located int avascula ly in a venous anatomic va iant,
veins and the SVC, malposition may not be app eciated by it was decided to emove this line and eplace it with a new cathete .
this subtle fnding. Misplaced cathete s should be epositioned
o eplaced.
Attention should also be given to the possibility o a etained
guidewi e. Although this complication is a e, i not specifcally Mo e commonly, imp ope location yields inaccu ate measu e-
conside ed it can be ove looked by both clinicians and ments o CVP o is associated with poo ow caused by kinking.
adiologists.112,113 An unusual complication att ibutable to imp ope tip position
A postp ocedu e adiog aph is outine a te initial placement, is ce eb al in a ction, which can occu ollowing inadve tent
but adiog aphs a e not always necessa y o outine eplacement cannulation o the subclavian a te y.
o cathete s ove guidewi es. I such patients a e stable and Misdi ection o inapp op iate positioning o the tip o a
hemodynamically monito ed, adiog aphy may be de e ed CVC, when p omptly ecognized and co ected, is an incon-
sa ely in the absence o appa ent complications o clinical se uential complication. Loop o mation, lodging in small neck
suspicion o malposition.114,115 veins, tips di ected caudally, and innominate vein position a e
common p oblems. reposition misplaced cathete s as soon as
logistically possible. I the cathete is being used o uid
Redirection of Misplaced Catheters esuscitation, the malposition may be tole ated o some time.
Imp ope cathete tip position occu s commonly. It has been I vasop esso s o medications a e in used, p ope positioning
epo ted that only 71% o SV cathete s a e located in the o the tip o the cathete is mo e c itical. A numbe o options
SVC on the initial chest flm. Complications o imp ope a e available to emedy malpositioning. One st ategy is to
positioning include hyd otho ax, hemotho ax, ascites, chest inse t a 2-F Foga ty cathete th ough the lumen o the cent al
wall abscess, embolization to the pleu al space, and chest pain. line and advance it 3 cm beyond the tip. Withd aw the enti e

booksmedicos.org
430 SECTION IV VASCULAr TECHNIqUES AND VOLUME SUPPOrT
assembly until only the Foga ty cathete is in the SV. Inject
1 mL o ai into the balloon and advance the Foga ty cathete .
It is hoped that blood ow will di ect the assembly into the
SVC. De ate the balloon and advance the cent al line ove
the Foga ty cathete , which is then withd awn.
Anothe anecdotal st ategy is to withd aw the cathete until
only the distal tip emains in the cannulated vessel. This
measu ement is best app eciated by compa ing the length o
the indwelling cathete with anothe unused cathete . The
clinician then simply eadvances the cathete in the hope that
it becomes p ope ly positioned. Othe manipulations with
guidewi es have been suggested, but einse tion with anothe
punctu e is o ten e ui ed o the misplaced cathete to be
positioned p ope ly. This app oach also dec eases the isk o
in ection by avoiding the int oduction o bacte ia into the
vessel om any nonste ile segment o the CVC.
SPECIAL CONSIDERATIONS
FOR OTHER VESSELS
External Jugular Vein Approach
Cent al venous cathete ization via the exte nal jugula vein is
time-consuming and o ten di fcult. The di fculty in conve ting
an exte nal jugula cathete into a CVC e uently ende s it
a lowe -yield clinical p ocedu e. Use o the exte nal jugula
vein o achieving cent al venous access e ui es that a guidewi e
be used. A te cannulation o the vein and int aluminal place-
ment o the guidewi e, advance the guidewi e into the tho ax
by otating and manipulating the tip into the cent al venous
ci culation. Advancement o the guidewi e is the most di fcult
and time-consuming po tion o the p ocedu e, and the time
e ui ement limits the use ulness o this techni ue in an
eme gency. A small- adius J-tipped wi e, a distended vessel
lumen, and exagge ation o patient head tilt, coupled with skin
t action, may acilitate success ul passage o the guidewi e.
Pa tially withd awing the wi e and twisting it 180 deg ees
be o e eadvancing the tip may also be help ul.
Basilic and Cephalic Approaches
Passing a cathete into the cent al ci culation is di fcult via
the basilic and cephalic outes, and ailu e is common. Inse tion
o a pe iphe al IV cent al cathete th ough these outes is
o ten pe o med by specialized teams and is less suitable o
eme gency indications. The cephalic vein may te minate inches
above the antecubital ossa o bi u cate be o e ente ing the
axilla y vein and send a b anch to the exte nal jugula vein.
The cephalic vein may also ente the axilla y vein at a ight
angle, the eby de eating any attempt to pass the cathete
cent ally. Fu the mo e, both the basilic and the cephalic systems
contain valves that may impede cathete ization. Abduction o
the shoulde may help advance the cathete i esistance nea
the axilla y vein is encounte ed. The incidence o ailu e to
place the cathete in the SVC anges om a high o 40% to
a low o 2%.47,116 The g eatest success ate (98%) epo ted
was obtained with slow cathete advancement with the patient
in a 45- to 90-deg ee up ight position.47 A exible cathete
was int oduced into the basilic vein until the tip was judged
to be p oximal to the junction o the cephalic and basilic veins
and distal to the junction o the IJ vein with the innominate
vein. The wi e stylet was withd awn 18 cm and the cathete
booksmedicos.org
was advanced slowly 1 cm at a time, with 2 seconds allowed
between each 1-cm inse tion. The natu al exibility o Ba d
cathete s cont ibuted to negotiation into the SVC when
the patient was up ight. This time-consuming techni ue is
cont aindicated when the patient cannot tole ate an up ight
position.
The basilic and cephalic venous systems a e ente ed th ough
the la ge veins in the antecubital ossa. Placement o a tou ni uet
aids venous distention and initial venous punctu e. When veins
a e not visible, they may be identifed with bedside ult asound
(as desc ibed in Chapte 66). The basilic vein, located on the
medial aspect o the antecubital ossa, is gene ally la ge than
the adially located cephalic vein. Fu the mo e, the basilic
vein usually p ovides a mo e di ect oute o passage into the
axilla y vein, SV, and SVC.
Vascular Access in Cardiac Arrest
Immediate vascula access is e ui ed o esuscitation du ing
ca diac a est. Int aosseous access is a easonable alte native
to cent al venous access. Femo al CVCs a e o ten used in this
setting. The in aclavicula SV app oach is also commonly
used du ing ca diac a est i logistics pe mit. The intuitive
ationale o emo al CVC placement has been that much o
the esuscitation activity, including chest comp essions, occu s
on the tho ax, thus limiting the clinician’s ability to sa ely place
a highe line. Du ing ca diac a est, the availability o d ugs
delive ed to the cent al ci culation may be slowe via the emo al
oute than via sup aclavicula SV o IJ vein in usions. 116,117
Additionally, pulsations elt in the g oin du ing CPr may be
venous instead o a te ial,31 and the e is a high ate o un ec-
ognized cathete malposition and a te ial inju y.31,118 To place
a emo al cathete blindly (without ult asound guidance o
clea identifcation o the a te ial pulse), divide the distance
om the ante io supe io iliac spine to the symphysis pubis
into thi ds. The a te y typically lies at the junction o the
medial and middle thi ds and the vein is 1 cm medial to this
location. Blind emo al cent al line inse tions du ing a est
a e less than optimal. The inc easingly available int aosseous
placement systems and bedside ult asonog aphy a e commonly
used to supplant such blind CVC placements du ing ca diac
a est and othe eme gencies that e ui e immediate vascula
access.
CVP MONITORING
CVP Measurement
Although desc ibed by Fo ssmann in 1931, it was not until the
ea ly 1960s that measu ement o CVP became commonplace
as a means o assessing ca diac pe o mance and guiding
uid the apy. 10 CVP measu ement has been used as a guide
o dete mination o volume status, uid e ui ements, and
investigation o tamponade,119 but its eliability has not been
consistently demonst ated in the lite atu e.120,121 Fu the mo e,
advancements in ou knowledge o complex hemodynamics
(pa ticula ly du ing sepsis) and imp ovements in noninva-
sive dynamic imaging (ult asound) have la gely supplanted
CVP monito ing in the c itical ca e envi onment.122,123 Still,
astute clinicians can maximize the use ulness o this diagnostic
tool by unde standing its basic p inciples, indications, and
limitations.124–126
 CHAPTEr 22 Cent al Venous Cathete ization and Cent al Venous P essu e Monito ing 431

o e ecting le t at ial p essu e and co esponding changes in

Physiology
Simply stated, CVP is the p essu e exe ted by blood against
the walls o the int atho acic venae cavae. Because p essu e
in the venae cavae is gene ally within 1 mm Hg o ight at ial
p essu e, CVP e ects the p essu e unde which blood is
etu ning to the hea t. P essu e in the cent al veins has two
signifcant hemodynamic e ects. Fi st, CVP p omotes flling
o the hea t du ing diastole, a acto that e ects ight ven-
t icula end-diastolic volume (p eload). Second, CVP also
ep esents the back-p essu e o the systemic ci culation, which
opposes etu n o blood om pe iphe al venous ci culation
to the hea t. CVP values a e dete mined by a complex inte ac-
tion o int avascula volume, ight at ial and vent icula unction,
venomoto tone, and int atho acic p essu es.119,124,125,127
To measu e CVP, the tip o a p essu e-monito ing cathete
is inse ted into any o the g eat systemic veins o the tho ax
o into the ight at ium.124,126 The emo al vein may also be
used o CVP measu ements as long as the e is no abno mally
inc eased abdominal p essu e.10,127 The cathete is connected
to a simple manomete o to an elect onic p essu e t ansduce
inte aced with a monito ing system that is capable o calculating
a mean p essu e value and displaying p essu e wave o ms.124,126
When the cathete tip is placed in the ight at ium the wave-
o ms p oduced co elate with the ca diac cycle and c eate a
typical wave patte n.
A common misconception is that CVP consistently e ects
p essu e in the le t side o the hea t. A di e ent measu ement,
called pulmona y capilla y wedge p essu e (PCWP), is capable
le t vent icula p essu e by t ansducing back-p essu es om
the le t-sided ci culation th ough the pulmona y capilla y
system. Additionally, ow-di ected pulmona y a te y cathete s
allow epeated calculations o PCWP, thus acilitating eliable
estimation o le t at ial p essu es.126
Indications for and Contraindications
to CVP Measurement
The fve t aditional majo indications o monito ing CVP
a e:
1. Acute ci culato y ailu e.
2. Anticipated massive blood t ans usion o uid eplacement
the apy.
3. Cautious uid eplacement in patients with comp omised
ca diovascula status.
4. Suspected ca diac tamponade.
5. Fluid esuscitation du ing goal-di ected the apy in patients
with seve e sepsis.
The p ocedu e is cont aindicated when othe esuscitative
the apeutic and diagnostic inte ventions take p io ity ove
cent al venous access and CVP t ansduce setup and calib ation,
o in the setting o la ge vegetations on the t icuspid valve,
SVC synd ome, o tumo s o th ombus in the ight at ium.
CVP monito ing is most help ul in patients without sig-
nifcant p eexisting ca diopulmona y disease. Nume ous studies
highlight the un eliability o ight-sided hemodynamic monito -
ing in patients with unde lying ca diac o pulmona y disease.114,118

Central Venous Pressure Measurement

Indications Equipment
Acute circulatory failure
Anticipated massive blood transfusion or fluid
replacement therapy Manometer (for manual measurement)
Cautious fluid replacement in patients with
compromised cardiovascular status
Suspected cardiac tamponade
Fluid resuscitation during goal-directed therapy
for severe sepsis Electronic
transducer system
(for automated
Contraindications
measurement)
Other resuscitative interventions that take priority over
central venous access and central venous pressure setup Connector
tubing
Large vegetations on the tricuspid valve
Superior vena cava syndrome
Right atrial tumor or thrombus

Complications
Faulty central venous pressure readings:
Increased intrathoracic pressure (ventilator, straining, coughing)
Failure to calibrate or zero the transducer
Malposition of the tip of the catheter
Obstruction of the catheter
Air bubbles in the circuit
Readings during the wrong phase of ventilation
Vasopressors (presumed)

Review Box 22.2 Cent al venous p essu e measu ement: indications, cont aindications, complications, and e uipment.

booksmedicos.org
432 SECTION IV VASCULAr TECHNIqUES AND VOLUME SUPPOrT

Ultimately, howeve , the inconsistencies noted a e not due to
the ailu e o CVP monito s to e ect cent al hemodynamics.
rathe , the disc epancies noted in the lite atu e simply highlight
the complex elationships between vent icula and vascula
compliance, blood volume, and flling p essu es in va ious
disease states. As with pulmona y a te y occlusion p essu e
measu ements, the clinician is cautioned to be awa e o the
assumptions inhe ent in taking these measu ements and to
ecognize the physiologic scena ios in which these assumptions
do not hold t ue.
Procedure
Although CVP may be dete mined with a manomet y column
assembled at the bedside (Fig. 22.20), the most common
techni ue in p actice is measu ement with an elect onic

Me as u rem e n t of Ce n t ra l V e n o u s P r es s u re : M a no m e t r y

1 2

Manometer

Flow

Flow

Assemble the manometer as depicted above. When the stopcock
is turned to direct flow of fluid to the patient, the manometer is
bypassed. This is the position that is maintained to keep the
catheter patent. Remember to always flush all tubing before
connecting it to the patient’s central catheter.
To measure central venous pressure, first
turn the stopcock to fill the manometer to
25 cm H 2O.

0
Flow

Patient reference point

Next, open the stopcock to the patient and the manometer. Allow
the column of water in the manometer to fall and stabilize before
a reading is taken. Note that the zero mark must be horizontally
aligned with the tricuspid valve (which is estimated as the
midaxillary line in a supine patient).

Figure 22.20 Measu ement o cent al venous p essu e with a manual manomete .

booksmedicos.org
 CHAPTEr 22 Cent al Venous Cathete ization and Cent al Venous P essu e Monito ing 433

Me a s u re m e n t of Ce n t ra l V e no u s P r e s s u re : T r a n s du c e r

Insert a bag of Flush all air bubbles

1 normal saline into a 2 from the system by
pressure bag and opening the stopcock
inflate to the and running saline
recommended through the line. Any
pressure (usually air left in the system
300 mm Hg). will cause erroneous
central venous
pressure readings.
Take care to not flush
air into the patient.

Connect the flushed Mount the

3 transducer tubing to 4 transducer at the
the patient’s central level of the patient’s
line (arrow) right atrium. This
level can be
approximated on
the skin surface as a
point at the
midaxillary line and
Transducer at level fourth intercostal
of right atrium space.

Adjust the stopcock Finally, set the

5 so that the 6 stopcock so that it is
transducer is open open to the
to air, and zero the transducer and the
system (arrow). The central venous
exact process for the catheter. Observe
zeroing procedure for a venous
will vary by the waveform and central
equipment venous pressure
manufacturer. reading on the
monitor (arrow).

Figure 22.21 Measu ement o cent al venous p essu e with an elect onic t ansduce .

t ansduce inte aced to a bedside monito ing system (Fig.
22.21). Typical t ansduce s include a nipple valve attached to
a p essu ized bag o saline to allow easy ushing o the system.
The t ansduce is connected th ough the patient’s cent al line
with a length o tubing flled with saline. A th ee-way stopcock
is placed between the patient and the t ansduce to simpli y
line ushing and calib ation.
Flush all ai bubbles om the system by opening the stopcock
to ai and ushing saline th ough the line. Do not ush ai
bubbles into the patient. Even tiny bubbles le t in the tubing
will dampen the CVP wave and potentially cause unde estima-
tion o venous p essu e.
A te the system has been ushed, place the stopcock (with
the t ansduce still open to ai ) at the level o the patient’s
ight at ium. Ze o (calib ate) the monito with the t ansduce
at the level o the ight at ium, which can be app oximated
on the skin su ace as a point at the midaxilla y line and the
ou th inte costal space.124,126 Finally, set the stopcock so
that the t ansduce is in continuity with the patient’s venous
cathete .
In spontaneously b eathing patients, take eadings at the
end o a no mal inspi ation. I the patient is eceiving positive
p essu e ventilation, the changes in CVP du ing the espi ato y
cycle a e eve sed: it ises with inspi ation and dec eases with
expi ation. In these patients, take eadings nea the end o
expi ation.126 Thus, du ing both no mal and mechanical ventila-
tion, the lowest eading is a use ul estimate o mean CVP.
readings should be taken only a te accu ate placement
o the cathete tip has been established. To ensu e optimal
measu ement, place the patient in the supine position. Wheneve
the patient is epositioned, take ca e to ensu e that the t ans-
duce has been ecalib ated to e ect the new position o the
patient.
Errors in CVP Measurement
A numbe o ext insic acto s may alte the accu acy o the
CVP eading (Box 22.1).119,124,126 In addition to the position
o the patient, changes in int atho acic p essu e, malposition
o the tip o the cathete , obst uction o the cathete , and
ailu e to calib ate o ze o the line may all adve sely impact
CVP measu ements. Activities that inc ease int atho acic
p essu e, such as coughing o st aining, may cause spu iously
high measu ements. Make su e that the patient is elaxed and

booksmedicos.org
434 SECTION IV VASCULAr TECHNIqUES AND VOLUME SUPPOrT
BOX 22.1 Reasons for Faulty Central Venous
Pressure Readings
Inc eased int atho acic p essu e (ventilato , st aining, coughing)
Failu e to calib ate o ze o the t ansduce
Malposition o the tip o the cathete
Obst uction o cathete
Ai bubbles in the ci cuit
readings du ing the w ong phase o ventilation
Vasop esso s (p esumed)
b eathing no mally at the time o measu ement. In mechanically
ventilated patients CVP will be elevated to an extent di ectly
p opo tional to the ventilato y p essu e being delive ed and
inve sely p opo tional to the mechanical compliance o the
lung. Ca e should be exe cised in inte p eting flling p essu es
in this ci cumstance because ventilato -induced elevations in
CVP a e not a ti actual but ep esent changes in the hemo-
dynamic physiology o the patient. As in spontaneously
b eathing patients, CVP measu ements a e meaning ul only
in elaxed, sedated, o pa alyzed subjects.
Anothe eason o aulty eadings is malposition o the tip
o the cathete . I the cathete tip has not passed a enough
into the cent al venous system, pe iphe al venous spasm o
venous valves may yield p essu e eadings that a e inconsistent
with the t ue CVP.
I the tip o the cathete has passed into the ight vent icle,
a alsely elevated CVP measu ement will be eco ded. recogni-
tion o a cha acte istic ight vent icula p essu e wave o m on
the patient’s monito should hope ully p eclude this e o . Such
uctuations may also occasionally be seen in app op iately
positioned CVP lines when signifcant t icuspid egu gitation
o at iovent icula dissociation (a cannon “a” wave) is p esent. 127
Inaccu ate low venous p essu e eadings a e seen when a
valve-like obst uction at the tip o the cathete occu s as a
esult o eithe clot o mation o contact against a vein wall.
Wave damping seconda y to ai bubbles in the t ansduce
tubing also leads to aulty eadings. Using poo ly ze oed lines
may esult in inaccu ate measu ements that may be inte p eted
as a change in the patient’s status when none has actually taken
place. The t ansduce should be ze oed to the same level o
eve y measu ement.
Interpretation of CVP Measurement
No mal CVP values a e as ollows:
Low: <6 cm H2O.
No mal: 6 to 12 cm H2O.
High: >12 cm H2O.
In the late stages o p egnancy (30 to 42 weeks), CVP is
physiologically elevated, and no mal eadings a e 5 to 8 cm H2O
highe . A CVP eading o less than 6 cm H2O is consistent
with low ight at ial p essu e and e ects a dec ease in the
etu n o blood volume to the ight hea t. This may indicate
that the patient e ui es additional uid o blood. A low CVP
eading is also obtained when vasomoto tone is dec eased, as
with sepsis, spinal co d inju y, o othe o ms o sympathetic
inte uption.
booksmedicos.org
A CVP eading alling within a no mal ange must be viewed
in elation to the clinical scena io. A eading highe than
12 cm H2O indicates that the hea t is not e ectively ci culating
the volume p esented to it. This may occu in a no movolemic
patient with unde lying ca diac disease, such as le t vent icula
hype t ophy (with associated poo vent icula compliance), o
in a volume-ove loaded patient with a no mal hea t. High
CVP can also be elated to va iables othe than pump ailu e,
such as pe ica dial tamponade, est ictive pe ica ditis, pulmona y
stenosis, t icuspid egu gitation, pulmona y hype tension, and
pulmona y embolism.128
Changes in blood volume, vessel tone, and ca diac unction
may occu alone o in combination with one anothe ; the e o e
it is possible to have a no mal o elevated CVP in the p esence
o no movolemia, hypovolemia, and hype volemia. 128 Inte p et
the specifc CVP values with espect to the enti e clinical
pictu e. The changes in CVP du ing an in usion a e mo e
impo tant than the initial eading.
Fluid Challenge
Monito ing CVP may be help ul as a p actical guide to uid
the apy.119,124–126,129 Se ial CVP measu ements p ovide a ai ly
eliable indication o the capability o the ight side o the
hea t to accept an additional uid load. Although PCWP
is a mo e sensitive index o le t hea t uid needs (and in
some clinical situations measu ement o PCWP is essential),
se ial measu ement o CVP can nonetheless p ovide use ul
in o mation.
A uid challenge can help assess both volume defcits and
pump ailu e.125 Although a uid challenge can be used with
eithe PCWP o CVP monito ing, only the uid challenge
o CVP monito ing is discussed he e. Slight va iations in the
methodology o uid challenge a e epo ted in the lite atu e.
Gene ally, uid boluses o 250 to 500 mL o c ystalloid a e
administe ed se uentially and CVP is measu ed 10 minutes
a te each bolus. repeat the uid challenge until measu ements
indicate that ade uate volume expansion has occu ed. Dis-
continue the uid challenge as soon as hemodynamic signs o
shock a e eve sed o signs o ca diac incompetence a e evident.
Cardiac Tamponade
In ca diac tamponade, pe ica dial p essu e ises to e ual ight
vent icula end-diastolic p essu e. The pe ica dial p essu e
encounte ed in pe ica dial tamponade cha acte istically p oduces
an elevated CVP.128 The deg ee o elevation in CVP is va iable,
and one must inte p et measu ements cautiously; CVP eadings
in the ange o 16 to 18 cm H2O a e typically seen with acute
tamponade, but elevations o up to 30 cm H2O may be
encounte ed. The p ecise CVP eading is o ten lowe than
one might intuitively expect, and it is not uncommon to
encounte tamponade with a CVP o 10 to 12 cm H2O. A
no mal o even low CVP eading may be seen i the tamponade
is associated with signifcant hypovolemia. An excessive ise
in CVP a te uid challenge may be mo e impo tant than a
single eading in the diagnosis o pe ica dial tamponade.
Additionally, physician-ope ated point-o -ca e ult asound has
p oven to be exceptionally sensitive o visualizing tamponade
physiology when pe ica dial p essu es have begun to impai
ight vent icula flling.129
Excessive st aining, positive p essu e ventilation, agita-
tion, in ation o pneumatic antishock ga ments, and tension
 CHAPTEr 22 Cent al Venous Cathete ization and Cent al Venous P essu e Monito ing 435

pneumotho ax may all inc ease int atho acic p essu e, p oduce
a high CVP eading, and e oneously suggest the diagnosis o
pe ica dial tamponade. Inc eases in vascula tone, as seen with
the use o dopamine o othe vasop esso s, may also elevate
CVP and thus mimic tamponade and complicate estimations
o volume.
COMPLICATIONS
The medical lite atu e is eplete with epo ts o CVC complica-
tions. Unde standing the pathophysiology su ounding CVC
complications helps clinicians anticipate, ecognize, and manage
complications should they a ise and bette educate patients
and thei amilies du ing the in o med consent p ocess.
Mo e than 15% o patients who eceive CVCs expe ience
some type o complication, and complications occu despite
p istine techni ue.45,76 This pe centage is not su p ising in
view o the close p oximity o vital st uctu es, the complexity
o patients’ medical conditions, and the exigent ci cumstances
unde which many o these p ocedu es a e o ten pe o med.
The numbe o complications inc eases, especially th om-
bosis and line in ection, with longe du ations o indwelling
cathete s and inc easing seve ity o illness.28 Common complica-
tions and the di e ent app oaches a e summa ized in Box 22.2
and can gene ally be catego ized as mechanical, in ectious, and
th ombotic. Key complications and inju ies by app oach a e
discussed in the ollowing sections.
The numbe o lumens does not di ectly a ect the ate o
cathete - elated complications.45,76 One 3-yea et ospective
eview o all cent al cathete s placed in the ED (sup aclavicula
SV, IJ, and emo al lines) epo ted a mechanical complication
ate o 3.4%, o 22 o 643 lines placed. 130 Complications we e
defned as pneumotho ax, hematoma, line misplacement,
hemotho ax, o any issue with the CVC (excluding in ection
o th ombosis) that e ui ed an inpatient consultation. In
gene al, ailu e and complication ates inc ease as the numbe
o pe cutaneous punctu es inc eases. Histo ically, ope ato skill
and expe ience have eliably p edicted complication o success
ates.45,76 It has p eviously been epo ted that clinicians who
have placed mo e than 50 CVCs have less than hal the
complication ates o those who have ewe than 50 attempts.76
Published complication ates va y in the lite atu e and
can now be classifed acco ding to whethe ult asound guid-
ance was used du ing the p ocedu e (Table 22.4).45,50 Studies
have demonst ated that ult asound-guided CVC placement
techni ues have imp oved success ates, educed complication
ates, and dec eased time needed to pe o m the p ocedu e.49–52

BOX 22.2 Complications of Central Venous Access

General Infectious SV and IJ Approaches Neurologic

Mechanical Bloodstream in ection Pulmonary Phrenic nerve injury
Puncture o an adjacent artery Generalized sepsis Pneumothorax Brachial plexus injury
Hematoma ormation Septic arthritis Hemothorax Cerebral in arct
Air embolus Osteomyelitis Hydrothorax Femoral Approach
Pneumothorax Cellulitis at the insertion site Chylothorax Intraabdominal
Pericardial tamponade Thrombotic Neck hematoma and tracheal obstruction Bowel per oration
Catheter embolus Pulmonary embolism Endotracheal cu per oration Psoas abscess
Arteriovenous stula Venous thrombosis Tracheal per oration Bladder per oration
Mural thrombus ormation
Large-vein obstruction
Dysrhythmias
Catheter knotting
Catheter malposition
IJ, Internal jugular; SV, subclavian vein.

TABLE 22.4 Frequency of Complications Without and With Ultrasound Guidance

Without Ultrasound With Ultrasound
COMPLICATION IJ SV FEMORAL IJ
A te ial punctu e 6.3–9.4% 3.1–4.9% 9.0–15.0% 1.8%

Hematoma <0.1–2.2% 1.2–2.1% 3.8–4.4% 0.4%

Hemotho ax 0% 0.4–0.6% NA 0%

Pneumotho ax <0.1–0.2% 1.5–3.1% NA 0%

In ection ( ate pe 1000 cathete -days) 8.6 4 15.3 NA

Th ombosis ( ate pe 1000 cathete -days) 1.2–3 0–13 8–34 NA

IJ, Inte nal jugula ; NA, not applicable; SV, subclavian vein.
Data om re e ences 47, 78, and 129.

booksmedicos.org
436 SECTION IV VASCULAr TECHNIqUES AND VOLUME SUPPOrT

As a esult, ult asound guidance o CVC placement is ec-

ommended by the US Depa tment o Health and Human
Se vices. repo ts by the AHrq list ult asound guidance o
cent al vein cannulation as one o its most highly ated sa ety
p actices.60,131

Mechanical Complications
The most commonly epo ted mechanical complications a e
a te ial punctu e, hematoma, and pneumotho ax. Inadve tent
a te ial punctu e and hematoma o mation a e usually easily
ecognized and cont olled with simple comp ession. ra ely,
an a te y is lace ated to such an extent that bleeding is signifcant
and ope ative epai is necessa y. In ca diac a est, low- ow,
o shock states, a te ial punctu e may not be obvious, and
a te ial cannulation and int aa te ial in usions have occu ed.
This can lead to the development o ischemia o th ombosis
o the a te y and limb. When systolic blood p essu e ises,
a te ial pulsations become mo e obvious. In c itically ill patients, A
howeve , this complication may escape detection o some
time. It has been epo ted that ult asound-guided placement
o IJ CVCs dec eases the ate o a te ial punctu e to 1.4%.50
Though poo ly studied, patients with coagulopathies may
expe ience signifcant bleeding om CVC placement, especially
i a te ial punctu e o lace ation has occu ed. Mumtaz and
cowo ke s cited a 3% bleeding ate in coagulopathic patients
who expe ienced only mino bleeding that could be cont olled
with digital p essu e.47 Although cent al venous access p oce-
du es may be pe o med sa ely in patients with bleeding dis-
o de s without antecedent co ection o the coagulopathy,
caution is st ongly u ged. A eas amenable to a te ial comp ession
a e p e e ed in these patients.47
Pneumotho ax occu s in up to 6% o subclavian veni- B
punctu es and can also occu with the IJ app oach45,76,132
(Fig. 22.22A). Initially, the impo tance o this complication Figure 22.22 Pneumotho ax and hemotho ax. A chest adiog aph
was minimized, but epo ts o atalities caused by tension should be taken outinely to assess the position o a cent al venous
pneumotho ax, bilate al pneumotho ax, and combined hemo- cathete int oduced via the subclavian o inte nal jugula oute. This
conf ms placement o the cathete . Chest adiog aphy can also show
pneumotho ax ollowed.58 One would expect a highe incidence
potential complications o the p ocedu e. A, La ge ight pneumotho ax
o pneumotho ax i the p ocedu e is pe o med du ing CPr a te ight inte nal jugula cathete ization. The cathete is still in
o positive p essu e ventilation. A small pneumotho ax can place (large arrow), and the absence o lung ma kings on the ight
uickly become a li e-th eatening tension pneumotho ax with and the pleu al e ection (small arrows) a e eadily appa ent. B, Le t
positive p essu e ventilation. T eatment o a cathete -induced hyd opneumotho ax a te le t subclavian venipunctu e (the cathete was
pneumotho ax is cont ove sial, but not all patients will e ui e emoved be o e this adiog aph). Note the st aight line o uid (ai - uid
o mal tube tho acostomy. Some autho s have epo ted that level, black arrows) and no meniscus, indicating that a pneumotho ax
many stable outpatients exhibiting a pneumotho ax a te must also be p esent. The edge o the pa tially collapsed lung is
inse tion o a CVC can be managed success ully by obse va- di fcult to app eciate. No clinician can place cent al venous cathete s
tion alone (60% in one se ies) o cathete (pigtail/Heimlich and ail to have at least some complications that a e inhe ent to the
p ocedu e, ega dless o even awless techni ue.
valve) aspi ation, with la ge tube tho acostomy being ese ved
o e acto y cases o eme gency settings.132,133 C itically ill
patients o those unde going mechanical ventilation a e mo e
likely to e ui e invasive t eatment o a cathete -induced
pneumotho ax. mino and clinically inconse uential amounts o ai ente
Hemotho ax may occu a te lace ation o the SV o the venous ci culation du ing many cannulation p ocedu es.
subclavian a te y, punctu e o the pulmona y a te y, o int a- Maintaining constant occlusion (with the ope ato ’s fnge ) on
tho acic in usion o blood (see Fig. 22.22B). Hyd otho ax occu s all needles that a e located in cent al veins can minimize this
as a esult o in usion o IV uid into the pleu al space. occu ence. A 14-gauge needle can t ansmit 100 mL o ai
Hyd omediastinum is also possible. These a e a ely se ious pe second with a 5–cm H2O p essu e di e ence ac oss the
complications, but atalities have been epo ted. Su gical epai needle.98 Ai embolism may occu i the line is open to ai
is occasionally e ui ed. A te iovenous fstula o mation has du ing cathete ization o i it subse uently becomes discon-
also been epo ted.134 Additional pulmona y complications nected. The ecommended t eatment is to place the patient
include t acheal and endot acheal cu pe o ation. in the le t late al decubitus position to elieve ai bubble
Ai embolism is a ve y a e, but potentially li e-th eatening occlusion o the ight vent icula out ow t act.98 I this is
complication o cent al venous cannulation. Undoubtedly, unsuccess ul, aspi ation with the cathete advanced into the

booksmedicos.org
 CHAPTEr 22 Cent al Venous Cathete ization and Cent al Venous P essu e Monito ing
ight vent icle has been advocated.98 Eme gency tho acotomy
to aspi ate ai (see Chapte 18) and ca diotho acic su gical
consultation may also be wa anted.
Cathete o wi e embolization esulting om shea ing o
a th ough-the-needle cathete by the tip o the needle is a
se ious and gene ally avoidable complication. Embolization
can occu when the cathete o wi e is withd awn th ough the
needle o i the gua d is not p ope ly secu ed. Adve se events
a te embolization include a hythmias, venous th ombosis,
endoca ditis, myoca dial pe o ation, and pulmona y embo-
lism.78 The mo tality ate in patients who did not have these
cathete s emoved has been epo ted to be as high as 60%.78
T ansvenous et ieval techni ues by inte ventional adiology
a e usually attempted, ollowed by open su ge y i unsuccess ul.78
Enti e guidewi es may also embolize to the gene al ci culation
i the tip is not constantly secu ed by the ope ato th oughout
the p ocedu e. Initiatives by national sa ety bodies such as the
National quality Fo um in the United States have ocused on
educing the incidence o etained wi es by classi ying them
as “neve ” events that e ui e mandato y epo ting in many
states.
Delayed pe o ation o the myoca dium is a a e, but gene -
ally atal complication o cent al venous cathete ization by any
oute.135 The p esumed mechanism is p olonged contact o
the igid cathete with the beating myoca dium. The cathete
pe o ates the myoca dial wall and causes tamponade eithe
by bleeding om the involved chambe o by in usion o IV
uid into the pe ica dium. The ight at ium is involved mo e
commonly than the ight vent icle.98 All clinicians who inse t
such cathete s o ca e o such patients should be awa e o
this deadly complication, which esults in p o ound dete io ation
with hypotension, sho tness o b eath, and shock. Eme gency
echoca diog aphy, pe ica diocentesis, and ope ative inte vention
by a tho acic su geon may all be e ui ed o salvage o the
patient. This can also occu with misplacement o the CVC
in the pe ica dioph enic vein.136,137 Fo tunately, this complication
is p eventable by using a postinse tion chest flm to conf m
the position o the tip o the cathete and et acting the cathete
i the tip is within the ca diac silhouette.
Cathete knotting o kinking may occu i the cathete is
o ced o epositioned o i an excessively long cathete is
used.136–138 The most common esult o kinking is poo ow
o IV uids, although a e complications as seve e as SVC
obst uction have been seen. 136–138
Tho acic duct lace ation is a e uently discussed complica-
tion o le t-sided subclavian venipunctu e; howeve , it is
ext emely uncommon and has been epo ted only as a complica-
tion o IJ vein, not SV, cannulation.
Neu ologic complications a e ext emely a e and p esumably
caused by di ect t auma om the needle du ing venipunctu e.
B achial plexus palsy and ph enic ne ve inju y with pa alysis
o the hemidiaph agm have been epo ted.139,140 In using
hype tonic medications into the IJ vein via a malpositioned
cathete may esult in a va iety o neu ologic complications
om et og ade pe usion o int ac anial vessels.141 Again, this
complication can be easily avoided by inspecting a postp ocedu e
x- ay to conf m p ope placement p io to utilization o a
newly placed cathete .
Infectious Complications
In ectious complications include local cellulitis, th ombophle-
bitis, gene alized septicemia, osteomyelitis, and septic a th itis.57
booksmedicos.org
437
The incidence o septic complications va ies om 0% to
25%.73,142 The e uency with which in ectious complications
occu is di ectly elated to the attention given to aseptic
techni ue du ing inse tion and a te ca e o the cathete . Femo al
venous cathete ization ca ies a g eate isk o in ection than
subclavian cathete ization. Me e and associates epo ted the
ove all in ectious complication ate om emo al and subclavian
cathete s to be 19.8% and 4.5%, espectively.135 Ult asound-
guided IJ CVC placement has esulted in a dec ease in the
ates o CLABSIs.52 The exact mechanism by which ult asound-
guided CVC placement esults in a lowe isk o in ection is
unclea ; it may be elated to a educed numbe o skin punctu es.
O ganisms most commonly ecove ed om colonized emo al
cathete s a e coagulase-negative staphylococci, Ente obacte-
iaceae, Enterococcus species, and Pseudomonas aeruginosa.135
CVCs cause an estimated 80,000 CLABSIs and a e implicated
in up to 28,000 deaths pe yea in patients in the intensive
ca e unit.63–65 The ave age cost has been estimated at $2.3
billion annually.63–65 The Cente s o Disease Cont ol and
P evention has ecommended that cent al line bundling policies
should be implemented to signifcantly dec ease the incidence
o CLABSI.64,65 This bundling policy includes fve evidence-
based inte ventions: (1) hand washing, (2) maximal ba ie
p ecautions, (3) chlo hexidine skin antisepsis, (4) optimal
cathete site selection with avoidance o the emo al vein i
possible, and (5) daily eview o the necessity o the line and
p ompt emoval o unnecessa y lines.66
Thrombotic Complications
Th ombosis and th ombophlebitis a e signifcant isks associated
with placement o a CVC. The isk o cathete - elated
th ombosis is di ectly elated to the site o access. In one t ial,
cathete - elated th ombosis was epo ted in up to 21.5% o
patients with emo al CVCs and in 1.9% o patients with SV
CVCs. Fo SV and IJ CVCs, it is impo tant to dete mine that
the tip o the cathete ests in the SVC, especially du ing the
in usion o i itating o hype tonic solutions.135 Th ombi may
o m seconda y to p olonged contact o the cathete against
the vascula endothelium. One autopsy study ound a 29%
incidence o mu al th ombi in the innominate vein, SVC, and
ight vent icle o patients who had cent al lines in place an
ave age o 8 days be o e death.68 The clinical impo tance o
these th ombi emains unclea ; howeve , any th ombosis has
the potential to embolize. Mo eove , cathete - elated th ombosis
is a cause o SVC obst uction synd ome.143
Subclavian Approaches
Although both app oaches to the SV a e elatively sa e, the
in aclavicula SV app oach is mo e likely to be associated
with complications. In a andomized, p ospective compa ison
o sup aclavicula SV and in aclavicula SV punctu e in 500
ED patients, complication ates we e 2.0% and 5.1%, espec-
tively.144 The most signifcant complications a e pneumotho ax
and punctu e o the subclavian a te y; the highest epo ted
incidence o pneumotho ax is 2.4%.18,69,144 Adhe ence to the
techni ues ecommended o sup aclavicula SV punctu e
dec eases the isk o these complications because the needle
is di ected away om the pleu al dome and subclavian a te y.
The elatively supe fcial location o the vein when app oached
om above the clavicle (1.5 to 3.5 cm) lessens the isk o
punctu e o lace ation o deep st uctu es.
438 SECTION IV VASCULAr TECHNIqUES AND VOLUME SUPPOrT

IJ Approach
Many complications o IJ vein cannulation a e simila to those
o SV access. The incidence o complications appea s to be
highe with use o the le t IJ vein than with the ight.16 One
common complication uni ue to the IJ app oach is a localized
hematoma in the neck.145 With the IJ app oach, p essu e can
easily be maintained on the a ea o swelling, and most hema-
tomas will esolve spontaneously. I punctu e o the ca otid
a te y is ecognized and t eated with comp ession, it a ely
causes signifcant mo bidity in the absence o ma ked athe o-
scle otic disease, although a te iovenous fstulas may occu
a te IJ vein punctu e.134 Seve al neu ologic complications A
uni ue to the IJ site o venipunctu e have also been epo ted
as a esult o hematomas o di ect inju y. Such complications
include damage to the ph enic ne ves, iat ogenic Ho ne ’s
synd ome, t auma to the b achial plexus, and even passage o
a cathete into the thecal space o the spinal canal.141 I the
ca otid a te y is punctu ed, one may again attempt IJ vein o
SV cannulation on the same side a te app op iate, p olonged
(15- to 20-minute) comp ession. The IJ vein valve is e uently
damaged when cannulated, which o ten esults in incompetence
o the valve. The clinical signifcance o this, i any, is
unknown.146

Femoral Approach
Because vital st uctu es in the neck and chest a e not at isk,
complications o emo al vein cannulation a e gene ally less
seve e than those o othe outes o cent al venous access.
The most common immediate complications involve bleeding
om damage to eithe the emo al a te y o the emo al vein
(Fig. 22.23). This can usually be managed with 10 to 15 minutes
o di ect p essu e. Ext a ca e should be taken in anticoagulated
patients o a te the administ ation o th ombolytic agents. In
ext eme cases when hemostasis cannot be achieved th ough
di ect p essu e, a vascula su geon should be consulted.
The pe itoneum can also be violated with esultant pe o a-
tion o the bowel. Bowel penet ation is especially likely i the
patient has a emo al he nia. Inju y to the bowel is usually
minimal and unlikely to e ui e specifc t eatment. Nonetheless,
the potential bacte ial contamination o the emo al punctu e
site can pose a signifcant p oblem. Aspi ation o ai du ing
placement o a emo al line necessitates emoval o the cathete
and einse tion at anothe site. Othe complications include
muscula abscesses, in ection o the hip joint, damage to the
emo al ne ve, and punctu e o the bladde . risk o these
outcomes can be mitigated by st ict aseptic techni ue, tho ough
assessment o landma ks, ca e ul cont ol o the needle’s depth,
and the use o bedside ult asound.
Two mo e complications me it special mention. The f st
is the inc eased isk o cathete in ection. P esumably caused
by anatomic association with the anogenital egion, many studies
have ound that emo al lines become in ected at signifcantly
highe ates than IJ vein o sup aclavicula SV lines do.64,65,68,135
O note, some studies have ailed to fnd a statistical di e ence,
and it is unclea how much o the e ect is due to the actual
location o the line ve sus how it is placed and managed. The
second is the incidence o deep vein th ombosis that is also
B
Figure 22.23 A emo al vein cathete is mo e p one to deep vein
th ombosis and in ection than a subclavian o inte nal jugula line,
but it is a standa d access oute in the eme gency depa tment. St ict
attention to ste ile techni ue and limiting use to a ew days will negate
most o the negatives o this app oach. A, Signifcant hemo hage
can occu a te punctu e o the emo al a te y, but this a ea is eadily
comp essed. The emo al oute may be the app oach o choice in a
patient with an inadve tently placed a te ial cathete who e ui es a
cent al line. B, Bleeding om an inadve tently placed a te ial cathete
that was emoved without ade uate p essu e in an anticoagulated
patient.
inc eased in lines placed via the emo al oute, which has been
shown in the majo ity o studies,135,147 although the clinical
signifcance o these clots has not been defnitively add essed.
TRAINING AND SIMULATION
CVC placement and ult asound guidance techni ues have a
elatively steep lea ning cu ve. Simulation is ecommended
by the AHrq to teach these techni ues.60,131 Simulation t aining
is independently associated with highe ates o co ect needle
inse tion on the f st attempt, as well as with highe success ul
CVC placement ates.131,148,149 The e a e many simulation models
that can be used. Kendall and Fa aghe desc ibed a phantom
model as an easy, inexpensive method o ult asound-guided
CVC placement t aining.150
REFERENCES ARE AVAILABLE AT www.expertconsult.com

booksmedicos.org