Central Venous Catheterization | Common Carotid Artery | Medicine

Central Venous Catheterization

Dr. Hiwa Omer Ahmed Assistant Professor

Indications for central venous catheter cannulation:
Monitoring of central venous pressures in shock or heart failure. management of fluid status. administration of total parenteral nutrition. prolonged antimicrobial therapy or chemotherapy

Location of catheterization site
A. The internal jugular approach should not be used in patients with a carotid bruit, carotid stenosis, or an aneurysm. B. The subclavian approach should be avoided in patients with emphysema or bullae.

C. The external jugular or internal jugular approach by direct cut-down may be preferable in patients with coagulopathy or thrombocytopenia. D. If a chest tube already in place, the catheter should be placed on the same side as the chest tube

Internal jugular vein cannulation
The internal jugular vein is positioned behind the sternocleidomastoid muscle, lateral to the carotid artery

The catheter should be placed at a location at the upper confluence of the two bellies of sternocleidomastoid at the level of cricoid cartilage.

Procedure
A. Place the patient in Trendelenburg's position, and turn the patient's head to the contralateral side. Choose a location on the right or left. If lung function is symmetrical and no chest tubes are in place, the right side is preferred because of the direct path to the superior vena cava. Prepare the skin with Betadine solution using sterile technique and drape the area. Infiltrate the skin and deeper tissues with 1% lidocaine

B. Palpate the carotid artery. Using a 22gauge scout needle and syringe, direct the needle toward the ipsilateral nipple at a 30 degree angle to the neck. While aspirating, advance the needle until the vein is located and blood back flows into the syringe

C. Remove the scout needle and advance an 18gauge, thin wall, catheter-over-needle (with an attached syringe) along the same path as the scout needle. When back flow of blood is noted into the syringe, advance the catheter into the vein. Remove the needle and confirm back flow of blood through the catheter and into the syringe. Remove the syringe and cover the catheter hub with a finger to prevent air embolization

D. With the catheter in position, advance a guidewire through the catheter. The guidewire should advance easily without resistance

E. With the guidewire in position, remove the catheter and use a No. 11 scalpel blade to nick the skin. Place the central vein catheter over the wire, holding the wire secure at all times. Pass the catheter into the vein, and suture the catheter to the skin with O silk suture. Tape the catheter in place, and connect it to an IV infusion at a keep open rate

F. Obtain a chest x-ray to rule out pneumothorax and confirm position.

Subclavian vein cannulation
The subclavian vein is located in the angle formed by the medial 1/3 of clavicle and the first rib , At the point of medial 1/3 and middle 1/3

PROCEDURE
A. Position the patient supine with a rolled towel located longitudinally between the patient's scapulae, and turn the patient’s head towards the contralateral side. Prepare the area with Betadine iodine solution, and, using sterile technique, drape the area and infiltrate 1% lidocaine into the skin and tissues

B. Use a 16-gauge needle, with syringe attached, to puncture the mid-point of the clavicle, advancing until the clavicle bone and needle come in contact

C. Then slowly probe down until the needle slips under the clavicle. Advance the needle slowly towards the vein until the needle enters the vein, and a back flow of venous blood enters the syringe. Remove the syringe, and cover the catheter hub with a finger to prevent air embolization

D. With the 16-gauge catheter in position, advance a 0.89 mm x 45 cm guidewire through the catheter. The guidewire should advance easily without resistance. With the guidewire in position, remove the catheter, and use a No. 11 scalpel blade to nick the skin. Pass the dilator over the wire.

E. Place the central line catheter over the wire, holding the wire secure at all times. Pass the catheter into the vein, and suture the catheter to the skin with 2-0 silk suture, tape the catheter in place and connect to IV infusion. Obtain a chest x-ray to confirm the position of the catheter tip and rule out pneumothorax

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