Central Venous Access

Mazen Kherallah, MD, FCCP

Indications
Need for IV access and failure of peripheral access
Peripheral access too painful or tenuous
Long term IV access anticipated
Medications indicated that are toxic to peripheral

veins
Hemodynamic monitoring
Volume resuscitation with large bore central lines
Special procedure: Swan Ganz, dialysis,
plasmapheresis

Site Selection

09/11/15

Site Selection

09/11/15

Site Selection
Site
Femoral

09/11/15

Pros
Easy access
Large vessel
Good access
during
resuscitation

Cons
Decreased
mobility
Increased risk
of thrombosis,
phlebitis &
infection
Easily
contaminated
Close to
femoral artery
Dressing
difficult to
maintain

Choice of Site
Subclavian

IJ

Femoral

Success Rate

90-95%

90-99%

90-95%

Arterial puncture

0.5-1%

10%

5-10%

Pneumothorax

1-5%

0-0.2%

Infectious rate

Lowest

Intermediate

Highest

Access during cardiac

arrest

2nd

3th

1st

Side of body
preference

Left: angle of
subclavian vein

Right: avoid thoracic

duct

None

Coagulopathy present

3th

2nd

1st

Hypovolemia present

1st: vein supported by

fibrous sheath

3th: vein collapses

2nd

Pacemaker

2nd

1st

3th

Anatomy of Great Vessels

Anatomy of Great Vessels

Anatomy of Great Vessels

Seldinger Technique

The Procedure
Patient position:
Patient is moved to the side of the bed so
physician would not lean over
The bed is high enough so physician would
not have to stoop over
Patient should be flat without a pillow,
Trendelenburg position if patient is
hypovolemic
The head is turned away from the side of the
procedure
Wrist restraints if necessary

The Procedure
Skin preparation:

Prepare before putting sterile gloves

Start at the center and work outward the
edges
Allow time for the sterilizing agent to dry
Disposable drape under the patient
Betadine or Chlorhexidine are acceptable
solution and have activity against gram
positive organisms

The Procedure
Drape:

Large enough
Handed sterilely by the assistant
Hole in the area of placement

Prepare the tray:

Handed sterilely by the assistant

Prepare the equipment before starting

Anesthesia

Use local anesthesia with lidocaine

YOUR ROLE AFTER THE INSERTION

Dispose all sharps
Place an occlusive sterile dressing
Flush lumens to maintain patency
Obtain a chest x-ray (ask for order if physician doesnt

mention it)
Monitor site for bleeding
Assess breath sounds
Assess circulation
Assess for hematoma
Document insertion, site, dressing and flushing

USING THE CENTRAL LINE

Flush q shift, before and after use with NS. Some places

also require heparin flush

Close clamps when not is use
Check P&P of facility, but usually fluids are changed
every 24 hours, tubing changed every 48-72 hours
Dressing is usually changed every 3 days
Line can be used for blood drawing - withdraw and
waste 10 cc, then withdraw blood for samples
If port becomes clotted, do not use - sometimes ports
can be opened up with urokinase (requires a doctors
order)

Complications
Immediate

Hemothorax
Pneumothorax
Arterial puncture
Vessel erosion
Nerve Injury
Dysrhythmias
Catheter malplacement
Embolus
Cardiac tamponade

Complications
Delayed

Dysrhythmias
Catheter malplacement
Vessel erosion
Embolus
Cardiac tamponade
Catheter related infection
Thrombosis

Vascular Erosion/Cardiac Tamponade

Large vessel perforation is uncommon
Vessel erosion more common with stiff

catheters, like dialysis catheters

Cardiac tomponade occur mainly if the tip is
located in the RA
Complication is fatal in 2/3 of cases

Air Embolism
Air is sucked in through the catheter due to negative

intrathoracic pressure during inspiration

Air can be pushed with flushing the catheter if it was
not pulled back before flushing
Complication is uncommon but can be fatal
Manifests with hypoxemia, cardiovascular collapse,
mental status changes and livedo reticularis
Place patient to left lateral position if suspected

Bleeding
More common in patients with coagulopathy
Easily controlled with femoral or IJ sites
Place local pressure and correct

coagulopathy

Arterial Puncture and Cannulation

If the artery is puncture local pressure is

applied for 3-5 minutes, observe for

hematoma formation
If the artery is cannulated, pulsatile reflux of
blood can be noticed, blood gas analysis
reveals arterial.
The catheter should not be used, and remove
it after coagulopathy is corrected if present

Thrombosis
Sleeve fibrin surrounding the catheter (occurs

on the majority of catheters)

Mural thrombus on the wall of the vein (1030% of catheters)
Occlusive thrombus (1-10%)

Pneumothorax
Most likely, pneumothorax is noticed after CXR is

seen, unless patient developed tension

pneumothorax with hypoxemia, cardiopulmonary
collapse and absent breath sound
Small pneumothorax may be watched closely without
chest tube placement in the spontaneously breathing
patients
Large pneumothorax requires chest tube placement
Even small pneumothorax in patients on positive
pressure ventilation requires chest tube placement

Catheter-Related Sepsis
Late complications
Femoral > IJ > subclavian
Triple lumen > single lumen
Large bore > smaller catheter
Sterility of procedure
Number of hub manibulations

Basic Pressure Measurements from

Swan Ganz Catheter
Measurement

Normal range

Central venous pressure

<10 mm Hg

Right atrial pressure

<10 mmHg

Right ventricular pressure, systolic

15-30 mm Hg

Right ventricular pressure, diastolic

0-8 mm Hg

Pulmonary artery pressure, systolic

15-30 mm Hg

Pulmonary artery pressure, diastolic

5-16 mm Hg

Pulmonary artery pressure, mean

10-22

Pulmonary artery wedge pressure, mean

8-12

Hemodynamic Monitoring
Position of Transducer

Components of the Atrial Waves

Differences in CVP and PCWP

EKG correlation

CVP Correlation with EKG

Normal CVP Tracing

Reading the mean of an A wave

22+10/2=16

Spontaneous Breathing
Reading CVP

Spontaneous Breathing
Insp./Exp. Ratio in Rapid Breathing

Spontaneous Breathing
Insp./Exp. Ratio in Rapid Breathing

Hemodynamic Monitoring
Central Venous Pressure: normal 4-10
Increased CVP:

Right heart failure

Right myocardial infarction
Cardiac tomponade
Tricuspid insufficiency
Left to right shunt
Pulmonary emboli
COPD and cor pulmonale
ARDS
Excess fluid
Tricuspid stenosis

Decreased CVP

hypovolumia
Decreased venous return
Excessive veno or
vasodilation
Shock

Central Venous Pressure Tracings

Normal EKG tracing

and right atrial pressure

waveform

Atrial fibrillation

Atrioventricular

dissociation

Central Venous Pressure Tracings

Normal EKG and right

atrial waveforms
Tricuspid stenosis
Mild to moderate

tricuspid insufficiency
Severe tricuspid
insufficiency
Constrictive pericarditis

Large A wave Secondary to Loss of Atrioventricular Synchrony

Simultaneous Atrial and Ventricular Contraction

Loss of A Wave
Atrial Fibrillation