Central Venous Access:Central Venous Access:Approach and ComplicationsApproach and Complications

IntroductionIntroduction

Options– Peripheral venous catheters– Central venous catheters

Central Venous access: Internal Jugular, Subclavian, Femoral

Arterial Line access: Radial artery, Femoral artery, Axillary artery.

Catheter choiceCatheter choiceSingle lumen short term

– IVF, TPN, Simple drug regimens

Multilumen short term– Complicated drug regimens, added TPN, frequent

blood draws, CVP monitoring

Long term (PICC): -Prolonged (>4 weeks) need for IV access

Current usesCurrent uses//IndicationsIndications

Vascular access– Fluids*– Transfusion*– Medications, Vasopressor agents, Inotropic agents– Parenteral nutrition– Hemodialysis

Hemodynamic resuscitation– Large bore 14G peripheral line preferred - if rapid volume

administration needed, Introducer catheter preferred. Hemodynamic monitoring

– Measurement of CVP– Pulmonary artery catheterization

Transvenous cardiac pacing

Temporary central venous Temporary central venous catheterscatheters

Procedures and Monitoring for the Critically Ill, Saunders, 2002

Temporary central venous Temporary central venous catheterscatheters

Descends in the carotid sheath to the medial end of the clavicle where it ends by uniting with the subclavian vein to form the innominate (brachiocephalic) vein.

Internal Jugular Vein AnatomyInternal Jugular Vein Anatomy

http://www.manbit.com/PAC/chapters/PAC.cfm

The carotid artery and internal jugular vein are well seen. The IJV is much larger than the artery.

Variable relationship of Internal Jugular Vein and Carotid Artery

Internal Jugular Vein AnatomyInternal Jugular Vein Anatomy

Coronal view through the thoracic inlet and thorax. Note that the most direct approach to the superior vena cava is via the right internal

jugular vein. Right IJ is preferred site for all IJ catheters initially whenever possible.

Internal Jugular Vein AnatomyInternal Jugular Vein Anatomy

http://www.manbit.com/PAC/chapters/PAC.cfm

Subclavian Vein AnatomySubclavian Vein Anatomy

Coronal view through the thoracic inlet and thorax.

http://www.manbit.com/PAC/chapters/PAC.cfm

The needle is inserted in the mid-clavicular line ~ 2 cms below the clavicle. Note that the index finger of the left hand is placed in the suprasternal notch.

Subclavian Vein ApproachSubclavian Vein Approach

Procedures and Monitoring for the Critically Ill, Saunders, 2004

Relation to thoracic ductRelation to thoracic ductThe confluence of the thoracic duct

and the left subclavian vein is shown in this diagram.

The duct loops behind the internal jugular vein to enter the subclavian vein in the region of its joining with the internal jugular vein. Thus it can be injured in left sided approach.

The point of insertion should be 1 cm medial to the artery and 2 cm inferior to the inguinal ligament.

Femoral Vein AnatomyFemoral Vein Anatomy

Procedures and Monitoring for the Critically Ill, Saunders, 2002

Femoral Vein/Femoral Vein/Artery variantsArtery variants

But…

-Vein may directly overlie the artery, or vice versa

-Femoral artery may overlie the vein in up to 13% of normal patients

Journal of Surgical Anatomy…May 1984

COMPLICATIONS

Up to 15% of patients who get central venous catheters have complications

Mechanical complications 5-19% of patientsInfectious complications 5-26% of patientsThrombotic complications 2-26% of patients

McGee DC, Gould MK. Preventing Complications of Central Venous Catheterizations.

N Engl J Med. 2003; 348 (12): 1123-33

Factors associated with Factors associated with Mechanical complicationsMechanical complications

Extremes of BMI (very low or high) Multiple prior catheterizations Advanced age Time needed to place catheter (multiple attempts) Prior radiotherapy, known history of vascular

disease

NEJM…2003;348;1123

Intensive care Med…2002;28:1036

Patient assessmentPatient assessment History:

– Bleeding history, Previous access, Radiation, Peripheral vascular disease, Existing catheters in place: PICC, HD access, AICD, Pacemaker, etc.

Medications:– Anticoagulants

Physical:– Clavicular anatomy, Flexibility, Trendelenberg positioning-- Can the patient be properly positioned?

Labs:– Platelets, PTT/PT INR

Ultrasound:– Vein compressible? Too close to the artery? Too small? Clot within the

vessel? Proper Site Selection

Thrombus within the Femoral Thrombus within the Femoral VeinVein

Vein overlying the ArteryVein overlying the Artery

Site Advantages & DisadvantagesSite Advantages & Disadvantages

Internal jugular– Large vessel, less complications– Ultrasound guidance is used– Uncomfortable, difficult to maintain dressings and catheter– Poor landmarks in obese pts– Vein collapses with hypovolemia– Prone to exposure to patients oral secretions.

Subclavian– Large vessel with high flow rate– Easy to dress and maintain, lower infection rate. – Vein less collapsible with hypovolemia– Pneumothorax, and Hematoma risk– Difficult to control bleeding, – Higher risk in ventilated patients, esp with high levels of PEEP.

Femoral– Easy access, Large vessel, Advantageous during code situations, can be placed

emergently, easier for inexperienced operators. – Uncomfortable, high rate of infection, thrombosis, phlebitis– More anatomic variations

Common Insertion MistakesCommon Insertion Mistakes

Multiple attempts at the same site– Max 3 attempts. Greater than 3 attempts is associated with

increased complication rates, regardless of operator skill. – Use Ultrasound when experienced operator available

Pushing the guidewire in too far Pushing the guidewire or catheter against resistance

– False passage can be created– Vessel can be torn– Guidewire can become entrapped

Pulling the guidewire or catheter against resistance– Entangled by other intravenous devices- AICD, PM, Vascath, etc– Knot formation

Right Internal Jugular Vein to Atrio-caval junction 16.0 cms

Right Subclavian Vein to Atrio-caval Junction 18.4 cms

Left Internal Jugular Vein to Atrio-caval Junction 19.1 cms

Left Subclavian Vein to Atrio-caval Junction 20 cm

How much guidewire is too How much guidewire is too much? much? Average Distance of atrio-caval junction from skin puncture site:

Crit Care Med 2000 Jan;28(1):138-42

16.5 cm should be considered the upper limit for most neck lines

Is the needle in the vein?Is the needle in the vein? Visual inspection of the color of the aspirated

blood. Observation of the blood flow characteristics

(pulsatility and volume) Measurement of the pressure within the vessel by

either a pressure transducer (CVP measurement) The use of ultrasound. Pulsatility and color may not be reliable indicators

of arterial vs venous placement in hypotensive or hypoxemic patients. Connect to CVP when in doubt.

Catheter complications: EarlyCatheter complications: Early

Injuries– Cardiac - arrhythmia– Lymphatic - Chylothorax– Great vessel perforation,– Vessel perforation or tears due to dilator or stiff

catheter Malposition

– 5% on post procedure CXR Air embolism

– Occurs during Insertion and removal– Cardiovascular collapse, wheel mill murmur– Rx: Left lateral decubitus positioning, air aspiration if

possible.

Catheter complications: EarlyCatheter complications: Early

Catheter embolism– Needs Radiologic retrieval

Guidewire complications– IVC filter entrapment– Guidewire entrapment on existing hardware– Loss of Guidewire

Pneumothorax– 2-10% with subclavian cannulation– 1-2% with internal jugular– Post procedure CXR mandatory– CXR needed before bilateral attempts!!

Mechanical Complications- PreventionMechanical Complications- Prevention

Recognize risk factors for difficult catheterization

Use ultrasound guidance during internal jugular catheterization; reduces the rates of unsuccessful catheterization, carotid artery puncture and hematoma formation

Do not schedule routine catheter changes; Insertion at a new site increases the risk of mechanical complications for the patient

A physician should only make 3 attempts; The incidence of mechanical complications after three or more attempts is six times the rate after one attempt

N Engl J Med. 2003; 348 (12): 1123-33McGee DC, Gould MK. Preventing Complications of Central Venous Catherizations

Pneumothorax/HemothoraxPneumothorax/Hemothorax

Serious and life threatening complication Reported incidence ranges from 0-6% Higher with Subclavian approach Pts may have Desaturation/hypotension after

placement, but 1/3 of pts are asymptomatic. CXR insensitive in making diagnosis early Presence of Pneumothorax must be ruled out after

any failed line attempt- esp prior to attempt on the opposite side.

PreventionPrevention

Optimal position Operator skill Alternate approach to subclavian site in high risk

patients- COPD, bullous disease, PEEP. Avoid multiple attempts Tredelenberg position

Bowyer MW, Bonar JP. Non-infectious complications of invasive hemodynamic monitering in the intensive care unit. In Complications in the ICU: recognition, prevention and management . 1997

Arterial PunctureArterial Puncture

Incidence ranges from 1-19%Easy to identify in pts with normal BP and

paO2. More obscure in hypoxemic, hypotensive pts.

Results in hematoma formation. Large hematoma formation in the neck can potentially cause airway compromise.

PreventionPrevention

Avoid multiple attempts Ultrasound guidance Correction of coagulopathies Use of small finder needle Do not use dilator when in doubt CVP/ABG for confirmation

Bowyer MW, Bonar JP. Non-infectious complications of invasive hemodynamic monitering in the intensive care unit. In Complications in the ICU: recognition, prevention and management . 1997

ArrhythmiasArrhythmias Atrial and ventricular arrhythmias frequently

accompany the insertion of CVP lines These arrhythmias occur as a direct result of

myocardial stimulation by the guidewire or catheter that has been advanced too far

Can be minimized by using the shortest catheter that will place the tip of the CVP catheter into the SVC just above the right atrium;

Bowyer MW, Bonar JP. Non-infectious complications of invasive hemodynamic monitering in the intensive care unit. In Complications in the ICU: recognition, prevention and management . 1997

Air EmbolismAir Embolism

Air may enter the great vessels directly when a needle is inserted

Most cases occur during use or catheter maintenance

Negative intrathoracic pressure in a spontaneously breathing pt can draw air into the vein

PreventionPrevention

Occlude hubs at all timesClear air bubblessFlush all catheter ports!!Trendelenberg postion increases CVP and

reduces likelihood of air entry

Thoracic duct injuryThoracic duct injury

The thoracic duct arches over the dome of the left lung lateral to the left internal jugular vein and joins the subclavian vein at the internal jugular-subclavian angle

Reported incidence of injury is 1%Most commonly occurs with left sided

subclavian cannulation

Catheter malpositionCatheter malposition

CXR confirms malpositionRepeat CXR can show migration of catheter

Radiographic assessment of Radiographic assessment of implanted catheterimplanted catheter

Tip of subclavian catheter at atrio-caval junction

Central Venous Catheter Tip PositionCentral Venous Catheter Tip Position

In the distal tip in the SVC for routine applications

In the upper right atrium, to achieve optimal performance of a hemodialysis or plasmapheresis catheter

The right tracheobronchial angle landmark

Journal Of Intensive Care..Feb 1999

Other ComplicationsOther Complications

Loss of Guidewire Guidewire perforation of vessel Guidewire kinking Dislodgement of IVC filters Guidewire fragmentation/embolization

Rx: Management of most of these complications will require interventional radiology or vascular surgery intervention.

Catheter InfectionCatheter Infection

Common (10%) and expensive (7 hospital days per infection, $6000-10,000)

10 to 20% mortality.Exit site, tunnel, catheter related sepsis,

septic thrombophebitis, metastatic bacteremia

Catheter infections: SourcesCatheter infections: Sources

Infection preventionInfection prevention

Strict Sterile technique Removal when no longer needed Catheter care teams

– Gauze dressing change Q48 hrs, transparent dressings Q7 days, intravenous tubing Q48-72 hrs, after blood transfusion or lipid infusion change with in 24 hrs

Scheduled Catheter replacements– Every 72-96 hrs for peripheral venous lines– No recommendations for peripheral arterial lines– No clear advantage to routine catheter change without sign

of infection.

Indications for Catheter Removal*Indications for Catheter Removal*

Bacteremia and/or clinical symptoms persisting beyond 48-72 hours despite appropriate IV antibiotic therapy through the catheter

Progressive exit site, insertion site, or subcutaneous tunnel infections

(especially Pseudomonas)

Reproducible chills or hypotension following irrigation of the catheter

Clinically unstable condition with line sepsis suspected

Evidence of septic emboli or endocarditis When catheter is no longer functional or required for

therapy

Removal of Central CathetersRemoval of Central CathetersNeck Lines

– Trendelenberg position advised Risk of air embolism is highest during removal

– Pressure

Limb lines– Reverse Trendenlenburg for femoral lines– Pressure– Occlusive dressing