Welcome to weekly Scientific Seminar

Venue: Casualty block 1Dhaka Medical College Hospital

Central Venous Catheterization&

Venous cut down Technique

Presented byDr. Mominul Haider

Resident (Phase A)Department of Urology

BSMMU

Central Venous Catheterization

Introduction

• Central venous access refers to lines placed

into the large veins of the neck, chest, or groin

and is a frequently performed invasive

procedure which carries a significant risk of

morbidity and even mortality.

• This procedure should be carried out in

operating theatre or high-dependency care

areas, always using a fully aseptic technique.

Indications• Monitoring of central venous pressure in critically ill

patient and after major surgery • Infusion of irritant drugs that may damage smaller

veins.• Insertion of pacing wires.• Renal replacement therapy.• Emergency venous access.• Parenteral feeding.• Resuscitation of patients who are intravascularly

depleted.

Relative Contraindications

• Uncorrected coagulopathy• Thrombocytopenia• Skin infection over the site of access• Obscure anatomical landmarks• Haemo or pneumothorax on the contralateral

side• Recent surgery to other structures nearby

such as carotidendartectomy

Sites

• Right Subclavian Vein• Internal Jugular vein• Femoral Vein

Site Advantage Disadvantage

Subclavian •Lower risk of infection

•Does not require movement of patient’s head and can be accessed during c-spine immobilisation

•Useful in emergencies

•Vein does not collapse fully in hypovolaemic states

•Highest chance of pneumothorax•Puncture of tracheostomy or ET tube cuff•Cannot apply pressure to stop bleeding

•Can be painful even with good skin anaesthesia

•Less easy to visualise with USG

Site Advantaqge Disadvantage

Internal jugular

•Anatomy readily visible with ultrasound

•Can be adapted to accommodate patient sizeand position

•Easily accessed surface of patient

•Puncture of internal carotid or misplaced line in the internal carotid

•Pneumothorax is a recognised complication

•Difficult to nurse long term.

Site Advantaqge Disadvantage

Femoral •Safest vein to place large lines, for example forveno–veno haemofiltration because there arefewer important structures nearby.

•Puncture of femoral artery can usually be treatedwith pressure

•Femoral artery puncture leading to retroperitoneal bleed

•Femoral nerve damage

•Difficult to nurse and keep clean

•Highest likelihood of infection

Central line kit containing: Additional items:

• needle or a cannula over needle• central venous catheter• guidewire• dilator• anchoring clips.

• suture• scalpel• appropriate dressing• syringes• blue and green needles• three-way taps, one for each lumen• drapes• cleaning fluid (2% chlorhexidine gluconate in 70% isopropyl alcohol is recommended)• swabs• Gallipot or similar• sterile ultrasound probe sheath• 0.9% normal saline

Equipments needed

Basic Principles• Must Decide if the line is really necessary• Should know the anatomy• Should be familiar with the equipments• Must obtain optimal patient positioning and cooperation• Should not try to do it fast• Must use sterile technique• Always have a hand on the guide wire• Should ask for help• Always aspirate as you advance as you withdraw the

needle slowly• Always withdraw the needle to the level of the skin before

redirecting the angle• Obtain chest x-ray post line placement and review it

Subclavian Approach • Positioning

– Right side preferred– Supine position, head neutral, arm abducted– Trendelenburg (10-15 degrees) – Shoulders neutral with mild retraction– Right side preferred

• Needle placement– Junction of middle and medial thirds of clavicle– At the small tubercle in the medial deltopectoral groove– Needle should be parallel to skin – Aim towards the supraclavicular notch and just under the

clavicle

Internal Jugular Approach• Positioning

– Right side preferred– Trendelenburg position– Head turned slightly away from side of venipuncture

• Needle placement: Central approach– the triangle formed by the clavicle and the sternal and

clavicular heads of the SCM muscle is located– three fingers of left hand are gently palced on carotid

artery – Needle should be placed at 30 to 40 degrees to the

skin, lateral to the carotid artery– Aim toward the ipsilateral nipple under the medial

border of the lateral head of the SCM muscle– Vein should be 1-1.5 cm deep, deep probing in the

neck should be avoided.

                                                                                              

Internal Jugular Central Approach

Femoral Approach

• Positioning– Supine

• Needle placement– Medial to femoral artery – Needle held at 45 degree angle – Skin insertion 2 cm below inguinal ligament– Aim toward umbilicus

Femoral artery

Femoral nerve

Femoral Vein

Post-Catheter Placement

• Aspirate blood from each port• Flush with saline or sterile water• Secure catheter with sutures• Cover with sterile dressing (tega-derm)• Obtain chest x-ray for IJ and SC lines• Write a procedure note

Procedure Note

• Name of procedure• Indication for procedure• Comment on consent, if applicable• Describe what you did, including prep• Comment on aspiration/flushing of ports• How did patient tolerate procedure• Any complications

Maintenance of CV line• Hepsol flush 8 hourly• Central Short channel is used for measuring

CVP• Rest two channels are used for medication

and TPN• The dressing should be changed at regular

interval• Catheter should not be kept for more tha 3

weeks

Ultrasound-Guided Central Venous Access

• Becoming standard of care• Vein is compressible• Vein is not always larger• Vein is accessed under direct

visualization• Helpful in patients with

difficult anatomy

                                                                                 

                                                                                                                                                                  

Needle entering IJ

                                                                                 

FemoralVein

Femoral Artery

Compression of veinwith US probe

Complications • Vascular

– Air embolus– Arterial puncture– Arteriovenous fistula– Hematoma– Blood clot

• Infectious– Sepsis, cellulitis, osteomyelitis, septic arthritis

• Miscellaneous – Dysrhythmias– Catheter knotting or malposition– Nerve injury– Pneumothorax, hemothorax, hydrothorax,

hemomediastinum

Venous cut down

• Venous cutdown is a surgical technique by which a selected vein is exposed and mobilised and then cannulated under direct vision.

• It has been largely replaced by central venous and intraosseous access, but remains a useful alternative when other methods fail or are not available.

Cutdown sites

• Basilic vein (antecubital fossa)• Adult: 2–3 cm lateral to the medial epicondyle

of the humerus. • Child: 1–2 cm lateral to the medial epicondyle

of the humerus.

Cutdown sites

Long saphenous vein (groin)• Adult: 4 cm inferior and lateral to the pubic

tubercle.

Long saphenous vein (ankle)• Adult: 2 cm anterior and superior to the

medial malleolus.• Child: 1 cm anterior and superior to the

medial malleolus.

Step-by-step cutdown method

• Place a venous tourniquet proximal to intended cutdown site where possible.

• Identify cutdown site and inject local anaesthetic along the intended incision line if the patient is conscious.

• Make a transverse incision through skin being careful not to damage the underlying vein

• Spread the skin and identify the vein lying at right angles to the line of the incision.

• Mobilise a 2-cm length of vein by blunt dissection using curved forceps

• Pull a loop of suture (e.g. 2/0 vicryl) under vein.

• Cut the loop to form proximal and distal sutures.

• Tie off distal suture and transfix vein with a needle

• Make a vertical stab incision down onto the transfixing needle to produce a hole (venotomy) in the anterior vein wall

• Insert a cannula or the cut end of a sterile giving set through venotomy into vein

• Tie off proximal suture around vein and inserted cannula.

• Suture and dress wound.

Complications of venous cutdown

• Damage to adjacent structures• Posterior wall perforation• Haematoma• Extravasation of fluid or drugs• Local cellulites• Phlebitis• Venous thrombosis• Scarring

Thank you