Chapter 43

• Intravenous hemodynamic monitoring.
• Central venous sampling.
• Parenteral nutrition.
• Hemodialysis.
• Transvenous pacing.
• Placement of pulmonary artery catheters.

• Significant coagulopathy, especially with platelet counts < 50,000/μL.

• The patient should be supine, in Trendelenburg (head-down) position for subclavian and internal jugular lines, and in reverse Trendelenburg (head-up) position for femoral lines.
• For infraclavicular subclavian vein access in larger patients, and those in whom the clavicle is difficult to palpate, a rolled towel can be placed between the shoulder blades to facilitate access.
• For femoral lines the patient should be placed supine with the leg slightly abducted and externally rotated.
• The patient should be placed on continuous monitoring.
• The area chosen should be widely exposed and all necessary hair trimmed.
• The area is prepared with a chlorhexidine-based skin solution and sterile drapes are applied.

• Placement of internal jugular and subclavian central venous catheters is confirmed with a chest radiograph; no radiographs are required for femoral line placement.
• In general, it is recommended that the catheter tip lie within the superior vena cava, outside of the right atrium and above the pericardial reflection. On chest radiographs, therefore, the tip should lie above the level of the carina.
• A sterile dressing is applied to the central line, which is changed weekly.
• Current guidelines indicate that catheters should only be replaced if there is evidence of sepsis or localized infection, and that routine replacement is not indicated.
• Topical antibiotic ointment at the insertion site does not reduce infection rates and should not be used.
• Central venous catheters should be removed as soon as possible.

• Each year 250,000 central venous catheter-related infections occur in the United States, with an associated mortality of 12–25% and a cost of $25,000 per infection. • Femoral venous catheters have higher rates of infection and iliofemoral thrombosis in comparison with subclavian and internal jugular sites. • When the femoral technique is used in patients during cardiac arrest, misplacement in the retroperitoneum, femoral artery, or elsewhere occurs in up to 30% of cases. • Pneumothorax may occur with both internal jugular and subclavian vein access approaches. • Review of the literature reveals no difference in the rates of major complications, including pneumothorax, between subclavian and internal jugular vein catheters. • If a patient might require dialysis in the future, an internal jugular approach is preferred to a subclavian approach to prevent the possible complication of subclavian vein stenosis, which would limit arteriovenous dialysis access options. • Malposition of the catheter. • Dysrhythmia, often caused by advancing the wire into the right atrium. • Arterial puncture. • Guidewire loss. • Venous thrombosis and stenosis. • Retroperitoneal dissection. • Arteriovenous fistula, a late complication. ### MyAccess Sign In Username Password Want remote access to your institution's subscription? Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access. Ok ### About MyAccess If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus. ## Subscription Options ### AccessAnesthesiology Full Site: One-Year Subscription Connect to the full suite of AccessAnesthesiology content and resources including procedural videos, interactive self-assessment, real-life cases, 20+ textbooks, and more$995 USD

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