Chapter 36. Central Venous Catheterization

Introduction

Central veins are routinely cannulated in the intensive care unit (ICU) for pressure monitoring, drug administration and access to large vessels for procedures such as hemodialysis or administration of parenteral nutrition.

Definitions and Terms

• ▪  Central venous catheter (CVC): Typically a catheter whose tip lies within the thorax, although a femoral venous catheter may be considered a CVC
• ▪  Central venous pressure: The pressure measured at the tip of a CVC
• ▪  Multilumen CVC: CVC with multiple separate channels with orifices lying at varying points along the catheter—each lumen can be treated as a separate fluid path
• ▪  Antibiotic impregnated catheter: A CVC impregnated with chlorhexidine, silver sulfadiazine, minocycline, and/or rifampin designed to decrease the rate of CVC associated infections
• ▪  Internal jugular (IJ)
• ▪  Subclavian vein (SCV)

Techniques

• ▪  Indications for central line placement.
  • —Central venous pressure monitoring
  • —Administration of vesicant drugs that cause phlebitis or pain in peripheral, slow flowing veins
  • —Alternative access when peripheral veins are unavailable due to dehydration, hemorrhage, or prior intravenous access with scarring
  • —Parenteral nutrition
• ▪  Contraindications.
  • —Coagulopathy
  • —Skin infection
  • —Contralateral carotid disease, where IJ cannulation may result in injury to remaining (ipsilateral) carotid
  • —Subclavian cannulation when contralateral lung is diseased or absent, and ipsilateral pneumothorax puts patient at relatively increased risk
• ▪  Prior to procedure, obtain patient consent, prep and drape, and perform universal protocol as described in Section I.
• ▪  Identify cannulation site based on patient anatomy and clinical situation (Figure 36-1 and Table 36-1).
• ▪ Preparation.
  • —Skin: The CDC recommends preparation of the cannulation site with a 2% aqueous chlorhexidine-gluconate solution (Figure 36-2), which has been associated with lower blood stream infection rates than povidine-iodine or alcohol-based preparations. The skin and tissue around the vessel should be infiltrated with 1% lidocaine solution, except in patients with a known allergy to lidocaine, in whom alternative local anesthetics can be used.
  • —Hygiene: The operator should observe proper hand hygiene and use maximal barrier precautions including gown, mask, and gloves and a large sterile drape or multiple drapes covering a large area (Figure 36-3).
• ▪  Methods (see Chapter 34 on vessel cannulation).
  • —Direct cannulation is typically used for subclavian cannulation.
  • —Transfixion may be used for internal jugular and femoral cannulation.
  • —Small gauge finder needle to identify vessel location (Figure 36-4).
  • —Seldinger technique can be used as an adjunct for catheter exchange with either of the above cannulation techniques (Figures 36-5 and 36-6).
  • —Ultrasound-guided vessel location and cannulation has been advocated for internal jugular cannulation and is equally appropriate for femoral cannulation.
• ▪  The cannulation site should be below the level of the heart during vessel cannulation during IJ and SCV cannulation to prevent air entrainment, and needles and catheter lumens occluded with a finger or obturator.
• ▪  Many experts recommend transduction of vascular pressure prior to passage of a large bore ...