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.
- ▪ 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)
- ▪ 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
- —Parenteral nutrition
- ▪ Contraindications.
- —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
- —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
- —Transfixion may be used for internal jugular and
- —Small gauge finder needle to identify vessel location
- —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 catheter into the ...