- Hemodynamic pressure monitoring
- Central venous pressure (CVP); right-heart filling pressures, surrogate of left-heart filling pressures
- Pulmonary artery catheter insertion
- Pulmonary capillary wedge pressure monitoring
- Coronary sinus catheterization for minimally invasive cardiac surgery
- Large-bore intravenous access
- Rapid fluid resuscitation
- Rapid administration of blood replacement therapy
- Infusion of therapeutic drugs
- Vasoactive substances
- Chemotherapy
- Hyperalimentation
- Other substances that would be too caustic to the subcutaneous or peripheral vascular spaces
- Plasmapheresis, apheresis
- Renal dialysis
- Transvenous pacing
- Aspiration of air embolism
Absolute Contraindications
- Patient refusal
- Infection at the insertion site
- Anatomical variance at the insertion site
- Superior vena cava syndrome (except femoral venous line)
Relative Contraindications
- Coagulopathy
- Systemic infection
- Right-sided ventricular assist device
- Presence of indwelling catheters or pacing wires at the insertion site
- Sterile mask, gloves, and gown
- Standard monitors, such as pulse oximeter, blood pressure cuff, and ECG
- When possible, peripheral IV with infusion solution
- Sterile prep solution (e.g., chlorhexidine)
- Sterile drapes
- 5-mL sterile syringe with 25- or 30-gauge needle for local anesthetic infiltration
- Local anesthetic (usually 1% lidocaine)
- 22-gauge, 1.5-inch needle
- 18- or 20-gauge intravenous catheter (over a needle) on a syringe, or 18-gauge hollow-bore needle
- Pressure tubing
- Guidewire
- No. 11 scalpel blade
- Central venous catheter with dilator
- 3.0 suture on cutting needle
Central venous line placement is typically performed at four sites in the body: the right or left internal jugular vein (IJV), or the right or left subclavian vein (SCV). Alternatives include the external jugular and femoral veins. A long catheter may be advanced into the central circulation from the antecubital veins as well.
The internal jugular vein follows a line from the inferior aspect of the external acoustic meatus to the medial aspect of the clavicle. It passes deep to the sternocleidomastoid muscle between the two heads and joins the subclavian vein to form the brachiocephalic vein, posterior to the clavicle closest to the sternum.
The subclavian vein is a continuation of the axillary vein draining the arm. It begins at the lateral border of the first rib and ends at the thoracic inlet where it meets the IJV to form the brachiocephalic vein. The SCV passes over the first rib and apical pleura and runs along the underside of the clavicle parallel with the subclavian artery but is separated from the artery at the anterior scalene muscle, with the vein passing over the muscle.
Central venous catheterization via the internal jugular vein has a lower incidence of pneumothorax compared to catheterization via the subclavian vein, and it can be easily compressed after catheter removal or after unintentional arterial puncture. Ultrasound can be a valuable adjunct for IJV cannulation, because the incidence of anatomical variants may be as high as 8.5%. Subclavian vein catheterization is more comfortable for awake patients and less prone to contamination from respiratory secretions, particularly in patients with tracheotomies.
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Figure 2
:
Internal jugular vein. From Drake R, Vogl AW, Mitchell AWM, Tibbitts RM, Richardson PE: Gray's Atlas of Anatomy. Philadelphia, Churchill Livingstone/Elsevier, 2008, p 491.
Figure 3
:
Mediastinal course of the internal jugular vein, subclavian vein, and brachiocephalic vein on the right and left. From Drake R, Vogl AW, Mitchell AWM, Tibbitts RM, Richardson PE: Gray's Atlas of Anatomy. Philadelphia, Churchill Livingstone/Elsevier, 2008, p 95.
Figure 4
:
Subclavian vein, formed by the union of the axillary vein draining the arm, and the internal jugular vein. From Drake R, Vogl AW, Mitchell AWM, Tibbitts RM, Richardson PE: Gray's Atlas of Anatomy. Philadelphia, Churchill Livingstone/Elsevier, 2008, p. 377.
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