Central Venous Line Placement (General Surgery)

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SAMPLE EXCERPT
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PRE-PROCEDURE
INDICATIONS
  • 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
CONTRAINDICATIONS

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
EQUIPMENT
  • 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
ANATOMY

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.


PROCEDURE
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The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
CARE
  • Flush lumens on catheter with saline.
  • Obtain chest radiograph to confirm position of catheter and exclude pneumothorax.
  • Use sterile technique when injecting drugs or connecting tubing to lumens of catheter.
  • Routinely replace sterile dressings, cleansing the site with chlorhexidine before applying a new dressing.
  • Examine the insertion site daily for signs of infection.
  • While the catheter is in place, leave sterile caps in place at all times and cleanse ports with alcohol before connecting anything to them.
  • When preparing to remove the catheter, place the patient in Trendelenburg?s position. Ask the patient to exhale as the catheter is removed, to prevent air embolism, and apply pressure over the site for 1 to 2 minutes for hemostasis.
COMPLICATIONS

Infrequent

  • Minor hematoma formation at insertion site
  • Local infection
  • Arterial (carotid, subclavian, vertebral) puncture
  • Arrhythmia

Serious, Rare Complications

  • Major hematoma compressing airway
  • Major trauma to large vessels with hemorrhage
  • Cardiac perforation with tamponade
  • Pneumothorax or hemothorax (diagnosis via chest radiograph)
  • Thoracic duct injury, usually associated with left subclavian or internal jugular approach (diagnosis established by the presence of chyle in pleural fluid)
  • Sepsis
  • Venous air embolism
  • Nerve injury
  • Venous thrombosis and pulmonary emboli
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