Abstract
Central venous access is obtained via the internal jugular vein (IJV), subclavian vein (SCV), or femoral vein.
General Principles
Central venous access is obtained via the internal jugular vein (IJV), subclavian vein (SCV), or femoral vein.
Central venous catheter (CVC) use should be minimized, and lines removed as soon as possible to prevent infection.
Indications for placement include:
◦ Administration of vasopressors or other venous irritants
◦ Parental nutrition
◦ Hemodynamic monitoring
▪ Central venous pressure monitoring
▪ Central venous oxygen saturation
▪ Pulmonary artery catheter
◦ Facilitation of transvenous pacing (right IJV or left SCV only)
◦ Large volume resuscitation
◦ Peripheral access is unobtainable
Ultrasound guidance can increase the accuracy of CVC placement and may decrease the number of attempts, and therefore the associated complications.
Instruments
Multiple commercially available kits exist for CVC placement. The operator should ensure familiarity with the specific product prior to use. General contents of a kit include 18-gauge needle for accessing the vein, 10 cc syringe, guidewire, dilator (sometimes multiple), and catheter (Figure 16.1).
Additional equipment that may not be included in the kits are chlorhexidine prep, sterile drapes, gloves, gown, local anesthetic, appropriately sized needles, additional syringes, sterile saline, chlorhexidine-impregnated sponge, and sterile dressings.
Ultrasound equipment, a high-frequency linear probe (greater than or equal to 7 MHz for optimal resolution of superficial structures), and a sterile probe cover are required for ultrasound-guidance.
Multiple types of catheters are available. The most common CVC placed is the 7-Fr standard triple lumen catheter. It allows for simultaneous administration of medications and/or blood products through three separate lumens. For patients requiring rapid, large-volume resuscitation, a single lumen 8.5-Fr percutaneous sheath introducer is recommended. If a transvenous pacer is necessary, a 6-Fr percutaneous sheath is recommended. Use of a larger catheter will result in blood backing up into the catheter and leaking around the pacer wire.
Antiseptic (chlorhexidine/silver sulfadiazine) or antibiotic-bonded (minocycline/rifampin) catheters should be considered if the duration of the catheter stay is expected to be >5 days.
Figure 16.1 General contents of a commercially available central venous catheter kit.
Preprocedure
Consent from the patient or family member should be obtained whenever possible.
Elective procedures should be performed under full sterile precautions, including full-body draping, gown, mask, and sterile gloves. Skin disinfection with chlorhexidine is superior to alcohol or betadine. The skin entry site should be covered with dry gauze or transparent breathable dressing. When ultrasound is used, the probe should be covered with a sterile probe cover.
Positioning and Landmarks
Internal Jugular Vein
The patient should be placed in the Trendelenburg position. This position dilates the IJV and also reduces the risk of air embolism. Ideal positioning involves turning the patient’s head 45 degrees to the contralateral shoulder. Alternatively, a neutral position can be used for patients requiring cervical spine precautions.
Surface anatomic landmarks include the sternocleidomastoid muscle, its division into sternal and clavicular heads, as well as the clavicle, the external jugular vein, and the suprasternal notch (Figure 16.2).
Several approaches have been described; however, the use of ultrasonography is now considered standard of care. The landmark approaches should be reserved for situations in which ultrasound is not available.
In the most common landmark approach, the skin is punctured at a 30-degree angle at the apex of the division of the sternocleidomastoid muscle and advanced toward the ipsilateral nipple.
In the ultrasound-guided approach the IJV is identified as the lateral, compressible vessel in the neck. The carotid artery is located medially, and pulsation of the artery can be observed on ultrasound. The probe is held in the operator’s nondominant hand and can be oriented to visualize the vein in the short axis, long axis, or oblique axis. The skin is punctured at a 30–45-degree angle, and the needle is visualized in real time as it is advanced into the vein (Figure 16.3, Figure 16.4).
Figure 16.4 Access of the IJV using ultrasound guidance.
Subclavian Vein
The patient should be placed in the Trendelenburg position to reduce the risk of air embolism.
Ideal positioning involves a roll placed under the patient’s shoulders. Alternatively, a neutral position can be used for patients requiring cervical or thoracic spine precautions.
Surface anatomic landmarks of the infra-clavicular portion include the middle of clavicle and the sternal notch.
Under ultrasound guidance, the IJV should first be located as described above. The ultrasound probe should then be moved caudally into the supraclavicular fossa, where the confluence of the IJV and SCV is identified. The SCV is anterior to the subclavian artery (Figure 16.5).
Using the landmark approach, the nondominant hand of the operator is placed over the clavicle, with the index finger in the sternal notch and the thumb at the angle of the clavicle in the deltopectoral groove (Figure 16.6).
The SCV should be punctured as it crosses under the clavicle, at the lateral border of the medial third of the clavicle. The skin should therefore be punctured 1–2 cm inferior and lateral to this point.
The needle is advanced inferior to the clavicle while aiming at the sternal notch.
