all you need to know about central venous catheterisation

1. CENTRAL VENOUSCENTRAL VENOUS
CATHETERISATIONCATHETERISATION
Dr Arundev P Nair
Government Medical College
Kottayam

2. • A Central Venous Catheter (CVC) is an
indwelling intravenous device that is
inserted into a vein of the central
vasculature.

3. Sites for CVC placement
• 3 main sites are used for CVC placement
IJV, Subclavian and Femoral
• All have the options of either right or left
placement

4. Indications
• High volume resuscitation & surgery
involving large fluid shifts
• CVP monitoring
• Aspiration of air embolism

5. Indications
• Inability to obtain peripheral venous access
• Repetitive venous sampling
• Haemodialysis or plasmapheresis
• Infusion of irritant substances
• Insertion of transvenous cardiac
pacemakers
• Pulmonary artery catheterization &
monitoring of PAP

6. When should you not insert a
central line??
• Absolute CI
SVC syndrome
Pneumothorax/haemothorax on
contralateral side
• Relative CI
Coagulopathies
Carotid disease
Diaphragmatic dysfunction

7. • Relative CI
Newly inserted pacemaker wire
Thyromegaly
Previous neck surgery
Burns scar
Skin infection
No consent/uncooperative patient

8. History…

9. 1st
cardiac catheterization
performed on a living animal
• English physiologist Stephen Hales 1711

10. • By accessing the IJV and carotid artery of a
horse, Hales performed his experiment with
a Brass pipe as the catheter connected by a
flexible goose trachea to a long glass
column of fluid. The pressure of beating
heart was transmitted which raised the
column of fluid

12. Cardiac catheterization in
humans
• I st done by Werner Theodor Otto
Forssmann who was a german surgeon
• Performed venous cut down of his own
antecubital vein and passed a urinary
catheter to a distance of 65cms and climbed
down several flight of stairs to the radiology
suite to confirm that it terminated in right
atrium

15. • Duffy reported a lot of femoral, jugular and
antecubital approached by around 1949
• By 1952, Dr Aubaniac while working for
French army developed the infraclavicular
subclavian approach in the battlefield to
resuscitate the wounded soldiers
• Supraclavicular subclavian approach was
developed later by Yoffa in 1965

17. • The most important advancement in the
field of modern CVC came by 1953 when
the Swedish radiologist named Sven
Seldinger developed a novel and safe
method of advancing flexible catheters over
a flexible wire inserted through a
percutaneous needle

20. Sites for CVC placement
• 3 main sites are used for cvc placement
IJV,Subclavian and Femoral
• All have the options of either right or left
placement

22. • Let us review the surface anatomy of three
sites for CVC placement

23. IJV

28. Location of IJV

31. Positioning
◦ Right side preferred
◦ Trendelenburg position 15 degree
◦ Head turned slightly away from side of
venipuncture
◦ Roll is placed between the shoulder
blades
◦ Head ring may be removed

33. • Real time ultrasound in CVC placement is
now regarded the gold standard as opposed
to the conventional landmark technique
• Monitors are to be attached
• Oxygen to be administered via SFM

35. Different ways of imaging the
needle

37. Preparative steps

48. 3 approaches
• Anterior
• Central
• Posterior

53. Local infiltration given

55. 22 G Finder
Needle
1&1/2inch(3.7cm)

56. 18G 2&1/2 inch(6.4cm)

59. How to confirm iv placement
• Lack of pulsatile flow
• Usg
• Visual colorimetry
• Attach a transducer & compare wave forms

70. Subclavian Approach

73. Needle placement
◦ Junction of middle and medial thirds of clavicle
◦ At the small tubercle in the medial deltopectoral groove
◦ Needle should be parallel to skin
◦ Aim towards the suprasternal notch and just under the
clavicle

77. Femoral Venous Cannulation

79. N A V y

80. • Palpate the femoral artery
• Vein lies medial
• Puncture it
• 15-20 cm catheter reaches upto common
iliac vein
• 40-70 long catheter reaches cavo atrial
junction

83. Post-Catheter Placement
• Aspirate blood from each port
• Flush with saline or sterile water
(heparinised)
• Secure catheter with sutures
• Cover with sterile dressing (tega-derm)
• Obtain chest x-ray for IJ and SC lines
• Write a procedure note

84. Catheter position confirmation
• Inside operation theatre 
Aspiration of blood
Movement of fluid column with ippv
• Post op in icu
CXR

85. Where should the tip of catheter
be??
• Above the level of carina
• Above the level of 3rd
rib
• Above T4/T5 interspace

88. 1.9 TO 15%

90. • hemothorax, Cardiac conduction
abnormalities, asystolic cardiac arrest of
unknown etiology, inferior vena cava (IVC)
trauma, pericardial tamponade

91. • Guide wire related complications like
Kinking, looping, or knotting of wire,
entanglement of previously placed
intravascular devices, Breakage of the
distal tip of the guide wire with subsequent
embolization and intravascular loss of a
guide wire

93. • During central venous catheterization,
guide wire-related complications are
uncommon and essentially preventable.

94. The following precautions
should be taken:
• Inspect the wire for defects before
insertion
• Consider a guide wire to be a delicate and
fragile instrument

95. • When resistance to insertion is met,
remove and inspect the wire for damage,
reposition the introducer so that no
resistance to its passage is felt

96. • Particular caution should be used when
attempting central catheter placement in
patients who are predisposed to thrombosis
or have had repeated catheterizations of a
particular vessel

97. • If multiple manipulations are needed,
reinspect the wire and replace it if
necessary

98. • Pass catheter over wire into the vein
• Make sure that the wire is visible at the
proximal end, before the catheter is
advanced

99. • The catheter should be ‘railroaded’ over
the guide wire into the vein, holding the
wire, and not pushing catheter and wire
together into the vein

100. • Always inspect the wire for complete
removal at the end of the procedure
• Hold onto the wire at all times until
removal from the vessel.

102. 2ND
most common

103. Caveats & Helpful hints
•
•
•
If there is a concern about possibility of bleeding –
avoid Subclavian approach, as direct compression is difficult and
surgical exploration is required

104. If anticipating Transvenous Pacemaker
or PA catheter insertion,
use either Right IJV or Left Subclavian
approach, as this aligns
catheter trajectory with SVC and RA.

105. The catheter tip should be positioned in
the SVC and not the right atrium.
In most adults, the right atrium is 10–15
cm
From the subclavian vein. Be sure that the
catheter is not inserted deeper than this.

106. Caveats & Helpful hints
.
•
•
If pneumothorax occurs and central access remains a priority,
subsequent attempts should be made on the same side of the
thorax as the pneumothorax to prevent the development of
bilateral pneumothorax
•

107. If the pulse cannot be palpate
(e.g. cardiac arrest),
divide the distance from the anterior
superior iliac spine to the symphysis pubis
into thirds.

108. The artery typically lies at the junction of
the medial and the middle thirds and the
vein is 1 cm medial to this location.
Excessive contralateral head rotation
increases overlap of the
carotid by the internal jugular and may
increase the risk for arterial injury.

109. A N D R É F. CO U R N A N D
Nobel Lecture, December 11, 1956
“For us in 1943, the cardiac catheter was only the key in
the lock. To guide our hand in turning this key, we had all
the knowledge accumulated through the years by
physiologists in their studies of animals”

110. And certainly this valuable key
has unlocked the door to
expanded diagonostic capabilities
and therapeutic interventions