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Demonstration of central line insertion
1. Demonstration of
Peripheral & Central
Line Insertion
Presented By Moderated by
Dr. Rajat Maheshwari Dr. Sanjay Sisodiya (MS)
RSO 2ndYear
2. PERIPHERAL VENOUS LINE
▪ A Peripheral venous line or peripheral venous access catheter is a
catheter (small, flexible tube) placed into a peripheral vein for
intravenous therapy such as medication fluids.
3. Requirements
▪ IV cannula of appropriate size(18-20G in adults and 22G in children)
▪ Tourniquet
▪ Sterile gloves
▪ Alcohol swab
▪ Dressing
4. GAUGE COLOUR FLOW RATE(ml/min)
24G Yellow 20
22G Blue 35
20G Pink 60
18G Green 105
16G Gray 220
14G Brown 330
7. Central Line Catheterisation
▪ A catheter (tube) that is passed through a vein to end up in the
thoracic (chest) portion of the vena cava (the large vein returning
blood to the heart) or in the right atrium of the heart is called Central
Line Catheterisation.
▪ It is also called CentralVenous Line or Central Line or CentralVenous
Access Catheter.
8. SITES OF CENTRAL LINE INSERTION
Catheters can be placed in veins in the :
▪ neck (internal jugular vein),
▪ chest (subclavian vein or axillary vein),
▪ groin (femoral vein),
▪ or through veins in the arms (also known as a PICC line, or
peripherally inserted central catheters).
9. INDICATIONS
▪ High volume fluid resuscitation & surgery involving large fluid shifts.
▪ Long-term intravenous antibiotics
▪ Long-term parenteral nutrition, especially in chronically ill persons
▪ Drugs that are prone to cause phlebitis in peripheral veins (caustic),
such as:
– Calcium chloride
– Chemotherapy
– Hypertonic saline
– Potassium chloride (KCl)
– Amiodarone
– Vasopressors (for example, epinephrine, dopamine)
10. ▪ Plasmapheresis
▪ Peripheral blood stem cell collections
▪ Haemodialysis
▪ Frequent or persistent requirement for intravenous access
▪ Need for intravenous therapy when peripheral venous access is
impossible
▪ Monitoring of the central venous pressure (CVP) in acutely ill people
to quantify fluid balance
11. ▪ Insertion ofTrans venous Cardiac Pacemakers.
▪ Pulmonary Artery catheterisation and measurement of Pulmonary
artery pressure.
14. PROCEDURE
THE SELDINGERTECHNIQUE:
▪ Set up the equipment and sterile preparations.
▪ Land marking the access sites.
▪ Infiltration of local Anaesthesia.
▪ Location of the vein .
▪ Inserting the introducer needle into the vein.
▪ Assessment of venous or arterial placement.
▪ Insertion of guide wire.
15. ▪ Removal of the introducer needle.
▪ Skin incision at the site of insertion of guide wire.
▪ Insertion of the dilator.
▪ Removal of the dilator and insertion of the catheter over the guide
wire.
▪ Removal of the guide wire.
▪ Flushing and capping of the lumens.
▪ Securing the catheters with sutures
16.
17. Internal Jugular venous Access
A rough surface marking of the Internal JugularVein is from the ear
lobe to the sterno clavicular joint.
It lies between the two heads of Sternocleidomastoid muscles and
usually lateral to the carotid artery.
The patient is explained the procedure and made to lie supine with his
neck tilted to the opposite side and a sand bag placed between the
shoulder blades and neck slightly extended to 5 degrees to distend the
neck veins.
The area is painted and draped and infiltrated with 1% lignocaine.
There are 3 approaches to IJ venous cannulation: anterior, central and
posterior approach.
18.
19.
20.
21. Internal Jugular venous cannulation
merits & demerits
Merits
▪ Good external landmarks.
▪ Less risk of pneumothorax than
with SCV
▪ Can recognise and control
bleeding.
▪ Almost a straight course to the
SVC on the right side.
▪ Malposition of the catheter is
rare.
Demerits
▪ Higher risk of infections than
SCV access.
▪ Higher risk of thrombus
formation than SCV.
▪ More difficult and inconvenient
to secure.
22. Subclavian Venous Cannulation
▪ The axillary vein courses medially to become the subclavian vein as it
passes anteriorly to the first rib. After crossing the first rib, the vein
lies posterior to the medial third of the clavicle at the change in
curvature of the clavicle.
▪ The goal of subclavian venipuncture is to pass a needle inferior to the
clavicle and superior to the first rib to access the subclavian vein as it
courses over the first rib.
▪ The patient is placed supine with head tilted to the opposite side and
sand bag placed between the shoulder blades.The shoulder of the
site of insertion is slightly retracted.
23. Paint and drape the clavicular
region and infiltrate the skin
below the midpoint of clavicle
with 1% lignocaine.
The site of needle insertion is
around 1cm below the
junction of medial and middle
1/3rd of clavicle with the angle
of needle parallel to the skin
and directed towards the
suprasternal notch.
Subclavian Venous Cannulation
24. Subclavian Venous Cannulation Merits &
Demerits
Merits
▪ Lesser risk of infection than IJV.
▪ Lesser risk of thrombus than
IJV.
▪ Good external landmarks.
Demerits
▪ Higher risk of pneumothorax.
▪ Unable to compress bleeding
vessel.
25. The surface landmark for
femoral vein lies within the
femoral triangle in the groin.
The femoral vein lies medial
to the femoral artery below
the inguinal ligament.
Under aseptic precautions and
after infiltrating the region
with 1% lignocaine, the
femoral artery pulsations are
palpated and the needle is
inserted 45degrees to the skin
around 1cm medial to the
artery and 2-3cm below the
inguinal ligament in cephalic
direction pointing towards the
umbilicus.
Femoral Venous Cannulation
26.
27.
28. Femoral Venous cannulation Merits &
Demerits
Merits
▪ Good surface landmarks
▪ Useful alternative with
coagulopathy
Demerits
▪ Highest risk for infection
▪ Higher risk for thrombus
▪ Difficult to secure in
ambulatory patients
▪ Not reliable for CVP
measurement.
29. Peripherally inserted central catheter
▪ It is a catheter that enters the body through the skin (percutaneously)
at a peripheral site, extends to the superior vena cava (a central
venous trunk), and stays in place (dwells within the veins) for days or
weeks.
▪ A peripherally inserted central catheter (PICC or PIC line), less
commonly called a percutaneous indwelling central catheter, is a
form of intravenous access that can be used for a prolonged period of
time (e.g., for long chemotherapy regimens, extended antibiotic
therapy, or total parenteral nutrition) or for administration of
substances that should not be done peripherally (e.g.,
antihypotensive agents a.k.a. pressors).
30. ▪ it is an alternative to central venous catheters in major veins such as the
subclavian vein, the internal jugular vein or the femoral vein. Subclavian
and jugular line placements may result in pneumothorax (air in the pleural
space of lung), while PICC lines have no such issue because of the method
of placement.
▪ Generally PICCs are inserted into the basilic and cephalic veins of the
antecubital space, or brachial veins.The basilic vein is preferred as it offers
the largest diameter of upper extremity vessels and affords a non-tortuous
entry into the subclavian vein.
▪ The cephalic vein (~6mm) is smaller than the basilic vein (~8mm) and
angles 90 degrees to enter the terminal portion of the axillary vein,
sometimes making catheter advancement difficult.
▪ Brachial veins lie deep in the centre of the mid to upper arm and cannot be
outwardly visualised or palpated; ultrasound guidance is required for
access.
31. The basilic vein is relatively
superficial and has the largest
diameter and the greatest blood
flow of the peripheral arm veins.
The basilic vein also offers the
straightest route to the superior
vena cava (SVC).
The median cubital vein has a
small diameter and a variable
course but it may offer the
second best insertion choice for
smaller catheters. This is
because it often takes a direct
path to the basilic vein and then
on to the SVC.
The cephalic vein may be the
third best insertion choice
because it often narrows along
its path and may form an angle
where it joins the axillary vein.
Both of these issues increase
the risk of insertion related
mechanical phlebitis.
32.
33. COMPLICATIONS
▪ Pneumothorax (for central lines placed in the chest); the incidence is
thought to be higher with subclavian vein catheterization.
▪ All catheters can introduce bacteria into the bloodstream, but CVCs are
known for occasionally causing Staphylococcus aureus and Staphylococcus
epidermidis sepsis, central line-associated bloodstream infections (CLABSI).
If a central line infection is suspected in a person, blood cultures are taken from both
the catheter and a vein elsewhere in the body. If the culture from the central line grows
bacteria much earlier (>2 hours) than the other vein site, the line is likely infected.
▪ CVCs are a risk factor for forming blood clots including upper extremity
deep vein thrombosis. It is thought this risk stems from activation of
clotting substances in the blood by trauma to the vein during placement.
34. ▪ CVC misplacement is more common when the anatomy of the person is
different or difficult due to injury or past surgery. CVCs can be mistakenly
placed in an artery during cannulation. During subclavian vein central line
placement, the catheter can be accidentally pushed into the internal jugular
vein on the same side instead of the superior vena cava.A chest x-ray is
performed after insertion to rule out this possibility.
▪ Rarely, small amounts of air are sucked into the vein as a result of the
negative Intra-thoracic pressure and insertion technique. Air embolisms are
a very infrequent complication related to central venous catheter removal.
The threat of air embolism is minimized by proper CVC removal with
Trendelenburg positioning.
▪ Hemorrhage (profuse bleeding) and formation of a hematoma (bruise) is
slightly more common in jugular venous lines than in others.
35. References
▪ Pye’s Surgical HandicraftTextbook
▪ Marino‘s ICU Book by Paul L. Marino 4th edition
▪ Zollinger's Atlas of Surgical Operations
▪ Https://en.wikipedia.org/wiki/Central_venous_catheter
