Central Venous Access

1. Central Venous Access Mazen Kherallah, MD, FCCP

2. Indications • Need for IV access and failure of peripheral access • Peripheral access too painful or tenuous • Long term IV access anticipated • Medications indicated that are toxic to peripheral veins • Hemodynamic monitoring • Volume resuscitation with large bore central lines • Special procedure: Swan Ganz, dialysis, plasmapheresis

3. Site Selection

4. Site Selection

5. Site Selection

6. Choice of Site

8. Anatomy of Great Vessels

9. Anatomy of Great Vessels

10. Anatomy of Great Vessels

11. Seldinger Technique

12. The Procedure • Patient position: • Patient is moved to the side of the bed so physician would not lean over • The bed is high enough so physician would not have to stoop over • Patient should be flat without a pillow, Trendelenburg position if patient is hypovolemic • The head is turned away from the side of the procedure • Wrist restraints if necessary

13. The Procedure • Skin preparation: • Prepare before putting sterile gloves • Start at the center and work outward the edges • Allow time for the sterilizing agent to dry • Disposable drape under the patient • Betadine or Chlorhexidine are acceptable solution and have activity against gram positive organisms

14. The Procedure • Drape: • Large enough • Handed sterilely by the assistant • Hole in the area of placement • Prepare the tray: • Handed sterilely by the assistant • Prepare the equipment before starting • Anesthesia • Use local anesthesia with lidocaine

23. YOUR ROLE AFTER THE INSERTION • Dispose all sharps • Place an occlusive sterile dressing • Flush lumens to maintain patency • Obtain a chest x-ray (ask for order if physician doesn’t mention it) • Monitor site for bleeding • Assess breath sounds • Assess circulation • Assess for hematoma • Document insertion, site, dressing and flushing

26. USING THE CENTRAL LINE • Flush q shift, before and after use with NS. Some places also require heparin flush • Close clamps when not is use • Check P&P of facility, but usually fluids are changed every 24 hours, tubing changed every 48-72 hours • Dressing is usually changed every 3 days • Line can be used for blood drawing - withdraw and waste 10 cc, then withdraw blood for samples • If port becomes clotted, do not use - sometimes ports can be opened up with urokinase (requires a doctor’s order)

27. Complications • Immediate • Hemothorax • Pneumothorax • Arterial puncture • Vessel erosion • Nerve Injury • Dysrhythmias • Catheter malplacement • Embolus • Cardiac tamponade

28. Complications • Delayed • Dysrhythmias • Catheter malplacement • Vessel erosion • Embolus • Cardiac tamponade • Catheter related infection • Thrombosis

29. Vascular Erosion/Cardiac Tamponade • Large vessel perforation is uncommon • Vessel erosion more common with stiff catheters, like dialysis catheters • Cardiac tomponade occur mainly if the tip is located in the RA • Complication is fatal in 2/3 of cases

30. Air Embolism • Air is sucked in through the catheter due to negative intrathoracic pressure during inspiration • Air can be pushed with flushing the catheter if it was not pulled back before flushing • Complication is uncommon but can be fatal • Manifests with hypoxemia, cardiovascular collapse, mental status changes and livedo reticularis • Place patient to left lateral position if suspected

31. Bleeding • More common in patients with coagulopathy • Easily controlled with femoral or IJ sites • Place local pressure and correct coagulopathy

32. Arterial Puncture and Cannulation • If the artery is puncture local pressure is applied for 3-5 minutes, observe for hematoma formation • If the artery is cannulated, pulsatile reflux of blood can be noticed, blood gas analysis reveals arterial. • The catheter should not be used, and remove it after coagulopathy is corrected if present

33. Thrombosis • Sleeve fibrin surrounding the catheter (occurs on the majority of catheters) • Mural thrombus on the wall of the vein (10-30% of catheters) • Occlusive thrombus (1-10%)

34. Pneumothorax • Most likely, pneumothorax is noticed after CXR is seen, unless patient developed tension pneumothorax with hypoxemia, cardiopulmonary collapse and absent breath sound • Small pneumothorax may be watched closely without chest tube placement in the spontaneously breathing patients • Large pneumothorax requires chest tube placement • Even small pneumothorax in patients on positive pressure ventilation requires chest tube placement

35. Catheter-Related Sepsis • Late complications • Femoral > IJ > subclavian • Triple lumen > single lumen • Large bore > smaller catheter • Sterility of procedure • Number of hub manibulations

36. Basic Pressure Measurements from Swan Ganz Catheter

37. Hemodynamic MonitoringPosition of Transducer

38. Components of the Atrial Waves

39. Differences in CVP and PCWP EKG correlation

40. CVP Correlation with EKGNormal CVP Tracing

41. Reading the mean of an A wave 22+10/2=16

42. Spontaneous BreathingReading CVP

43. Spontaneous BreathingInsp./Exp. Ratio in Rapid Breathing

44. Spontaneous BreathingInsp./Exp. Ratio in Rapid Breathing

45. Increased CVP: Right heart failure Right myocardial infarction Cardiac tomponade Tricuspid insufficiency Left to right shunt Pulmonary emboli COPD and cor pulmonale ARDS Excess fluid Tricuspid stenosis Decreased CVP hypovolumia Decreased venous return Excessive veno or vasodilation Shock Hemodynamic MonitoringCentral Venous Pressure: normal 4-10

46. Central Venous Pressure Tracings • Normal EKG tracing and right atrial pressure waveform • Atrial fibrillation • Atrioventricular dissociation

47. Central Venous Pressure Tracings • Normal EKG and right atrial waveforms • Tricuspid stenosis • Mild to moderate tricuspid insufficiency • Severe tricuspid insufficiency • Constrictive pericarditis

48. Large A wave Secondary to Loss of Atrioventricular SynchronySimultaneous Atrial and Ventricular Contraction

49. Loss of A WaveAtrial Fibrillation