Indications for insertion
- Haemodynamic monitoring
- Administration of vasoconstrictors
Before starting inform the patient and assemble the equipment that you will require. Strict asepsis is vital so you will need skin disinfectant, a suture set and sterile gloves, gown, mask, cap and drapes. You will also need googles to protect yourself. The patient may require oxygen during the procedure and he/she should be monitored with continuous ECG monitoring and pulse oximetry. In addition you will need syringes and saline for flushing the central venous catheter and for taking blood cultures if appropriate. If the patient is awake he or she will need local anesthetic and possibly sedation.
The central venous catheter kit usually contains the catheter, guide wire, dilator, needle, syringe and device for fixing the catheter at the skin entry point. A scalpel blade, three way taps and a suture are also required, and may be included in the kit. Finally an additional syringe and some saline are needed to flush the catheter lumens.
After scrubbing and putting on the mask, goggles, gown and gloves lay out your equipment. Attach three way taps to the proximal and medial ports of the triple lumen catheter and flush with saline. Leave the distal lumen as this will be used to pass over the guide wire
Internal jugular approach
In general the right internal jugular is easier to cannulate than the left. In addition the right side has several other advantages over the left: the apex of the lung is lower on the right so the risk of a pneumothorax is smaller, the thoracic duct may be injured on the left and the right side offers a more direct route to the superior vena cava.
Position the patient in a head down positon with the head turned away from the side to be cannulated. The internal jugular vein passes between the two heads of sternomastoid with the internal carotid artery lying deep and medial to it
Stand at the head of the bed. Clean the patient’s skin thoroughly with disinfectant
and then drape with sterile drapes. Palpate the neck to find the apex of the triangle formed by the two heads of sternomastoid with the clavicle as the base of the triangle. Unless the patient is deeply unconscious infiltrate the skin and the subcutaneous tissue with local anaesthetic
Insert the needle and syringe at an angle of 45-60 degrees to the frontal plane and directed towards the ipsilateral nipple. Advance the needle slowly, aspirating as you go. It should not need to be advanced more than 3-5 cm depending on the size of the patient
When the vein is entered there is a rapid flush of blood back into the syringe. Check that it has the dark color of venous blood not the bright red of arterial blood. If the vein is not entered withdraw the syringe slowly aspirating all the time. It is quite common to collapse the vein with the needle, pass straight through it and only aspirate blood on re-entering it during withdrawal of the needle.
Once the needle is in the vein carefully remove the syringe, occlude the end of the needle and then insert the guide wire. It should be possible to advance the guide wire with minimal resistance. Take care not to advance the guide wire too far or it may enter the heart and stimulate arrhythmias
Remove the needle leaving the guide wire in place
Make a nick in the skin with the scalpel blade. This needs to be large enough to allow the dilator to pass through the skin
Pass the dilator over the guide wire into the vein and then remove it.
Now advance the catheter over the wire making sure that you keep hold of some part of the guide wire
At all times. Otherwise there is a risk that the wire will become lost in the patient
Advance the catheter to a depth of about 12 cm. Remember that the tip should lie in the superior vena cava not in the right atrium. Next remove the guidewire, leaving the catheter in place, aspirate blood from the distal lumen to check that it is in the vein and to remove any air and then flush the lumen with saline.
Attach the anchoring hub to the catheter at the skin entry point
And then attach the locking device
Suture the hub and locking device to the skin
And then suture the catheter to the skin
And apply a dressing
And Take a CXR to check the position of the line and to check for a pneumothorax
Femoral vein line
- Femoral vein medial to artery
- Puncture below inguinal ligament
- Increased risk of deep vein thrombosis ± infection
Cannulation of the femoral vein involves a similar procedure with the obvious exception that the anatomy is different. The femoral vein lies medial to the femoral artery, which is used as the anatomical landmark for this procedure. The needle should be inserted just medial to the artery, below the inguinal ligament. It is important to ensure that the vessel is punctured below the inguinal ligament so that any bleeding is into the thigh rather than into the retroperitoneal space where it is difficult to detect. Cannulation of the femoral vein is associated with an increased risk of deep vein thrombosis and possibly with a higher rate of catheter related infection.