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Outline

Author(s): Sandeep Hothi and David Sprigings

Indications, contraindications and potential complications are given in Table 116.1.

The use of ultrasound to guide central vein cannulation increases the success rate of the procedure from 60% to >90%, and reduces the complication rate from 30% to <10%. Ultrasound should be used when available and for elective procedures. For central vein cannulation in an emergency, the most rapid and safest method should be selected, depending on the operator's experience, patient factors and ultrasound availability.

Equipment needed is given in Table 116.2. You will need at least one assistant to monitor the patient during the procedure and assist with the equipment.

Choosing the Approach!!navigator!!

The internal jugular, femoral and subclavian veins are the veins most commonly used for central access.

  • Cannulation of the internal jugular vein is generally associated with fewer complications than with the subclavian vein, and is the recommended approach in patients with a bleeding tendency (because of the risk of uncontrollable bleeding from inadvertent puncture of the subclavian artery) or respiratory failure (because of the greater risk of pneumothorax with subclavian access). The right internal jugular vein is preferable to the left as it is contralateral to the thoracic duct, and the circulation of the dominant cerebral hemisphere in the right-handed.
  • Cannulation of the femoral vein may be the preferred approach if rapidity of access is paramount (e.g. for placement of a temporary pacing lead in a haemodynamically unstable patient), or if central venous access is required during cardiopulmonary resuscitation. Its drawbacks are a higher rate of infection, venous thrombosis and restricted mobility of the leg.
  • An antecubital fossa vein can be used to place a central line for infusions, but manipulation of a pacing lead via this route can be very difficult. Use of antecubital and forearm veins should be avoided in patients with advanced renal disease as they may be needed for arterio-venous fistula formation.

Ultrasound-Guided Cannulation of the Internal Jugular Vein!!navigator!!

Preparation

  1. Confirm the indications for the procedure. Explain the procedure to the patient and obtain consent.
  2. Prepare the surroundings: clear the bedside and remove the bed head; adjust the bed height so that the operator is comfortable; ensure adequate lighting; position your trolley, clinical waste bowl and ultrasound device.
  3. Prepare the patient: connect ECG and oxygen saturation monitors; give oxygen via a mask (which will lift the drape off the face). Remove the pillow and place an absorbent pad placed under the neck and shoulder. Lie the patient supine with head-down tilt (Trendelenburg position) unless not tolerated, for example due to pulmonary oedema or other respiratory compromise. The head-down tilt is important to reduce the risk of air embolism, particularly for jugular venous access (as opposed to femoral access).
  4. Visualize the internal jugular vein with ultrasound. The vein can be distinguished from the artery by compressibility and phasic change with respiration of the former (Figures 116.1 and 116.2). If the internal jugular vein is relatively flat (i.e. central venous pressure is low), head-down tilt or peripheral IV administration (if not contraindicated) may increase its calibre.
  5. Open the procedure pack onto the trolley by the bedside. Scrub up in an aseptic manner and don hat, mask, gown and gloves. Prepare the skin with chlorhexidine or povidone-iodine and apply drapes. Put the windowed drape over the target area, and additional drapes to cover the end of the bed and to bridge from the bed to the procedure trolley.
  6. Open the sterile sheath for the ultrasound probe. Identify the open (distal) end and place sterile ultrasound gel inside it. Your assistant should hold the probe vertically by its cable and lower it into the open end of the sheath. Then unfurl the sheath along the probe and secure the open end over the probe with a sterile elastic band/tape, ensuring that the sheath is flush with the probe face.
  7. Reconfirm the location of the internal jugular vein with the sheathed probe. Assess the distance from the skin to the vein. Plan your vein puncture site and ‘upstream’ skin puncture site guided by the depth of the skin to the vein.
  8. Anaesthetize the skin with 2 mL of lidocaine 1% using a 25 G (orange) needle. Ensure that the skin bleb will cover the area needed for sutures. Then infiltrate a further 2–3 mL of lidocaine along the planned needle path.
  9. While the local anaesthetic is taking effect, prepare the venous catheter. Flush all lumens with normal saline. Leave the central lumen open for passage of the guidewire but cap the other ports. Flush the dilator with normal saline. Ensure the guidewire flows freely from its coil. Prepare a sterile site adjacent to the patient where you can conveniently put the guidewire with the straightener for the J tip in place. Have the skin blade and dilator close to hand.

Venepuncture

  1. Mount the needle for the central vein puncture on a 10 mL syringe containing 5 mL of normal saline and flush it. Ensure that the needle is not put on too tightly. Taking the probe in your left hand, visualize the vein at the target puncture site.
  2. With the syringe and needle in your right hand, puncture the skin upstream of the probe and then stop. Angle the probe towards the needle and identify the needle artefact. Adjust the needle angle to ensure the artefact is in line with the centre of the vein. Slowly advance the needle with continuous gentle aspiration. Monitor and adjust the probe angle to track the needle tip if feasible. Venepuncture is indicated by aspiration of venous blood or visualized puncture of the vein. Stop advancing the needle and re-aspirate to confirm you are in the vein.

  3. Hold the needle steady in position and carefully place the ultrasound probe on a sterile surface. Then use your left hand to stabilize the needle at the skin. Check again by aspiration that the needle is still in the vein. Remove the syringe while supporting the needle. Blood should drip from the needle. If it does not, then cover the hub of the needle with your thumb and use a clean syringe to aspirate venous blood. If blood cannot be aspirated, leave the needle in place and rescan the vein. Do not alter the angle of the needle while within the skin/soft tissue – doing so can result in laceration injuries.

    If you are not sure if the needle is in the vein or the artery, either aspirate blood and check oxygen saturation, or connect to a pressure transducer.

Placing the catheter

  1. Having confirmed you are in the vein, pick up the guidewire and gently advance it (J end leading) into the needle and vein. Take care not to displace the needle while you are doing this. If resistance is felt, withdraw the guidewire slightly, depress the needle hub to reduce the angle into the vein and try again to pass the wire. If it still will not pass, remove the guidewire and re-aspirate to check the needle is indeed in the vein. Pass the guidewire to just beyond the 20 cm marking. Withdraw the needle over the guidewire and cover the puncture site with a piece of gauze, held in place with your left hand.
  2. Use the blade to make a short incision along the guidewire at the site of skin puncture to allow passage of the dilator and catheter.
  3. Mount the dilator on the guidewire and advance it with gentle rotation and forward pressure to insert it to a depth of 3–4 cm. There is no need to insert the whole length of the dilator: doing so risks perforation of the vein.
  4. Remove the dilator keeping the guidewire in place and again cover the puncture site with gauze. Mount the catheter onto the guidewire and advance it with gentle rotation and forward pressure to insert it to a depth of around 12 cm. Remove the guidewire. If blood cultures are required, take them at this point. Aspirate the central lumen to confirm venous blood and then flush with normal saline. Close the port with a sterile bung. Confirm satisfactory placement of the catheter with ultrasound.
  5. Apply suture wings to the catheter as it exits the skin and suture through each wing hole, taking care that the sutures are placed deeply and not tied too tightly.
  6. Remove the sterile drape from around the catheter and clean the skin with wet gauze to remove any blood. Blot with dry sterile gauze. Use an alcohol swab to clean the skin and the line, and when the alcohol has dried, cover the skin puncture site with a bio-occlusive dressing. A second dressing should be used to support the upper part of the catheter.

Final points

  1. Remove all drapes and sit the patient up. Check that the dressings are satisfactory. Clear up and dispose of sharps safely. Arrange a chest X-ray to confirm the position of the catheter. The tip of the catheter should be at or above the carina to ensure that it lies above the pericardial reflection.
  2. Write a note of the procedure in the patient's record, documenting technique (i.e. ultrasound-guided or not), vein used, any complications and post-procedure chest X-ray findings. If the catheter needs to be used immediately, use pressure monitoring to confirm the location is venous and not arterial before any infusion is started (Figure 116.3).

Troubleshooting

Frequent ventricular extrasystoles or ventricular tachycardia during procedure may indicate that the tip of the guidewire has passed across the tricuspid valve into the right ventricle: draw it back.

Landmark-Guided Technique for Cannulation of the Femoral Vein!!navigator!!

  1. Lie the patient flat. The leg should be slightly abducted and externally rotated. Identify the femoral artery below the inguinal ligament: the femoral vein usually lies medially (Figure 116.4). Shave the groin. Prepare with skin with chlorhexidine or povidone-iodine and apply drapes.
  2. Infiltrate the skin and subcutaneous tissues with 5–10 mL of lidocaine 1%. Nick the skin with a small scalpel blade. Place two fingers of your left hand on the femoral artery to define its position. Holding the syringe in your right hand, place the tip of the needle at the entry site on the skin. Move the syringe slightly laterally, and advance the needle at an angle of around 30° to the skin whilst aspirating for blood. The vein is usually reached 2–4 cm from the skin surface.

  3. If the vein is not found, withdraw slowly whilst aspirating. Flush the needle to make sure it is not blocked. Try again, aiming slightly to the left or right of your initial pass.

    The above method can be easily supplemented for use with ultrasound guidance and this is recommended wherever possible.

Management of Central Venous Catheters!!navigator!!

  • Minimize the duration for which the catheter is kept in situ.
  • Daily inspection of the entry site.
  • Regular dressing changes.
  • Aseptic technique whenever using or handling the catheter.
  • Use heparinized catheter lock solutions.

Catheter infection

Staphylococcus aureus and Staph. epidermidis are the commonest pathogens, but infection with Gram-negative rods and fungi may occur in immunocompromised patients.

If the catheter is obviously infected (tenderness, erythema and purulent discharge at the skin exit site), the catheter must be removed and the tip sent for culture. If the patient is febrile or has other signs of sepsis, take blood cultures (one via the catheter and one from the peripheral vein) and start antibiotic therapy.

Initial treatment should be with IV vancomycin or teicoplanin (to cover methicillin-resistant Staph. aureus (MRSA) plus gentamicin if Gram-negative infection is possible.

If cultures show Staph. aureus infection with bacteraemia, IV antistaphylococcal therapy should be given for two weeks. For Staph. epidermidis and Gram-negative infection, give IV therapy until the patient has been afebrile for 24–48 h. For Pseudomonas infection, give IV therapy for 7–10 days. Seek advice from a microbiologist.

If the catheter is possibly infected (fever or other systemic signs of sepsis, but the skin exit site is clean), take blood cultures (one via the catheter and one from the peripheral vein). The decision to remove the catheter before culture results are back depends on the likelihood of it being infected, how long the catheter has been in and if there is another source of infection. If both blood cultures grow the same organism, the catheter must be removed and antibiotic therapy given as above.

Further Reading ⬆

Ortega R, Song M, Hansen CJ, Barash P (2010) Videos in clinical medicine. Ultrasound-guided internal jugular vein cannulation. N Engl J Med 362, e57. http://www.nejm.org/doi/full/10.1056/NEJMvcm0810156.

Smith RN, Nolan JP (2013) Central venous catheters. BMJ 347, f6570. DOI: 10.1136/bmj.f6570