Central Venous Access

Last Updated on by FRCEM Intermediate

Indications

  • Monitoring eg CVP
  • Infusion of irritant drugs that may damage smaller veins.
  • Insertion of pacing wires.
  • Renal replacement therapy.
  • Emergency venous access.
  • Parenteral feeding.
  • Resuscitation of patients who are intravascularly depleted.

contraindications

Absolute

  • patient Refusal

relative 

  • uncorrected coagulopathy
  • thrombocytopenia
  • skin infection over the site of access
  • obscure anatomical landmarks
  • haemo- or pneumothorax on the contralateral side
  • recent surgery to other structures nearby such as carotid endarterectomy.

Anatomy

Internal jugular vein (IJV)

  • The IJV runs from its origin at the jugular foramen to the sternal margin of the clavicle. Here it terminates by joining the subclavian vein (SCV) to form the brachiocephalic vein
  • The IJV is surrounded by the carotid sheath which also contains the carotid artery and the vagus nerve. It lies in the anterior triangle of the neck laterally to the internal carotid artery.

Subclavian vein (SCV)

  • The SCV is a continuation of the axillary vein. It begins at the outer border of the first rib and ends at the medial border of scalenus anterior, where it joins the internal jugular vein to form the brachiocephalic vein behind the sternoclavicular joint.

Femoral vein

  • The femoral artery, vein, and nerve lie within the femoral triangle, arranged from lateral to medial: nerve, artery, vein. The artery can easily be palpated on a subject, and the vein lies 2 cm medial to the pulsation.

Factors to consider when choosing a site for central venous access.

Use of US

  • Ultrasound can be used to identify the vessels and to avoid important nearby structures
  • The vein will usually be larger and lateral to the artery which will have a visible arterial pulsation. Compress the neck with the probe; the vein should be compressible and the artery will retain its shape.

Surface landmarks

Right internal jugular vein

  • The patient should be lying as flat as possible with the head resting on one pillow and turned to look to the contralateral side. The trolley should be tipped head down to about 15°, the Trendelenburg position, which distends the veins and decreases the risk of air embolism.
  • Identify the sternocleidomastoid and look for where the sternal and clavicular heads divide. The IJV runs directly beneath the apex formed by the bifurcation of the two muscle bellies.
  • The internal carotid artery is palpated and gently lifted medially. The vein now lies lateral to the artery.
  • Insert the needle at 30° to the skin aiming for the ipsilateral nipple.

Right subclavian vein

  • The key surface landmark is the clavicle. Palpate it along its entire length and establish the point between the medial third and the middle third. This lies on the most curved part of the clavicle where it turns to run posteriorly.
  • The needle is introduced at this point and passed under the clavicle.
  • When it is under the clavicle, flatten the syringe to the skin and aim for the suprasternal notch. The SCV should be reached at approximately 4 cm.

Right femoral vein

  • Identify the femoral triangle at the top of the thigh below the inguinal ligament.
  • find the pubic tubercle and palpate laterally until the femoral artery pulsation is felt. The vein lies 2 cm
    medial to the femoral artery.
  • Approach the skin one finger’s breadth medial to the artery at 30° aiming for the contralateral shoulder.

Complications

  • Pneumothorax
  • air embolism
  • carotid or subclavian artery may be either punctured or cannulated which may cause stroke, hemorrhage, and inadvertent administration of drugs into the arterial system
  • Venous thrombosis is a potential complication for all of the veins , especially the femoral.
  • potential site for introduction of infection and for colonization by microorganisms
  • Arrhythmias

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