Central Venous Cannulation

Sites

  • Internal jugular (IJV)

  • Left and right Subclavian (SCV)

  • Femoral vein (FV)

Types

  • Central venous cannulation - any of the above sites

  • Pulmonary artery catheterisation - Internal Jugular(IJ) and Subclavian veins (SCV)- Preferably the right IJ or the left SCV veins because of its anatomical position and accessible routes to right ventricle and pulmonary artery.

  • Vascath or dialysis catheter (usually 2 lumens) - they are primarily bored, preferable sites are the IJ or the femoral veins. Senior intensivists or trainees mostly use subclavian cannulation with expertise.

  • Temporary pacemaker insertion - most commonly the internal jugular on the right, but both IJ and subclavian are used. The left subclavian is usually left untouched in ICU for permanent pacemaker if required.

Before starting

  • Revise the landmark. The anatomical landmark of SCV lies just beneath the clavicle and 1st rib curving into the SVC, around mid-clavicular and only about 2 cm below the clavicle ( most books describe medial to the mid-clavicular line) - I prefer to go slightly lateral.

  • Always see and feel the area for anything unusual such as signs of skin infections, swelling etc

  • Shave the hair (makes it easy for sticking dressings later) and ask the patient which side he/she may prefer.

Trolley Set Up

  • I believe in organising my procedure trolley myself, in doing so, I don't miss out on any sterile or other essential instruments that I need for the procedure. Starting from bungs, local, stitches, syringes, sticky stuff, bowls to heparin saline, etc. Streamlining this daily will hasten the procedure, and minimise complications

  • Please get a spacious trolley for all central line procedures to avoid unnecessary contamination and overcrowding 

  • In most ICU's, the norm is to use the 3-lumen catheter. The length of the catheter has been debatable. But I believe in anatomy, and so for appropriate measurement of CVP or central venous gas (ScVO2), I prefer 13-15 cm for right IJ or SCV where the tip of the catheter will be approximately on the border of SCV and RA. For left IJ or SCV, I prefer 18-20 cm with the tip of the catheter at the same position as described above. For femoral veins, the length should be 20 cm.

  • 3 x 5ml syringes, and size 11 scalpel blade to puncture the skin at the insertion site. Sometimes scalpel blade will be found in the CVC package, but it's better to have one at hand.

  • 1 x 20G (blue needle) for local anaesthesia (LA)

  • Stitches - 2-0 cotton/silk, needle holder, stitch cutter or scissor,

  • 3 x rubber bungs to close the 3 lumens and blunt plastic cannula to puncture the bungs.

  • Heparin saline or normal saline as preferable - I use heparin saline unless contraindicated.

  • Local anaesthetics and some patients may require a touch of sedation. My preference is 0.5 to 1 mg of Midazolam or whatever one chooses to use in small amount without any side effects.

  • Ultrasound machine (optional) - it's important to know how to use it, the probe to use, and don't forget sterile probe cover and gel.

Self and Patient Preparation

  • Once the trolley is prepared - I prepare myself for the procedure by wearing sterile gowns and gloves. I prefer to cover my patients from top to bottom as much as I can depending on the situation of the patients in ICU. Properly scrub the area of the procedure, and explain clearly to the patient about the importance of sterility.

  • Explain the procedure to the patient, its potential complications, and how you would treat the complication if there is any. Ask the patient to let you know or the nurse about any distress or discomfort during or after the procedure. I take time to talk to my patient during which the cleaning and scrubbing to sterilise the area goes on hand in hand.

Tips

The position of the patient during the procedure is critical.

For internal jugular vein cannulation, turn patient's head to about 45-60 degree on the opposite side. Turning more than 60 degree makes the patient uncomfortable under the sterile sheath. If the patient is intubated and or sedated, be careful of other tubes and lines while turning the head.

If  CVC is a change of line for a long-stay patient, find out beforehand what's running through the lumen of existing CVC, especially inotropes and vasopressors. Do NOT stop any infusion from other CVC while changing to new lines.

Always point the pigtail/or the guidewire loop downwards while inserting to prevent guidewire going onto the other side (like a necklace and also prevents looping of CVC upwards)

SCV central lines have the lowest incidence of line infection and are also preferred by patients since it's usually out of the way of moving the neck. But it is also the most frequent place to puncture the SVC artery and the lungs.

Do not attempt SCV cannulation in patients with coagulopathy, or anti-coagulation therapy.

Following the anatomical landmark is the best way to cannulate SCV. USG  may be used, but the visualization of SCV depends on the patient body stature, which may sometimes make it challenging to visualise easily. 

​Be careful on ventilated patients, severe COPD and emphysematous patients and in those with acute SOB where the patient may not be able to lie down.

​Be careful cannulating SCV in fragile and anorexic patients, because of loss of fat/adipose tissue, which makes the anatomical landmark and the depth slightly variable.

​Check for coagulation parameters and haemoglobin, history of any coagulation disorders or if on any anti-coagulation drugs. Commonly  ICU patients may be on heparin infusion, or anti-platelet medications and other coagulation therapy. 

During procedure

  • For SCV, always aim the needle towards the clavicle, at the angle of the sternal notch, until one can touch the clavicle bone with the needle tip. Then gradually walk down the clavicle with the tip of the needle and slowly advance, and aspirate as you go. It should be about 3-8 cm in depth depending on the body stature but commonly around 4-5 cm.

  • Once the big vein is punctured with 18 G needle, and blood is aspirated, keep the syringe attached to the needle to avoid air embolism, especially in dehydrated patients or in patients with a significant SOB.

  • While inserting the guidewire, know the length as they are marked 5 cm apart. I prefer to use my thumb to close the needle port while I introduce the guidewire, thus avoiding accidental misplacement of the needle before inserting the guidewire. Look for arrhythmias, which sort of confirms the position. But you may need to pull out the guidewire a little to prevent irritating the heart.

  • Once cannulated, remove the guidewire. Close the distal lumen port with your thumb and bung it. Aspirate and flush all lines again to ensure free flow. Connect the distal end to the monitor and see the waveform. Call for X-Ray or Ultrasound to confirm the position of the catheter in the vein. Many hospitals use Chest X-Ray for final confirmation.

  • After the guidewire is removed, show it to the bedside nurse or senior personnel around. Some hospitals have CVC stickers, which include the details of the procedure and guidewire removal. If the guidewire has not been removed, on flushing the distal lumen, there will be NO free flow. Always check the lumen for a guidewire, especially in femoral vein cannulation where an x-ray is not required to confirm.

Complications

  • Chances of pneumothorax and arterial puncture are higher with SCV line compared to other sites, especially the IJ. A puncture in a patient with normal coagulation will require compression for at least 10 mins or so before attempting another one.

  • If there is bleeding around the cannula, give pressure for 5-10mins, Do Not leave it to the nurses; I have seen small to huge haematomas requiring surgical intervention.

  • If there is persistent bleeding, mostly oozing around the catheter, CALL for HELP. I usually take a circular stitch about a cm below the insertion site around the central cannula stem and tie a knot to put enough pressure and tamponade on the area.

  • Pneumothorax- Learn to diagnose pneumothorax and its signs and symptoms.

  • Check X-Ray

  • talk to the patient for SOB

  • In USG look for signs such as the absence of lung sliding, lack of B-Lines, and loss of "waves on a beach" sign in M- mode

  • Pneumothorax can be life-threatening if missed. Learn to decompress by inserting large bore cannula at the mid-clavicular line about 2-3 ICS, learn to insert intercostal drain placement for PTx, and it is easy and fast and life-saving.

  • Many times too much turning of head in case of IJ cannulation results in looping of the cannula upwards or rotating laterally or medially, into  SCV or the other IJ. The probable reason is that by stretching the IJ,  the lumen size decreases and the guidewire bumps off the tight lumen and escapes through whatever route available, which usually tends to go upwards or either side. One can avoid this by placing a finger at the SCV to prevent the cannula from going laterally. This may not be an issue if you are using USG as one can visualise the guide wire easily. IJ  CVC usually coils upward, CVP monitoring may not be accurate in such situations, and so inotropes or vasopressors should be avoided. 

  • In SCV cannulation, sometimes the catheter may turn upward to IJ or the other SCV. If contemplated beforehand,  compressing the ipsilateral IJ  just above the bifurcation helps. With experience, you should be able to feel the guidewire movement; therefore, I usually keep the loop/pigtail turned towards the feet to follow the contour of the SCV.

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