Central Venous Catheter: Insertion Guide
Central Venous Catheter: Insertion Guide
Central Venous Catheter: Insertion Guide
Venous
Catheter
Insertion Guide
Central venous catheters (CVCs) are useful devices essential to the care of
critically ill patients. However, CVCs are associated with life threatening NSW health requires all practitioners inserting CVCs to have appropriate accreditation.
complications. To minimise these complications each CVC insertion This accreditation process has two components:
needs to be carefully planned with regard to indication, type, site, inser- 1. Theoretical knowledge of CVC insertion planning and proceedure
tion procedure and subsequent management.
2. Demonstrated capability of safe CVC insertion
Making the most of the available evidence this guide hopes to teach you: The completion of this learning package and associated assessment is a requirement
for the first component of the accreditation process.
• When and when not to insert a central line
• To choose the right insertion site for the patient in front of you
• To insert a central line as safely as possible
The ongoing care and maintenance of central lines is not covered by Date of last edit: December 2012
this guide. Correspondence via www.philippelefevre.com
Contents
Choosing the Most Appropriate Site............................................................ 3 Peripherally Inserted Central Catheter (PICC).........................................17
Electrical Safety............................................................................................... 5
Ultrasound Guidance..................................................................................... 6
Depth Guide.................................................................................................... 9
A central venous catheter, often called a central line, is an intravascular • Administration of sclerosing infusions
catheter placed so that the tip lies near the centre of circulation in one
• High flow blood access for dialysis or plasmapheresis
of the vena cavae. These veins have a large luminal diameter and high
blood flow that makes them suitable for: • Haemodynamic monitoring
• Venous access when peripheral access is unavailable
• Long term venous access
Broadly speaking, there are two types of central line: short centrally • Site of insertion
inserted central catheters (CICCs) inserted into the axillary, subclavian,
• Tunnelling
internal jugular or femoral veins; and longer peripherally inserted central
catheters (PICCs) usually inserted into one of the mid arm veins. • Antibacterial coating
• Length
Central lines can also be categorised by:
• Number of lumens
• Total and luminal gauge
Complications
The more common or serious complications of a central line insertion include:
• Pneumothorax • Incorrect catheter tip position
• Air embolus • Central vein perforation
• Haematoma • Tamponade
• Haemorrhage • Cardiac arrhythmia
• Thrombosis • Embolised, fractured or irretrievable guide wires
• Stenosis • Infection
• Arterial puncture / catheterisation
Choosing the most appropriate site will Patients vary: coagulopathy, active However, formal comparison in randomised controlled trials of the rate of
injuries, old scars, skeletal abnormalities, vascular surgery, venous throm- catheter related bloodstream infections (CR-BSI) in critically ill patients
bosis, stenosis, presence of vascular filters, pacemakers and defibrillators, shows no difference between PICCs and CICCs.8,9
and a history of difficult central venous access should inform your decision
making process. It is important to review each patient’s history, perform a
focussed vascular examination, examine the available relevant radiological AXILLARY & SUBCLAVIAN VEINS
images and investigate for coagulopathy.
Subclavian central lines carry the lowest risk of arterial puncture and line
sepsis. A methodologically sound RCT compared subclavian with femoral
PATIENT ASSESSMENT central line insertions. It found subclavian access to be associated with a
History Examination significantly lower rate of any infectious complications (4.5% vs 19.8%; P >
• Respiratory failure • Scars (surgical and vascular 0.001) and a trend toward a lower rate of suspected or confirmed catheter
• Ability to lie flat procedures)
related bloodstream infections (1.5% vs 4.4%; P = 0.07).10
• Claustrophobia • Pacemaker / ICD
• Clotting disorders • Confusion & level of cooperation
• Allergies (esp. chlorhexedine) • Skin infection / inflammation The major risk of subclavian vein catheterisation is pleural injury leading
• Previous venous access devices to pneumothorax or haemothorax — serious complications that often
Investigations
• Pacemaker / ICD / IVC filter require a chest drain insertion. Patients who are in severe respiratory
• Clotting studies
• Likely hood to need long term • Platelet count failure may not have the reserves to contend with a pneumothorax and
dialysis
• Ultrasound so the subclavian site should be avoided. If a patient has a chest drain
• Chest X Ray to predict depth in situ consider inserting a subclavian or axillary line on the same side.
In a patient who has an inferior vena cava filter, femoral line placement One last consideration is that
RIGHT VS LEFT
should only be performed by a radiologist with the benefit of fluoroscopy right handed proceduralists
to ensure that the guide wire does not become entangled with the filter.15 will find central line inser- Advantages of the Right
tions on the right of the patient • IJ has larger diameter
• IJ is more superficial
more comfortable and easier to
• Lower risk of delayed perforation
INTERNAL JUGULAR VEIN accomplish. Vice versa for left
• Better flows for dialysis
handed proceduralists. • Lower risk of thoracic duct damage
Internal jugular catheter inser- • Lower risk of pleural injury
INTERNAL JUGULAR
tion carries an intermediate risk Never attempt central lines on
Advantages of the Left
of line sepsis, arterial puncture, Advantages opposite sides of the chest with- • Catheters fed through the left
pneumothorax and haemotho- • Low rate of infection out performing a chest X-ray subclavian vein are less likely to
• Very low risk of pleural injury
rax. Of the three CICC sites the in between to avoid bilateral divert up the internal jugular vein
internal jugular vein is the most Disadvantages pneumothoraces.25
suitable for coagulopathic patients. • Limited number of lumens
An internal jugular catheter is • Potential to increase venous
resistance and exacerbate cerebral
incompatible with a rigid cervical oedema SUMMARY
spine collar.
Make yourself aware of each patient’s specific considerations. In the
non-coagulopathic patient who is not in severe respiratory failure, a
subclavian central line is the most appropriate choice. That leaves the
LEFT vs. RIGHT internal jugular vein as a useful site for patients with a coagulopathy or
profound respiratory failure providing they can lie flat for the procedure.
For a number of reasons, central lines of the upper body are better Femoral lines are useful as an alternative when there is a compelling
inserted on the right. reason to avoid an upper body central line, often because of venous
thrombosis, stenosis or a preexisting central line already residing in the
Left sided lines have to traverse the acute angle between the left innomi- SVC. A peripherally inserted central catheter is an alternative unless the
nate vein and superior vena cava. As a consequence catheters inserted line is required for rapid infusions, thermodilution or multiple concurrent
via the left innominate are associated with a greater risk of delayed but incompatible infusions. In the upper body the right side of the patient
perforation 16,17 thrombosis,18 and greater resistance to flow. is preferable to the left.
Electrical Safety
FUNDAMENTALS EQUIPMENT
Ultrasonic sound waves radiate out from an ultrasound probe, reflect at Some ultrasound machines are specifically designed for vascular
interfaces between substances and can be detected back in the probe. The access (Figure 9) almost any ultrasound machine can be adjusted to
time taken for a sound wave to be emitted, reflected and then detected suit. It is best to use a linear probe with a high frequency range (> 5 MHz)
indicates the depth of the reflection. The pattern of timed reflections along to provide fine detail at a shallow depth.
the length of the probe is compiled to produce a real-time 2-dimensional
image of the medium beneath the probe. The degree to which sound is In general there are just 4 settings that you will need to adjust:
reflected at an interface is dependent on the difference in impedance
1. On/off button
between the two mediums. When travelling through a homogenous
medium, for example blood inside a blood vessel, the sound waves are 2. Gain — the degree of signal amplification
transmitted freely, there is no reflection and the medium appears dark. It
3. Depth — use the lowest depth required to visualise all important
is thanks to the subtle heterogeneity of soft tissues that they have defini-
structures (this uses the highest frequency and gives the greatest
tion on ultrasound. When there is a large change in acoustic impedance
resolution). There are centimetre and half-centimetre depth
at an interface, as between soft
marks superimposed on the image.
tissue and bone, almost all of the
sound is reflected. This creates a 4. Doppler (sometimes labelled colour) — helps to identify venous
C high contrast impression of the thrombosis and distinguish veins from arteries. It is useful
interface and a shadow beneath it during the initial planning ultrasound but is usually unhelpful
where ultrasound imaging is lost during cannulation.
AS
(Figure 5). Indeed, this is why jelly
is needed between the probe and
skin — to displace highly reflective
Figure 5 Acoustic Shadow
air-tissue interfaces. When there
The clavicle casts an acoustic shadow are two highly reflective surfaces
that obscures underlying structures. in view, for example two ribs,
C — clavicle, AS — acoustic shadow.
sound can bounce between them
creating reverberation artefact in
the image (Figure 6). As the sound
energy travels out away from the
probe it is dissipated and absorbed.
To correct for this natural decay
in energy and image intensity, the
ultrasound machine amplifies the
image according to depth. This
can give rise to acoustic enhance-
ment of tissues below areas of low
Figure 6 Ultrasound Reverberation
This long axis view shows a CVC guide
energy absorption (Figure 7). Figure 9 Sonosite™ S-Series Ultrasound Machines
The ultrasound machines used in John Hunter Hospital intensive care department.
wire entering into the femoral vein. Back
and forth reflections between the guideA reflecting surface in motion with
wire and the deep vein wall have caused
respect to the sound wave will
a reverberation artifact. Also, notice the
diference in the appearence of the wire affect the frequency of the reflected THE EVIDENCE FOR ULTRASOUND GUIDANCE
depending on its orrientation to the sound (the Doppler effect). This
ultrasound probe. It shows up as a clearinformation is readily detected by Ultrasound imaging should be used to plan and guide all central line
echogenic line where it is ‘in plane’ with
the probe. the ultrasound probe and can be insertions. A meta-analysis of randomised controlled trials showed that
superimposed as a colour pattern direct ultrasound guidance reduces the rate of failure (relative risk 0.33,
on a duplex image (Figure 8). It is CI 0.18–0.45); mechanical complications (relative risk 0.22, CI 0.1–0.45)
conventional to represent movement away from the probe as blue and and multiple attempts before success (relative risk 0.6, CI 0.45–0.79) for
movement towards the probe as red (mnemonic: BART — Blue Away; central line insertions of the internal jugular and subclavian vein.30 A
Red Towards). Be aware that the colour representation of the Doppler more recent RCT comparing direct ultrasound to landmark guidance
effect can be reversed in the settings of most ultrasound machines. for axillary central line insertions found even more strongly in favour of
ultrasound guidance.31 Only one small RCT has investigated ultrasound
guidance for femoral line insertions. It showed a similar trend towards
reduced rates of failure but did not reach statistical significance (relative
risk 0.29; CI 0.07–1.21).14
The first concern is to ensure that the catheter is advanced far enough
into the vein to avoid extravasation from the most proximal lumen of
the catheter into the soft tissues overlying the vein. This is checked at
the time of insertion by making sure that blood can be easily aspirated
through each of the catheter lumens.
Upper body central lines (of the arm, axillary, subclavian and internal
jugular veins) require careful tip positioning to prevent later complica-
tions. The ideal resting position for the tip is in the superior vena cava
(SVC), half way along its length. This puts the tip just above the pericardial
reflection. Beyond this, perforation risks tamponade and although rare, is
often fatal.35 Unfortunately, retreating distally up the superior vena cava
carries other more insidious but equally serious possible complications.
When the distal portion of a catheter is in either of the innominate
(brachiocephalic) veins there is a risk that the tip will abut the inner wall
of the SVC and cause delayed vessel perforation. This is especially true
on the left owing to the more acute angle between the left innominate
vein and the SVC.17 High placement also appears to increase the risk of Figure 12 Post Insertion Chest X-Ray
thrombosis.18 This chest X-ray shows a right arm PICC advancing correctly into the superior vena
cava. The catheter tip is perfectly in line with the height of the carina, it is lying verticaly
and there is no evidence of pleural injury.
A plain chest X-ray should be
THINGS TO CHECK ON
performed after each upper body CHEST RADIOGRAPH
central line to detect pleural injury
and confirm position. The carina • The tip of the catheter should be
within 3 cm of the hight of the
appears 31/2 cm above the lower carina
border of the SVC on a chest X-ray • The end of the catheter should lie
and provides a convenient radio- within 40 degrees of the vertical
logical landmark for the midpoint line of the SVC
• Evidence of pleural injury
of the SVC, which is approximately
6 cm long. The tip of the catheter
should be within 3 cm of the height
of the carina on a chest X-ray (Figure 12).
The chest X-ray is also useful for detecting lines that are abutting the
inner wall of the SVC. Laboratory36 and clinical17,37 evidence suggests
that when the CVC tip is at an angle to the SVC of greater than 40 degrees
it is more likely to erode through the vessel wall (Figure 13). When this
is detected the line should be repositioned or replaced.
Visceral type chest pain on infusion via the central line is a serious warn-
ing that the tip may have perforated a vessel wall.
Taking the time to properly plan catheter depth will prevent catheter
height height
repositioning manoeuvres and save you a lot of time in the long run. RIJ =
10
-1 LIJ =
10
+2
Arterial puncture is one of the most common complications of central Blood gas analysis on a sample from the vessel can provide another way
line insertions. When it is recognised early, the needle removed and to delineate vein from artery. In a well oxygenated patient, a partial
pressure applied for 5 minutes the consequences are minimal (incidence pressure of oxygen (PO2) less than 50 mmHg suggests venous blood. In
2.0–4.5%).42 If, on the other hand the artery is dilated and cannulated a desaturated patient the venous partial pressure (PvO2) can be low, in
(incidence 0.1–0.5%),42 the consequences include life-threatening haem- which case, it is helpful to compare blood from the cannulated vessel
orrhage and stroke.43-45 with blood sampled simultaneously from a confirmed arterial catheter.
A PO2 difference greater than 20 mmHg confirms venous cannulation
Ensure that blood from the introducing needle is non-pulsatile and darkly with 99.7% confidence47
deoxygenated. Be aware that flow and colour can be unreliable indica-
tors — an incompletely cannulated artery can have low, non-pulsatile The wire can be fed into the vessel and, before dilating, checked with
flow and arterial blood of a desaturated patient can look quite venous. ultrasound to make sure that it feeds into the vein (Figure 6). However,
this is an unreliable check that does not protect against mistaken arte-
When using the catheter-on-needle combination to cannulate the vessel riovenous identification on ultrasound.
(see ‘The Seldinger Technique’ bellow) it is straight forward to remove
the needle and transduce the pressure via the catheter to help determine If you are in doubt after these checks, abandon and reattempt the proce-
accidental arterial cannulation. Digital manometry can be used but there dure with senior help.
is a simpler solution. Attach a 50 cm length of intravenous tubing between WAYS TO CHECK FOR
a small syringe and the intravascular catheter. Fill the syringe by aspira- ARTERIAL CANNULATION
tion. Disconnect the syringe, hold the intravenous tubing vertically, and
• Pressure transduction
observe the column of blood. A descending column indicates venous • Concurrent blood gas analysis
placement. An ascending column regardless of respiratory cycle indicates • Ultrasound
arterial placement. A static column of blood suggests catheter kinking,
vessel wall impingement or partial catheter placement in the vessel, in
which case, the catheter can be carefully adjusted until continuous flow
is demonstrated.46
STEPS
1. Planning 7. Sterile equipment setup 12. Insertion of the wire (ultrasound 17. Suture or StatLock™ the line in
2. Informed consent 8. Site antisepsis guided) place
3. Patient preparation - wash, shave, 9. Drape 13. Dilation 18. Clean and dry skin
position, ultrasound, monitor 10. Local anaesthetic infiltration 14. Line insertion over the wire 19. Apply dressing
4. Trolly setup (ultrasound guided) 15. Aspirate blood and saline flush 20. Chest radiograph (upper body
5. Face mask and hair cap 11. Cannulation and confirmation of each lumen lines only)
6. Scrub and gown venous acces 16. Heparin lock (optional) 21. Document
Begin by preparing the equipment you wish to use. Attach the introducing catheter in place. The guide wire can then be passed through the plastic
needle to an empty 10 ml syringe. Small handed proceduralists might be catheter. The catheter eliminates the risk of snaging the guide wire on
more adept with a 5 ml syringe. It is helpful to align the numbers on the the introducing needle and can make it easier to transduce pressures
syringe with the bevel of the needle tip so that with the needle tip beneath and take blood gas samples to confirm the vessel. The dissadvantage
the skin it is still possible to determine the orientation of the bevel. The of thecatheter-on-needle is that it is less ridgid and can be harder to
needle and syringe should be attached firmly but loosely enough to manipulate — particularly at the subclavian site and in large patients.
easily separate with minimal effort. Some proceduralists like to have a
small volume of saline in the syringe but dilution of the aspirated venous Prepare the wire. Remove the white plastic cap and slide the wire in
blood causes it to appear bright red and can cause confusion about the and out of the plastic guide wire holder to loosen it. Take note of the
position of the needle.48 orientation of the J-tip of the wire. Retract the wire into the plastic snail
so that the tip is just protruding and the bend in the wire is straightened.
Introducing Needle vs. Catheter-on-Needle Place the wire on the drapes within convenient reach.
The Arrow™ kit comes with a catheter-on-needle combination (Figure
15) that can be used instead of the unsheathed introducing needle. Once A 5 ml syringe should be used for the lignocaine to help distinguish it
the the vein has been cannulated the needle can be removed leaving the from the 10 ml saline flushing syringe and avoid accidental intravenous
CAD
G
RG
UPC PC
USJ
CN B
S
SM NH F
SN
SS
LA IN GW D CVC
SFS
DT
Place the introducing needle at the skin distal to the ultrasound probe at
an angle of 45 degrees to the skin pointing in line with the vein proximally
towards the ultrasound probe. The needle should be at a distance from
the ultrasound probe such that as it is advanced the needle will intersect
with the vein directly below the probe. Deeper vessels will require larger
separation between probe and needle.
Figure 18 Fractured Guidewire
Advance the introducing needle, aspirating gently as you go. Watch The guidewire can catch and unravel on the needle aperture if it is retracted back
carefully for a flashback of venous blood. The pressure of the advancing through the needle.
needle will deform the soft tissues and often completely occlude the target
vein. When this happens it is common to pass right through the vein this disconnection is a vital last opportunity to prevent an accidental
without a flashback. This is not a problem. Slowly withdraw the needle arterial dilatation and catheterisation (see ‘Detecting Arterial Puncture’
while aspirating. The traction will open the vein and provide a flashback above). The somewhat cumbersome hollow blue syringe is best avoided.
of blood when the needle tip reaches back into the vein lumen. Set the
ultrasound probe aside and instead use your non-dominant hand to Once you are satisfied that you have appropriate venous access feed the
secure and anchor the needle to the patient. wire into the needle hub. The wire has a J-tip at its leading end. Orientate
the wire to the needle such that the J-tip bends cleanly through the bevel
Ensure easy aspiration of blood. Remove the syringe from the introducing of the needle towards the heart (Figure 16). This might involve a 180 degree
needle. Venous blood should drip slowly from the needle hub. The Arrow™ rotation of your dominant, guide wire holding hand.
kit comes with a hollow blue syringe designed to allow the guide wire
to pass down its length into the needle without disconnection. However, With the guide wire holder in the hub of the needle the wire protrudes
from the tip of the needle as the 10 cm mark passes over the pinch mark
on the guide wire holder. If you meet with resistance at the 10 cm mark,
the implication is that the needle tip is no longer cleanly inside the vein.
Remove the wire and reattach the syringe. Make small adjustments to
the needle whilst aspirating on the syringe to re-establish the needle in
the vein and reattempt to feed the wire. Sometimes adjusting the needle
and syringe to be at a shallower angle to the vein will help the wire pass
more easily. If you encounter resistance to the wire beyond the 10 cm
mark you are meeting an obstruction within the vessel beyond the needle.
Rotating the wire as you advance it can help the J-tip of the wire negotiate
tortuosities in the vein. You should be able to pass the wire freely 20 cm
into the vein with minimal resistance. Excessive force on the wire can
perforate the great veins with dire consequences. Do not withdraw the
guide wire back through an introducing needle — it can catch on the
needle aperture and unravel (Figure 18). If you are having difficultly
passing the wire, it is likely safer to abandon the procedure, remove the
needle and wire together and reattempt at another site with senior help.
1 2 3
4 5 6
7 8 9
10 11
Anatomy notably those with raised intracranial pressure or severe respiratory fail-
The internal jugular (IJ) vein is a continuation of the sigmoid sinus at the ure, it is advisable to avoid the Trendelenburg position. Another reason-
base of the brain. The internal jugular exits the skull inferiorly through able situation in which to avoid the Trendelenburg position is in patients
the jugular foramen and travels inferiorly with the carotid artery and with pulmonary oedema and demonstrably raised venous pressures.
vagus nerve in the carotid sheath towards the ipsilateral clavicular head.
At the jugular foramen the IJ lies posteriorly to the carotid artery. Further Once the patient is in an optimal position use the ultrasound to ensure
inferiorly the vein lies laterally to the artery. At the level of the clavicle that there is minimal variation in vein diameter with the ventilatory
there is some separation between vein and artery (Figure 20). The carotid cycle. If you suspect that the risk of air embolus is high consider inserting
sheath lies beneath the sternocleidomastoid, omohyoid and sternothyroid femoral or basilic vein catheter instead.
muscles at a relatively shallow depth in most patients (2–3 cm).
A small degree of head rotation (10–20 degrees) away from the midline
Position towards the contralateral side may be necessary to gain manual access to
A patient who is intravascularly dry or non-ventilated and in respiratory the neck. However, more extreme rotation should be avoided as it reduces
distress can generate large negative venous pressures on inspiration. the size of the vein and the separation between artery and vein.54-56
These negative pressures can draw in a large air embolus through the
introducing needle while it is in the vein. The best means of prevention Finding the Internal Jugular Vein
is to lie the patient in the Trendelenburg position — supine with 15–30 Three approaches to the IJ are described in the literature (anterior, central
degrees of head down tilt. In addition to reducing the risk of air embolism and posterior). The central approach, described in this guide, is the best
this increases the diameter of the internal jugular vein.50-52 suited to ultrasound guidance. The ultrasound probe is placed over the
sternocleidomastoid muscle just inferior to the midpoint between the
The Trendelenburg position is much less important in intubated patients sternal head and the mastoid process. The needle is advanced through
receiving positive pressure ventilation.53 In some intubated patients, the sternocleidomastoid and into the vein below.
SN BCV
AV
SCM
SCM
IJV IJV
CA
CA
MP
Position
Lie the patient in the Trendelenburg position
(flat with 20 degrees of head down tilt). Unlike
the internal jugular vein this does not increase
the diameter of the subclavian vein57 but it
does help avoid air embolus (see above). A
folded towel between the scapulae helps to
retract the shoulder and enlarge the proce-
dural field.58
Approach
The clavicle hides most of the subclavian
vein from ultrasound view. To overcome
this, the cannulation occurs more laterally
into the deeper axillary vein. Ultrasound
guided infraclavicular catheterisation of the
subclavian vein is in fact catheterisation of
the axillary vein31 (this distinction is often
ignored in the published literature and clini-
cal communication).
SCV R1
TM
C
AV
AA
CB
C
AA
AV
TM
AA
AV
Anatomy A high rate of mechanical complications and the lack of reliable surface
The femoral vein runs inferiorly through the femoral triangle, an area anatomy landmarks makes ultrasound guidance particularly impor-
on the anterior upper leg bound superiorly by the inguinal ligament; tant. Anatomically guided techniques rely on the femoral vein being
laterally by the sartorius muscle and medially by the medial border of just medial to the point of maximal pulsation in the femoral triangle.
the adductor longus muscle. The floor of the femoral triangle is formed Unfortunately, this can be misleading, in some individuals the point of
by the iliopsoas and pectineus muscles. Near the inferior border of the maximal pulsation arises from the superficial rather than the common
femoral triangle the femoral vein is joined by two major veins: the great femoral artery.
saphenous medially and the profunda femoris posterior-laterally. Near
the superior border of the femoral triangle, at around the height of the Position
inguinal ligament the femoral vein is joined anteriorly by the superficial The proceduralist should stand on the ipsilateral side of the patient. The
epigastric vein. The ideal point for catheter insertion is in between these patient should be lying flat but not necessarily horizontally. The femoral
junctions at the midpoint between the inguinal ligament superiorly and canal can be made more accessible by externally rotating the leg and plac-
the branch of the deep saphenous vein inferiorly. Superior to this point, ing a folded towel under the ipsilateral buttock to slightly extend the hip.
the femoral vein runs more deeply to become the inguinal vein and
accessing the vein becomes more difficult; and inferiorly from this point Finding the Femoral Vein
it is common for the superficial femoral artery to overlie the femoral vein The ultrasound probe is placed on the patient just below the inguinal
raising the risk of arterial puncture (Figure 22). ligament at a distance from the inside leg that is in line with the midpoint
between the pubic symphysis and the anterior superior iliac crest.
SEV
FA
FV
EIV
IL
SEV
FA
FV
FA
GSV
FV
PFV
ALM
FA
GSV
PFV
FV
SM
Anatomy reach under the drapes to release the tourniquet. Feed the guide wire
The forearm is served by a network of veins that drain into the three major carefully into the vein with the soft flexible tip first. The wire must never
veins of the upper arm: the basilic, brachial and cephalic. PICC insertion be advanced stiff end first. Remove the needle or IV catheter leaving the
can be dishearteningly difficult. The key is distinguishing the basilic vein. wire in pace. A partially split sheath is supplied ready loaded on a dilator.
Feed this sheath and dilator combination as one over the wire carefully
The basilic vein runs from the posterior medial aspect of the forearm up through the soft tissues and into the vein. Continuous rotation in one
and around to the anterior medial aspect of the cubital fossa where it is direction helps the advance. The dilator should feed easily to the hub
joined by the median cubital vein. Near the border of the middle and once it is in the vein. Difficulty advancing can be a sign of misplacement,
inferior thirds of the upper arm it passes deep to the brachial fascia and stenosis or thrombosis. Ultrasound can help identify the issue. Remove
travels superiorly on the medial surface of the humerus in proximity to the dilator and wire together leaving the sheath in the vein. Feed the
the brachial artery, brachial veins, ulnar nerve and median nerve. The PICC into the sheath. The PICC is soft and flexible. Small advancing
basilic vein continues as the axillary vein in the axilla. The basilic is the motions are more successful than long ones. As you advance the PICC
largest vein of the upper arm. This and its straight course into the axillary have the patient bend his or her head to the side you are working on
vein make it the most suitable vein for a PICC.
Position BTC
CV
The patient can be lying in bed or reclined BA
on a chair. Either way, it helps to have the
patient’s arm somewhat adducted to the side BV
and resting on a support to allow easy access
to the medial aspect of the arm.
BTC
BTC
Groshong™ PICCs, which are finer, more BA
BA
BTC
1 2 3
4 5 6
7 8 9
10 11 12
With the exception of vascaths, central venous catheters are supplied with
a soft white rubber grip and blue plastic cover that needs to be clamped
around the catheter about 1 cm from the skin (Figure 26). A suture is
tied through each of the eyelets and then, separately, the skin. Further
sutures are placed through each of the two eyelets in the catheter hub
where the lumens separate. An infiltration of 1% lignocaine is necessary
to anaesthetise for the sutures.
Figure 27 StatLock™
Catheter grip and clamp set in a StatLock™ ready to be aplied to the skin.
At each attachment point there Clean the site around the secured
should be separate suture loops catheter with sterile saline and dry
through the skin and catheter the skin with gauze. Apply a clear,
eyelet (Figure 25). The skin loop impervious adhesive dressing,
should fit firmly without pinch- such as Mepore™, over the catheter.
ing the skin. Very tight central The skin can be swabbed with ben-
line sutures can cause a surpris- Figure 25 Catheter Sutures zoin resin in alcohol (Figure 28) to
Catheters should be sutured in a
ingly large blood loss and even cut make the dressing more adherent
figure-of-8 with two knots.
themselves loose. 3-0 is the thinest to the skin. Provide slack in the
Figure 28 Friars’ Balsam
suture material that should be used dressing as you apply it to avoid Benzoin resin can improve skin-to-
to secure a central line and a thicker suture material should be used for tenting around skin creases. dressing adhesion.
patients with fragile skin. Prolene™ (polypropylene) is our standard choice
of suture material. It is unbraided to reduce the risk of infection but it
is prone to unravel. To avoid this each knot requires 6 opposing throws
and 1 cm of spare thread on each end.
Internal Jugular Femoral Axillary & Subclavian PICC Vascath at any site
1. Sznajder JI, Zveibil FR, Bitterman H, Weiner 14. Hilty WM, Hudson PA, Levitt MA, Hall JB. 28. Chaiyakunapruk N, Veenstra DL, Lipsky
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