Procedures
Sanjiv J. Shah, M.D.
Carolyn S. Calfee, M.D.
Internal Jugular Vein Cannulation
Complications Of Central Lines
Procedures can only truly be taught by experience. Therefore, be aggressive about doing as many procedures as possible early on during your training. Resist the temptation to shy away from procedures due to lack of experience—instead, find someone with experience and make them teach you! If you find yourself lacking procedural skills and/or opportunities, find ways to gain experience (through anesthesia, ER, etc).
1. Flow rates of various catheters: determined by both diameter and length of catheter. Remember that triple lumen central venous catheters are useless for rapid fluid administration.
|
Catheter Size |
Length (inches) |
Flow rate (ml/min) |
|
3.50 |
160 |
|
|
14 gauge |
2.00 |
93 |
|
16 gauge |
2.00 |
75 |
|
16 gauge |
5.25 |
64 |
|
18 gauge |
2.00 |
62 |
|
18 gauge |
8.00 |
13 |
|
20 gauge |
2.00 |
42 |
|
24 gauge |
0.75 |
14 |
2. Major indications for central venous access:
· Cardiopulmonary resuscitation
· Intracardiac pacing
· Central venous pressure monitoring (CVP, PA lines)
· Rapid fluid administration
· Hemodialysis
· Hyperalimentation
· Vasoactive drug administration
· Administration of phlebitic medications
· Long-term intravenous therapy
3. Relative contraindications to central venous cannulation: remember that no absolute contraindications exist—you must weigh the risks and benefits for each patient individually.
· Subclavian vein: compromised pulmonary function (COPD, asthma), high levels of PEEP, coagulopathy, SVC thrombosis, upper thoracic trauma.
· Internal jugular vein: tracheostomy, excessive pulmonary secretions.
· Femoral vein: vena caval compromise (clot, extrinsic compression, IVC filter), local infection, cardiac arrest or low flow states, requirements for patient mobility.
4. Complications of central vascular access:
· Pneumothorax (PTX)
· Catheter/guidewire embolism
· Air embolism
· Central vein thrombosis
· Arrhythmias
· Myocardial or central vein perforation
· Pericardial tamponade
· Infection
· Hematoma
· Subcutaneous emphysema or fluid infiltration
· Arterial puncture and/or laceration
5. General approach to central venous catheterization:
· Obtain consent.
· Go over the procedure in detail with your supervisor prior to the procedure.
· Get all of your supplies ready and get rid of any unnecessary objects.
· Make sure the patient is optimally positioned and restrained (chemically or physically, only if necessary).
· The more sterile you are the better. This means sterile gown, sterile drape, hair cover, face mask/shield. No one was ever hurt by heightened sterile precautions.
· Prep the area with plenty of betadyne. Remember to ask about allergy to iodine or iodine-containing solutions and note that some catheters are incompatible with betadyne (mainly some dialysis catheters).
· Drape the area in sterile fashion and make sure you have all of your tools ready, positioned optimally, and in order of use. Don't forget to flush the catheter with saline.
· Infuse plenty of local anesthetic.
· Use the finder needle to locate the vein as described in the following sections on specific IV sites.
· Once venous blood is aspirated with the finder needle, insert the large bore needle at the same site and at the same angle.
· Once venous blood is aspirated, grasp the hub of the needle with your non-dominant hand and brace that hand against the patient.
· Lower the needle to the angle parallel to the vein and aspirate to reconfirm flow. If in doubt, confirm that the blood is venous by transducing. Remove the syringe while holding the needle in place and quickly feed the guidewire into the needle watching out for ectopy.
· Remove the needle over the guidewire and hold it in place with gauze (never let go of the wire!).
· Use scalpel to make a 3-4 mm stab through skin and fascia (sharp end away from guidewire).
· Pass dilator 3-4 cm over guidewire to dilate subcutaneous tissue.
· Pass catheter over guidewire which should exit out of the brown port (if using a triple lumen).
· Advance the catheter (don't lose the wire) and remove the guidewire.
· Aspirate blood and flush each port.
· Suture line in place and consider spacer in a small patient.
· Stat CXR to rule out pneumothorax and check line placement.
· Write procedure note and record procedure for your records and certification.
Iserson KV. High flow infusion techniques. In: Clinical Procedures in Emergency Medicine, 3rd ed., edited by Robert JR, Hedges JR, Philadelphia, WB Saunders, 1998, pp 352.
1. Advantages: fast, easy access; high success rate; no risk of pneumothorax; does not interfere with chest compressions or airway management.
2. Disadvantages: delayed circulation of drugs during CPR; difficult to keep site sterile; prevents patient mobility.
3. Anatomy
4. Approach:
· Find the femoral artery just below the inguinal ligament. Once found, remember that the vein is medial to the artery.
· The point of insertion should be one finger-breadth medial to the artery and two finger-breadths inferior to the inguinal ligament.
· Finder needle is optional here.
· With the bevel up and at a 45-60 degree angle above the skin, insert the needle parallel to the vessel. (The steeper the angle, the less chance of entering the peritoneum and the more medial the insertion angle of the needle, the less chance of entering the femoral artery).
5. Tips on successful cannulation:
· If you are right-handed, always stand on the right side of the patient, even if you are attempting to catheterize the patient's left femoral vein. Vice-versa if you are left-handed. This way, you won't be crossing your hands during the procedure and you will always have one hand on the femoral artery and one hand with the needle.
· Make sure the patient is lying flat on their back and not turned to one side.
1. Advantages: pneumothorax uncommon; easier control of bleeding; right IJ straight path to SVC.
2. Disadvantages: carotid artery puncture relatively frequent; poor landmarks in obese or edematous patients; difficult access with tracheostomies.
3. Anatomy
4. Approach: two approaches
· Turn the patient's head 45-60 degrees contralateral to the side of insertion. A triangle is formed by the clavicle and the two heads of the sternocleidomastoid muscle. At the apex of this triangle and lateral to the carotid is the optimal point of insertion.
· Another approach: Turn the patient's head 45 degrees to the contralateral side of insertion. Draw an imaginary line between the sternal notch and the mastoid process on the side of insertion. Half way between these two points and lateral to the carotid is the optimal point of insertion.
· Insert the needle at a 70 degree angle to the skin and aim for the ipsilateral nipple.
· First use finder needle and then access needle, always continuously aspirate while advancing and retracting.
· Aim lateral. If unsuccessful, withdraw and carefully go slightly medial. Reassess landmarks.
· Only insert the needle 0.5-1.0 inches and never > 1.5 inches (increases risk of PTX).
· Consider Site Rite® ultrasound if continued difficulty.
5. Tips on successful cannulation:
· Remove the pillow from underneath the patient's head and place the patient in trendelenburg.
· Most central line kits contain a long (approx 3 inch) angiocatheter that you can use as your needle instead of the regular needle. Once the vein is found, pass the catheter as you would a peripheral IV and take the needle out. This now gives you time to test whether you are in the artery or vein and to pass the wire with ease.
1. Advantages: most comfortable for patient; better landmarks in obese patients; large vein less collapsible during volume depletion or shock.
2. Disadvantages: higher risk of pneumothorax; bleeding difficult to control.
3. Anatomy
4. Approach:
· Place patient in Trendelenburg, remove pillow, and place towel roll between scapulae.
· Insert needle infraclavicularly 2 cm inferior to the junction of the lateral 1/3 and medial 2/3 of the clavicle. Aim for 2 cm above the suprasternal notch. Note that finder needle may not be long enough to reach vein.
· With non-dominant hand: index finger should be at the sternal notch and thumb should be at clavicle to guide placement.
· Remember to continuously aspirate on insertion and withdrawal.
· Keep the needle parallel to the floor and first aim for the clavicle. Once you have hit bone, march down until just below the clavicle remembering to push down on the needle tip and not on the syringe.
· Once under the clavicle and while continuously aspirating, advance needle approx 4-5 cm.
· If unsuccessful, withdraw needle and redirect more cephalad.
5. Tips on successful cannulation:
· An assistant can pull down on the patient's forearm on the ipsilateral side of insertion to further optimize insertion site by separating the shoulder from the clavicle.
· Insert the needle bevel up and once the vein is found, rotate the needle 90 degrees so that the bevel is facing caudally. This ensures easier advancement of the wire.
1. Which site has the most complications?
· Femoral vs. subclavian: a recent randomized controlled trial found that femoral lines had a higher incidence of thrombotic and infectious (late) complications. However, the study did not comment on early complications from the actual procedure itself (e.g. pneumothorax).
· IJ vs. subclavian: a recent systematic review found that there were more arterial punctures with the IJ approach but a higher chance of catheter misplacement with the subclavian approach. Interestingly, there was no difference in pneumothorax between the two approaches. There was not enough data on infectious complications to come to any conclusion. Note that these data were from nonrandomized studies and the trials were heterogenous in terms of operator skill-level. The bottom line: we need randomized controlled trials to truly say which route is safest in terms of complications.
2. Pneumothorax:
· Monitor with serial CXR's if small and asymptomatic.
· Always discuss with fellow/attending and surgery for possible chest tube placement.
· If sign of hemodynamic instability (tension PTX) place 14-16 gauge angiocath in the 2nd intercostals space, midclavicular line of affected side. Remove needle and leave open to air until emergent chest tube can be placed.
· Prevention: if having difficulty, use Site Rite® ultrasound or get someone more experienced. Consider alternate site in patients at high risk for PTX (COPD, bleb, bullous lesions).
3. Dysrhythmias: e.g. ectopy, VT, BBB, complete heart block
· Due to stimulation of the myocardium by catheter or guidewire.
· Typically resolves after withdrawal of catheter or guidewire.
· If VT treat with ACLS protocol; if complete heart block, initiate transcutaneous pacing.
· Prevention: estimate the distance from insertion site to SVC prior to catherization.
4. Vascular:
· Arterial puncture with needle only: withdraw needle and apply pressure for at least 5 minutes.
· Arterial puncture with dilator or catheter: surgical emergency. Leave line/dilator in place and get STAT surgical consult.
· Hematoma: most concerning with IJ placement (possible airway, carotid problems).
5. Catheter malpositioning or knotting:
· Get help and leave catheter in place (don't pull on catheter).
6. Air embolism:
· Rare; more common during disconnection of hub and not insertion.
· High risk patients: hypovolemic, low CVP, large negative intrathoracic pressure.
· If suspected, position the patient in the left lateral decubitus position and Trendelenburg to trap air in right ventricle.
Merrer J, De Jonghe B, Golliot F, et al. Complications of femoral and subclavian venous catheterization in critically ill
patients: a randomized controlled trial. JAMA. 2001 Aug 8;286(6):700-7.
Ruesch S, Walder B, Tramer MR. Complications of central venous catheters: internal jugular versus subclavian
access--a systematic review. Crit Care Med. 2002 Feb;30(2):454-60.
1. Always use sterile technique. Sterile gloves, field, and suture removal kit.
2. Make sure the line is not tunneled and does not have to be taken out by interventional radiology.
3. Procedure:
· Place the patient in Trendelenburg (reverse Trendenlenburg for femoral lines) and remove any pillows.
· Remove all bandages and gauze.
· Cut and remove all suture material being careful to not leave any behind.
· Instruct the patient to hum or valsalva while simultaneously and swiftly removing the central line.
· Dress the site with sterile gauze and place a Tegaderm or equivalent occlusive dressing on the gauze.
4. Proper technique is essential to prevent air embolism.
1. Indications:
· Diagnostic: to determine the cause of a pleural effusion.
· Therapeutic: to relieve symptoms of respiratory distress.
2. Contraindications (none are absolute): coagulopathy or any major respiratory impairment or lung disease on the contralateral side
3. Technique:
· Obtain informed consent and remember to use sterile technique at all times.
· If effusion on CXR, obtain a lateral decubitus film ipsilateral to the side of the effusion.
· If the effusion is small (< 1 cm on lateral decubitus film) or not free flowing, consider ultrasound to mark the effusion and/or look for loculation. Always go to ultrasound yourself to witness the marking and positioning of the patient! Make sure the mark is in the most optimal place and have ultrasound quantify the amount of fluid when doing a therapeutic tap.
· Have the patient sit up comfortably on the side of the bed and leaning forward slightly on the bedside tray table. If possible and especially for therapeutic taps, place the patient on a pulse oximeter.
· Find the optimal site by percussing the patient's chest wall and finding the fluid level. The usual site is the posterolateral aspect of the back, 1-2 interspaces below the fluid level but above the diaphragm. Aim to go just above the rib to avoid hitting any neurovascular structures. Mark the spot with a pen cap or something that won't be erased by betadyne.
· Using sterile technique, prep and drape the site.
· Use a 25 gauge or smaller needle for your initial wheal and subcutaneous anesthesia. Change to a 22 gauge needle (1.5 inch) and infiltrate lidocaine on the rib, marching up until you are just above the rib and into the pleural space. If you obtain fluid at this point, note the depth of the needle.
· Remember to use the same technique of marching up the rib when using your larger aspiration needle. For a diagnostic tap, use a 18-20 gauge needle attached to a 20-30 cc syringe.
· If performing a therapeutic tap, use an 18-gauge angiocath (or the catheter supplied in your kit) and place a stopcock on the end of the catheter once the needle is removed. Place non-collapsable tubing on to the stopcock and then drain the fluid in your container of choice. The use of vacutainer bottles may place too much negative pressure on the catheter, thereby collasping the catheter or tubing and making your life difficult. Removing more than a liter of pleural fluid increases the chance for reexpansion pulmonary edema.
· If some fluid comes out and then stops, check your catheter, tubing, etc. Having the patient valsalva can increase intrathoracic pressure and help the fluid flow.
· If you aspirate air (see air bubbles in your syringe) or the patient develops hypotension, desaturation, or respiratory distress, stop immediately and obtain a CXR or perform immediate needle decompression for tension PTX. If the patient has recently undergone thoracentesis, however, air bubbles may not indicate a pneumothorax.
· When removing the needle, have the pt. valsalva to reduce chance of PTX and bandage the site.
· Obtain a stat CXR post-procedure to rule out PTX.
4. Complications: PTX, hemothorax, infection, hypotension, reexpansion pulmonary edema, hepatic or splenic puncture.
5. Diagnostic studies: always send fluid for cell count, differential (lavender top); LDH, total protein (tiger top); gram stain (black top test tube); culture (culture bottles); pH. Other studies (cytology, glucose, AFB stains, etc) only if clinically indicated.
1. Indications:
· Diagnostic: to determine the cause of ascites.
· Therapeutic: to relieve symptoms of ascites.
2. Contraindications: none are absolute
· Coagulopathy, DIC, hernia at chosen site, caput medusae or superficial veins at chosen site.
3. Technique:
· Obtain informed consent and remember to use sterile technique at all times.
· If ascites is suspected but not evident on physical exam or is small, consider ultrasound to mark the fluid. Always go to ultrasound yourself to witness the marking and positioning of the patient! Make sure the mark is in the most optimal place and have ultrasound quantify the amount of fluid when doing a therapeutic tap.
· Have the patient urinate or use a foley to empty the bladder.
· Place the patient in the semirecumbent position (45-60 degrees) and percuss the level of dullness; insertion site should be inferior to umbilicus and level of percussed dullness. The usual insertion site is 2-3 fingerbreadths below the umbilicus. Midline insertion is the safest and first choice site. Contraindications to midline insertion are midline hernias (e.g. umbilical hernia) and previous scar as scar tissue is especially vascular. Second choice site is RLQ a few finger breadths above the inguinal ligament and should only be used for large ascites. Make sure the patient turns slightly to the ipsilateral side of needle insertion in this case.
· Using sterile technique, prep and drape the site of insertion. Anesthetize locally all the way to the peritoneum.
· Using the z technique retract the skin inferiorly relative to the abdominal wall and use a 20-22 gauge needle attached to a 20-30 cc syringe to aspirate ascitic fluid. Remember to continuously aspirate.
· For large volume paracentesis, use the same z technique but always use the Caldwell needle. Once fluid is aspirated, remove the needle from the metal catheter and attach pressurized, non-collapsable tubing. Use the needle you just removed and place it on the other end of the tubing and insert the needle into vacutainer bottle(s).
· For each liter removed, consider giving give the patient 50 cc of 25% albumin IV (the studies on this are equivocal but may prevent renal failure).
4. Complications:
· Infection (peritonitis), perforated viscous, hemorrhage, renal failure, hypotension.
5. Diagnostic studies:
· Send fluid for cell count, differential (lavender top); albumin, total protein (tiger or gold top); gram stain (black top test tube); culture (culture bottles).
· Other studies (amylase, cytology, AFB stains, etc.) only if clinically indicated.
1. Indications:
· Diagnosis of meningitis, subarachnoid hemorrhage, carcinomatosis, MS, etc.
· Measurement of CSF pressure, delivery of medications.
2. Contraindications:
· Increased intracranial pressure; if suspected (papilledema, headache), rule out with head CT.
· Infection near puncture site.
· Coagulopathy.
3. When should I get a CT before the LP? A recent study found a 97% negative predicted value if the answer to all of the following questions was “no”. If your patient has any of the following criteria, you should get a head CT prior to LP to minimize the risk of brainstem herniation.
· Age > 60 years.
· Immunocompromised state.
· History of CNS lesion (mass lesion, stroke, and/or focal CNS infection).
· Seizure in the past week prior to presentation.
· Neurologic findings (altered mental status, inability to answer two questions or follow two commands correctly, and/or any focal neurologic findings such as gaze palsy or arm drift).
4. Technique:
· Place patient on side and have them "roll up into a ball" with shoulders and pelvis perpendicular to the bed and chin down. Positioning is key. Locate the vertebral interspace between the posterior iliac crests (should be at L3, L4). Mark site with pen cap.
· Use sterile technique to prep and drape site. Anesthetize subcutaneously and to vertebrae.
· Insert spinal needle (bevel pointing up) into interspace and advance slowly with slight cephalad angle, aiming towards umbilicus. Periodically remove stylet fully to check for CSF.
· Once subarachnoid space reached and CSF fluid draining, attach manometer and measure pressure. Normal opening pressure is less than 20 cm H20.
· Drain CSF into tubes 1-4. Only ~ 2 cc necessary per tube. The less CSF removed, the less chance for headache.
· Re-insert stylet, remove needle, and apply dressing.
· If having difficulty, can withdraw and go in different intervertebral space (below L3). Ensure optimal positioning and ask for help if necessary. You can also try doing the LP in in the upright position. If difficulty persists, call neurology or anesthesia.
· After the procedure, instruct the patient to remain recumbent for 6 -12 hours and encourage fluid intake to prevent headache.
5. Complications:
· Headache, infection, hemorrhage, brainstem herniation.
6. Studies: check your local hospital for their specific guidelines on which studies are performed on individual tubes. Make sure that you always check a cell count with differential, glucose, total protein, gram stain, and culture. You can also send other chemistries and microbiology tests as clinically indicated. An additional black top test tube may be used for cytology. Note: most labs require quite a bit of CSF (8-10 cc) for AFB culture.
Hasbun R, Abrahams J, Jekel J, Quagliarello VJ. Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med. 2001 Dec 13;345(24):1727-33.