cvc-partner 1

Guide for Central Venous Catheterization

Central Venous Catheters

The handbook series cvc-partner deals with the use and application of central venous catheters. Arterial or pulmonary catheters, hemodialysis catheters, tunneled or implanted catheters are not included in the category of central venous catheters in this series. All information corresponds to the current standard of knowledge in the field. The absence of trademarks does not indicate that product names are not protected. This series has been prepared in consultation with many users to whom we wish to express our heartfelt gratitude for their various contributions. It is the intention of this series to assist the various users which needs a continuos dialogue with our readers. Any comment or tip is welcome and should be sent to info@cvc-partner.com or placed at the homepage www.cvc-partner.com.

Guide for Central Venous Catheterization

Preface

The present handbook is part of a new, unique concept where medical specialists demonstrate the technique of central venipuncture for other medical staff. The manual contains a concise summary of the skills necessary for central venipuncture, and in combination with the corresponding video tape Introduction of Central Venous Catheters by the Seldinger Technique all practical aspects of this intervention are described and shown in detail. Central venous catheterisation allows for an adequate therapy of critically ill patients during complex therapeutic interventions, especially in anaesthesia, intensive care and emergency medicine. A successful venipuncture requires profound knowledge of the indication and anatomic conditions, comprehensive experiences, a precise technique as well as high quality instruments (puncture set and catheter). Continuous technical developments and the resulting improvements led to a significant increase in patient safety. Todays medical professionals can choose from a variety of catheters and puncture techniques to match the individual requirements of each patient. In case of elective insertion of a central venous catheter the method of choice should be the Seldinger technique due to a reduced trauma and a larger variety of catheters available. After exact catheter positioning and verification of the correct catheter tip position in the vena cava (right in front of the atrium) by ECG-control via the Seldinger wire, an additional x-ray control is usually no more necessary. This significantly reduces the costs as well as the exposure to x-rays for both, patients and medical staff.

The techniques of central venous catheterisation and catheter placement via Seldinger wire can be learned easily by each medical specialist who is interested to do so. The present handbook on central venipuncture is a concise summary of the essential practical skills necessary for this intervention. The medical who is willing to learn these techniques can profit well from this practice-oriented manual. Tips from daily experiences will help to build on his own experiences and to quickly gain practical competence in this technique. To the experienced, this handbook gives a survey on the current technical improvements in catheter materials and puncture techniques. He will find information on how to further improve his technique as well as suggestions how to pass his knowledge and practical experiences on to medical assistants. I do hope that this excellent and practice-oriented manual will find many readers, eager to improve their knowledge.

Heidelberg, in March 2002 Prof. Dr. Johann Motsch Medical Director Department of Anaesthesiology University Hospital Heidelberg

Contents

1 When Is Central Venous Catheterization Indicated 2 Criteria for the Selecting of a Puncture Site 3 From venesection to the Seldinger technique 4 Selecting the proper catheter 5 Preperation for Catheterization 6 Catheter Placement with the Seldinger Method 7 Catheter Management 8 What To Do When Complications Occur 9 Glossary

7 10 14 18 23 26 32 34 38

When Is Central Venous Catheterization Indicated

The increased rate of morbidity among patients in critical care medicine often necessitates complex anesthesiological interventions where a central venous catheter can be essential. For each patient the reasons for catheterization must be given careful consideration.

When Is Central Venous Catheterization Indicated

The history of central venous cannulation starts in 1929 when Forssmann described the advance of a plastic tube to the heart by puncturing his own arm vein (1). At the beginning of the 1950s Aubaniac reported about the puncture of the subclavian vein. This puncture technique helped to broaden the use of this technically demanding procedure (2). Since this time central venous catheterization has developed to a standard procedure in routine clinical practice. In critical care and emergency medicine as well as for long-term therapies such as chemotherapy or dialysis, the use of central venous catheters or central lines has developed into an essential element of medical practice. The ongoing technical development of these medical products has resulted in a continual improvement of the therapeutic options for patients.

A central venous catheter is selected (3), when an i.v. catheter is not sufficient for the intended clinical therapy and it is necessary to have access to a large volume blood vessel for: Quick administration of large volume substitution and/or drugs Administration of i.v. solutions or drugs in the event of the collapse of peripheral vessels (shock) Administration of irritating or toxic drugs (e.g. catecholamines, chemotherapeutic agents) Administration of high-osmolarity solutions (> 800 mosm/l), e.g. for parenteral nutrition Therapies lasting several days or weeks which require a venous access Vein-venous hemofiltration (dialysis) Measurement of central venous pressure during or after an operation 8

Central Venous Catheters

The catheter tip of the central line is always in the superior or inferior vena cava thus guaranteeing the rapid distribution of infused solutions in the vascular system. So-called midline catheters are not advanced to the vena cava but are positioned in one of the large veins in the vicinity of the heart (e.g. subclavian vein). For patients with clotting disturbances, particular attention must be given to using a gentle puncture technique (e.g. the Seldinger method, Section 3 From Venesection to the Seldinger Technique). The puncture location must be carefully selected when the patient has skin abnormalities such as scars or burns or unusual anatomical features, e.g. a large goiter in the puncture area. This is also the case when the operation field is in close vicinity to the puncture site. The decision to make use of a central venous catheter must always be made on the basis of a strict risk-benefit analysis. The key point in making this decision is the following: A central venous catheter should only be used when other access routes or procedures are not appropriate. The catheter should be removed promptly as soon as it is no longer required.

Literature
(1) Forssmann, W.: Die Sondierung des rechten Herzens. Klin. Wschr. 1929, 8: 2080 (2) Aubaniac, R.: Linjection intraveineuse sosclaviculaire, advantages et technique. Presse Mdicale 1952, 60: 1456 (3) Kirby, R. R.: Clinical Anesthesia Practice. W.B. Saunders Philadelphia 2002, 2nd edition: 531541 9

Criteria for the Selection of a Puncture Site

A correct assessment of ones own experience, the patients condition and the purpose for which the central venous catheter will be used are the main factors determining the selection of a puncture site. Six different access sites have become widely used in clinical practice owing to their favorable risk-benefit profile.

10

Central Venous Catheters

The six most frequently used access routes for central venous catheters are: the internal jugular vein the subclavian vein the basilic vein the external jugular vein the brachiocephalic vein the femoral vein. A range of other puncture sites including locations such as the cephalic vein or the brachial vein in the upper arm are used less frequently because of their anatomical variability (1). For most of the access routes there are at least two different puncture directions which may be employed. For the subclavian vein, for example, there is an infraclavicular and also a subclavicular puncture approach. A detailed description of the various puncture approaches is to be found in Latto et al. (1). The most important factors determining the selection of the puncture site are: the experience of the user the condition of the patient, particularly the pressure conditions in the venous system the eventual use to which the central line will be put and the situation in which the catheter is inserted (e.g. the availability of sterile material for draping the patient and inserting the catheter). Physicians with less extensive experience should choose an access route where a puncture mistake cannot result in lifethreatening complications. A puncture location that fits this criterion is the basilic vein. This venous access is also used for long-term therapies or for inserting catheters which are not advanced all the way to the heart, e.g. midline catheters or peripherally inserted central venous catheters (PICC). If the circulatory condition of the patient is severely disturbed, then peripheral puncture locations are not suitable since the veins will be collapsed. In such cases, the subclavian vein or the brachiocephalic vein are possible choices because the lumens of these veins always remain open as a result of their placement in connective tissue. Risks associated with the puncture of these veins can be found in the table presented below (2). If infusions are to be administered to a conscious patient via a central venous catheter over a period of several weeks, then an access point should be selected that can be well tolerated by the patient and easily maintained. The basilic vein or the subclavian vein is generally preferred in such cases. The femoral vein is only used when other access routes have been rejected. Typical indications for the puncture of the femoral vein are burn injuries on the upper body or patients who are undergoing long-term therapy that requires a rotation of puncture locations .

The decision tree presented below provides assistance in selecting a puncture location depending on the specific situation. Internal and external jugular vein Subclavian vein Basilic vein Brachiocephalic vein Femoral vein

Some experience with central venous cannulation

No

Basilic vein

Almost normal blood pressure

No Reanimation/State of shock No

Subclavian vein Brachiocephalic vein Femoral vein Internal jugular vein External jugular vein Subclavian vein Brachiocephalic vein Basilic vein Femoral vein

Head injuries or Neck/Spine syndrome

Subclavian vein Femoral vein 11

Criteria for the Selection of a Puncture Site

Knowledge Internal jugular vein Beginner, experienced

Success rate Almost 95 %

Location Hospital

Remark regarding puncture Preferred: Internal jugular vein dextra (straight vein course)

Subclavian vein

Experienced

Almost 95 %

Hospital, Particularly well-suited for emergency medicine

Lumen is always open even for shock patients, because vein is fixed in mediastinal connective tissue

Basilic vein

Beginner, experienced

About 80 %

Hospital, Particularly well suited for non-sterile surroundings

Easy to puncture, comparable with i.v. cannula

External jugular vein

Beginner, experienced

60 %90 %

Hospital, particularly well suited for emergency medicine

Thrusting puncture of the vessel

Brachiocephalic vein (= Innominate vein)

Experienced

About 85 %

Hospital, particularly well suited for emergency medicine

Lumen is always open even for shock patients, because vein is fixed in mediastinal connective tissue

Femoral vein

Experienced

Almost 95 %

Hospital, Selected patients (burn cases, cardiology)

The puncture is done approx. 1 cm medial of the artery in a slightly diagonal direction towards proximal, in a depth of 24 cm

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Central Venous Catheters

Special Features Trendelenburg position, head turned away from puncture site Complications 1 Complication rate: 02 %; Puncture of the carotid artery; Pneumothorax, Hemothorax, Air embolism 2 Trendelenburg position, head turned slightly to the side; As catheter is advanced, head must be turned back towards puncture site; Valsalva maneuver can improve the filling of the vein Complication rate: 25 %; Pneumothorax, Hemothorax, Infusion thorax; Injury of the cranially positioned veins and arteries; Damage of the brachial

4 1 5 2
3

Difficulties in advancing the catheter can be avoided by overstretching the patients arm

Complication rate up to 17 % Incorrect catheter placement

4 Trendelenburg position, head turned away from puncture site; for better filling of the vein, apply pressure a fingers width above the clavicle Complication rate: 211 %; Unsuccessful puncture of the vein; Difficulty in advancing catheter; Incorrect catheter placement

5 Trendelenburg position, head turned away from puncture site; not suitable for cervical spine patients Complication rate: not available; Pneumothorax, Infusion thorax; Injury of the cranially positioned subclavian artery 6 Place a cushion under the patients buttock when puncturing the vena femoralis Complication rate: 515 %; Thrombosis, lung embolism, ascending infections

Literature
(1) Latto, I. P. et al. (2000): Percutaneous central venous and arterial catheterization. W. B. Saunders London 3rd edition (2) Malatinsky, J. et al.: Misplacement and Loopformation of central venous catheters. Acta Anaesth. Scan b. 1976, 20: 237247 13

From venesection to the Seldinger technique

Over the last 60 odd years, physicians have gradually been improving the technique for inserting central venous catheters beginning first with selfconstructed devices and later using industrially produced items so that the risks for patients have steadily declined. Today, the Seldinger technique is the method of choice in many countries for placing central venous catheters.
14

Central Venous Catheters

Surgical venous incision (venesection) Prior to the invention of percutaneous kits to place a central venous catheter it was always necessary to surgically expose the vessel in order to introduce a venous catheter. Today this technique is only rarely used, for example when implanting a longterm catheter or as last resort when other puncture techniques cannot be employed. To place the central venous catheter using this technique, the vessel is surgically exposed, clamped at two points and then opened with a small incision. The proximal vein clamp is opened and the catheter is then introduced into the vessel lumen through the opening. Following this, the vessel and surrounding tissue are surgically closed. This placement technique can only be used for large-bore veins. Careful maintenance of aseptic conditions is essential. The catheter placement requires a large amount of time and is therefore only suitable for special indications such as long-term catheterization. The technique should only be performed by experienced specialists and should not be employed on a routine basis.

(A)

(B)

(C)

Catheter-through-needle technique A significant improvement to the venesection was the first percutaneous method using a metal needle. After successful puncture of the vessel (A) the catheter is advanced through the needle to the vena cava (B). As soon as the intended position has been reached, the placement is checked by means of a chest radiograph. Then the steel needle is withdrawn and fixed at the distal hub of the catheter (C). To avoid injuring the patient, the sharp bevel of the needle must be secured, for example with a needle guard that is placed over the distal end of the catheter and the needle (1). This procedure represents a significant improvement over venesection. However, the juncture between the catheter and the puncture hole in the vessel wall is too loose which often results in hematoma formation. Another serious disadvantage is the fact that the plastic catheter is inside a metal needle. Withdrawal of the catheter through the needle must be avoided in all situations because this can result in the shearing off of the plastic catheter tubing. In the worst case, the sharp needle bevel cuts through the catheter. The resultant fragments can then enter the venous blood system and cause serious catheter embolisms (see chapter 8 What To Do When Complications Occur). This puncture technique puts the patient at unnecessary risk, as there are other procedures that allow a safe placement of a central venous catheter. The through-the-needle technique is not to be performed on a routine basis. 15

From venesection to the Seldinger technique

Catheter-over-needle technique Catheter-over needle kits quickly replaced the former puncture technique due to distinct technical improvements. For this method, a needle surrounded by a plastic cannula until close to the needle tip is used to perform the puncture (A). Distal to the patient, the plastic cannula gives way to a catheter, which is surrounded by a protective sheath. After puncture of the vein, the needle is withdrawn out of the catheter and the sheath via a fine wire (B). The catheter is then advanced into the blood vessel (C) (1). In contrast to the catheter-through-needle technique, there is almost no hematoma formation since the catheter over the needle completely fills the puncture hole created by the needle. A negative aspect of this method is the fact that a large-diameter puncture needle must be used, which makes the puncture of the vessel sometimes difficult. In addition, there is no interior guidewire along which the catheter can be advanced in the vein. This makes it difficult to successfully place the catheter along a venous course that is not straight, for example when puncturing the subclavian vein. This puncture technique is principally suited for routine applications and in emergency situations. However, it requires high manual dexterity and much experience.

(A)

(B)

(C)

Catheter-through-cannula technique The introduction of the catheter-through cannula technique in the Sixties greatly improved the placement security and the patient safety. With this technique, the blood vessel is prepunctured with an i.v. catheter. The i.v. catheter consists of a needle surrounded by a plastic cannula. After puncture of the vessel, the needle is withdrawn (A) and the cannula remains in the blood stream. The central venous catheter, which usually is contained in a protective sheath, is connected to the cannula by an airtight coupling (B). The catheter is then advanced through the cannula into the blood vessel. Positioning is facilitated by means of a mandrin inside the catheter. The cannula is removed distally after the correct catheter position has been reached (C) (1). As the catheter is advanced it slides over the smooth plastic walls of the cannula and not over a sharp needle edge. The shearing off or separation of fragments from the central venous catheter is clearly avoided. The through-cannula technique presents fewer risks for the patient and provides significantly better handling for the user, who is able to change the position of the central venous catheter at any time during the placement procedure. The catheter-through cannula technique is part of a physicians standard repertoire to be used in the hospital or in emergency situations for central venous puncture. 16

(A)

(B)

(C)

Central Venous Catheters

(A) Guidewire technique = Seldinger technique The Seldinger technique was first described in 1953 for an arterial approach (2). In the field of anesthesiology and critical care, the puncture technique quickly acquired a leading role. When puncturing the blood vessel, the user may choose between a steel needle or an i.v. catheter. For safety reasons, the i.v. catheter is preferred. When using the i.v. catheter, the steel needle is removed so that the plastic cannula remains in the vein. Through this cannula or alternatively a steel needle, a flexible guidewire is advanced into the vein (A). Then the needle or cannula is removed (B). The diameter of the puncture needle is always smaller than the central venous catheter. To facilitate the entry of the catheter through the tissue, a dilator made of plastic is put over the guidewire and advanced into the tissue. Then the central venous catheter is threaded over the wire and advanced into the vein (C). The guidewire stabilizes the plastic catheter and facilitates its positioning. After the placement of the catheter has been checked, the wire is removed (D). The puncture hole in the blood vessel can be kept very small using the Seldinger technique. This is a significant advantage with patients suffering from clotting disorders. The central venous catheter, which always has a larger diameter than the puncture needle, completely fills the original puncture hole. Hematoma formation is therefore almost entirely ruled out. Positioning of the central venous catheter is made much easier by the presence of the guidewire. The central venous catheter is much more readily advanced and directed through the vein thanks to the metal guidewire. Despite the exacting requirements for maintaining sterility and the complexity of the puncture procedure, the Seldinger technique has come to be very widely used. It is suitable for hospital use for all indications.

(B)

(C)

(D)

Literature
(1) Latto, I. P. et al.: Percutaneous central venous and arterial catheterisation. W. B. Saunders London 2000, 3rd edition: 1331 (2) Seldinger, S. I.: Catheter replacement of needle in percutaneous arteriography: new technique. Acta Radiologica 1953, 39: 368 17

Selecting the proper catheter

Technical advances have made central venous catheterization safe and easy, greatly expanding the application of central venous catheters. The wide range of catheters offered by different companies makes it possible to select an optimal product for the particular therapy requirements.
18

Central Venous Catheters

Material choice Central venous catheters intended for short-term use up to 30 days are usually made of polyurethane. Due to its low thrombosis rate this plastic material is clearly superior to polyvinyl chloride or polyethylene, which were commonly used in former times (1). At room temperature a catheter made of polyurethane is sufficiently stiff to easily push it forward into the vein. After a short time exposed to the 37 C temperature of the bloodstream, the polyurethane becomes softer and more flexible, thus reducing the risk of irritating the venous wall. Polyvinyl chloride and polyethylene catheters do not possess this softening characteristic and therefore should no longer be used (2).

Therefore central venous catheters are used for the short-term application espescially because of there mechanical characteristics (4). For the long-term application a lot of special catheters are available. They are made of silicon (3) witch is known for its high biocompatibilty and well proven mechanical characteristics.

19

Selecting the proper catheter

Soft tip The quality of the catheter tip is of particular importance for catheter placement. If the tip has sharp edges or uneven polymer outcroppings, these product faults can injure the sensitive venous wall during advancing of the catheter. Injuries of the venous wall might lead to thrombosis formation. A faulty catheter tip of this sort also creates risks after placement because the catheter moves in the blood vessel in conjunction with the heartbeat and might erode the venous wall. A rounded and readily malleable soft tip provides safety during placement and also while the catheter is in use.

Surface quality The surface and workmanship of the plastic catheter represents an important quality criterion that affects the rate of complications (5). Depending on the roughness of the catheter, blood cells and plasma components such as fibrinogen are deposited on the catheter surface. The deposited blood platelets and plasma proteins act as an initiator and center of thrombus formation. A smooth catheter surface, in particular at the lumen apertures, is therefore a crucial factor in determining whether there will be rapid thrombus formation. Specialized cardiological catheters (e.g. angiography catheters) often display special surface modifications such as hydrophilic polymers or heparin coatings that should reduce thrombus formation. In the anesthesiology field the importance of such modifications is a matter of dispute.

Placement control A modern central venous catheter should be visible along its full length in a radiograph. To make the catheter visible in most cases heavy metals are mixed into the plastic material. Should some portion of the catheter tubing be cut off inside the patient or should the catheter form a loop, the radiographic contrast allows easy recovery of the catheter. In many cases, a radiograph procedure is used to check the correct placement of the catheter. In recent years, however, the use of an ECG lead to check the position of the catheter tip has become increasingly widespread. This technique provides a reliable indication of catheter position even during catheter placement (see Handbook 2). Various manufacturers offer sets that allow the ECG signal to be conducted via a saline solution. A simpler and more elegant method is to conduct the ECG signal via a conductive wire like the Seldinger guidewire. In selecting a catheter set, this aspect of checking catheter position without additional x-ray exposure should be taken into account. 20

Central Venous Catheters

Guidewire Another important component of Seldinger systems in addition to the catheter is the metallic guidewire. Following puncture, this wire is advanced into the blood vessel and then serves as a guide for the placement of the catheter (see Section 6). The guidewire must be at once sturdy (so as to withstand high tensile force when being pulled) and highly flexible to facilitate the advance of the catheter. These characteristics are obtained when special hardened steel thread is closely wrapped around a core. In addition, many manufacturers offer guidewires either with straight or so-called Jtips. The J-tip gives way as soon as it encounters an obstacle and is therefore preferred so as to protect the venous wall. Due to this high pliability, however, it is in rare instances difficult to find the access route to the vena cava. In such cases, a second attempt should be made using a straight tip. Both types of tip should, of course, have a rounded end and not have any outcroppings. Needles Other components of the catheter set differ depending on the manufacturer, the intended use and the preferences of the user. General recommendations are therefore difficult to make. B. Braun offers three different introduction needles for the puncture of the vein: a Seldinger needle, an i.v. catheter or a valve needle. When using the i.v. catheter, the catheter is advanced through the plastic cannula that remains in the bloodstream, making it highly unlikely that the catheter could be sheared off by mistake. The Seldinger needle and valve needle Literature each consist of a steel needle; the valve needle, however, (1) Curelaru, I. et al.: provides a second access port in a Y-fixture. Both needles are Thrombogenicity in Central Venous Catheterization III. used for the Seldinger method. The guidewire is advanced A Comparison Between Soft Polyvinylchloride and Soft through the steel needle. This must be performed with great care Polyurethane Elastomer, Long, Antebrachial Catheters. because the sharp bevel of the needle can damage the guidewire Acta Anaesth. Scan. 1984, 28: 204208 (see Section 6). Both of these needle types should therefore only Pottecher et al.: be used by experienced physicians. The second port of the valve Thrombogenicity of central venous catheters. needle allows to advance the Seldinger wire into the blood Europ J Anaesth 1984, 1: 361365 vessel while a syringe is attached to the needle. (2) Pearson, M. L. and the Hospital Infection Control Practices Advisory Committee (HICPAC): Guidelines for prevention of intravascular-device-related infections. Infect Control Hosp Epidemiol 1996, 17: 438473. (3) Moss, A. H. et al.: Use of a silicone catheter with a Dacron cuff for dialysis short-term vascular access. Am J Kidney Dis 1988, 12: 492498. (4) Lind, T.: Stability of intravenous catheter in long term use. Lancet 1981: 673 (5) Hecker, J. F., Scandrett, L. A.: Roughness and thrombogenicity of the outer surfaces of intravascular catheters. J Biomed Mat Res 1985, 19: 381395 21

Selecting the proper catheter

Leading manufacturer offer a broad range of catheters suited to the age of the patient, the puncture site and the puncture technique. The following table show the product range of B. Braun Melsungen indicative of the wide variety of catheters available on the market. A summary of catheters available from B. Braun Melsungen is attached to this handbook at the end. Certofix Seldinger guidewire with J-tip Catheter with soft tip, transparent extension tubing and Safsite valves, available with various puncture sets Cavafix Catheter with transparent protective sheath Catheter with plastic mandrin or ECG J-wire as mandrin, available with various puncture sets

Adults Diameter: 4F (18G) 5F (16G) 6F (14G)

Children Diameter: 3F (22G) 4F (18G)

Adults Diameter: 3F (22G) 4F (18G) 5F (16G) 6F (14G)

Length: 15 cm, 20 cm, 30 cm Diameter: 7F: 16G/16G 14G/18G 9F: 13G/13G 12F: 11G/11G

Length: 10 cm, 15 cm, 20 cm Diameter: 4F: 22G/22G 5F: 18G/20G

Length: 32 cm, 45 cm, 70 cm Diameter: 4F: 18G/20G 6F: 16G/18G

Length: 15 cm, 20 cm, 25 cm, 30 cm Diameter: 7F: 16G/18G/18G 12F: 16G/12G/12G

Length: 8 cm, 13 cm, 20 cm Diameter: 5,5F: 20G/22G/22G

Length: 20 cm, 32 cm, 45 cm, 60 cm, 70 cm

Length: 15 cm, 20 cm, 25 cm, 30 cm Diameter: 9F: 16G/18G/18G/14G

Length: 8 cm, 13 cm, 20 cm

Length: 15 cm, 20 cm, 30 cm Diameter: 12F: 16G/18G/18G/18G/12G

Length: 15 cm, 20 cm, 30 cm 22

Preparation for Catheterization

Like all anesthesiological procedures, central venous catheterization demands good knowledge of the patient. Preventive measures such as positioning of the head or aseptic technique during inserting of the catheter as well as follow-up activities such as checking the catheter lumens for obstruction help to avoid complications.
23

Preparation for Catheterization

Anamnesis / Reviewing medical records The following subjects should be addressed with particular attention: Medication intake, in particular anti-coagulant therapy Previous infectious, pulmonary or cardiac illnesses Known allergic reactions Visual inspection of the intended puncture site and the ausculation of the lungs and heart are essential elements of the patient examination. If the intended puncture site is not usable owing to a skin ailment or if it is located in the operating area, then a more suitable point of access should be selected. An ongoing anti-coagulation therapy necessitates a careful risk/benefit analysis and the selection of a puncture site where a bleeding incident could be kept under control (e.g. jugular vein, basilic vein). Clotting status Prior to the insertion of a central venous catheter, the clotting status of the patient must be known. The following clinical parameters are taken into consideration (1): Thrombocyte count: Normal range 150400 x 109/l. Thrombocytes are essential for blood clotting. Thrombopathy begins at 30 x 109 thrombocytes/l. With an elevated thrombocyte count, the patient must be closely monitored following the procedure so as to quickly recognize any developing infection. Fibrinogen concentration: Normal range 24 g/l. Fibrinogen is essential for hemostasis. At 1,20 g/l the fibrinogen concentration is no longer sufficient for hemostasis during an operation. Partial thromboplastin time (PTT): Normal range: 2640 seconds, longer with anti-coagulation therapy. Measure for the speed of blood clotting. Prolonged PTT times and a reduced thromboplastin time (see below) are indicative of serious disorders in the clotting system (e.g. consumptive coagulopathy, liver damage, anti-coagulation therapy). Thromboplastin time or INR: Normal range: 0.71 (70100%). Anti-coagulation therapy reduces the value to 0.15. Measure for the speed of blood clotting. INR value of of 0.5 (delayed blood clotting) requires a drug therapy to increase the value before a central venous catheter may be inserted. Thrombin time (TT): Normal range 1822 seconds. This time becomes longer when the patient undergoes heparin therapy or when there is a high concentration of fibrinogen breakdown products. Measure for the speed of blood clotting. 24

Length measurement After selection of the puncture location, the necessary catheter length is determined by use of a measurement tape. When puncturing the right subclavian or jugular vein the correct catheter position immediately before the right atrium is reached in 1316 cm. The approach from the left side of the body requires 1520 cm. If the anatomical landmarks are unclear, it is advisable to conduct an ultrasound examination of the course of the vein so as to make an accurate estimate of the required catheter length (2). Ultrasound examination of the vein It may be advisable to conduct an ultrasound examination of the course of the vein depending on the experience of the user or the anatomical situation of the patient (3). If it is not possible to get a clear imaging of the course of the vein at the planned puncture location, then it is better to select a different puncture site.

Central Venous Catheters

Positioning of the patient In the neck and shoulder region, the liquid pressure in the large veins is lower than the atmospheric pressure. Unimpeded air entry through an 18G puncture needle could therefore allow as much as 100 ml of air to enter the venous system in a single second. This can result in an air embolism and the death of the patient. When puncturing the internal or external jugular veins as well as the subclavian or brachiocephalic veins, it is advisable to put the patients head in the Trendelenburg position. This entails lowering the head by 1530 with the patient in a supine position so as to increase the venous pressure (caution: cranio-cerebral injuries with increased cranial pressure). No special positioning of the patient is necessary for puncture in the region of the arm. For the most frequently used puncture techniques the patient is placed in a dorsal position (4). Sterile catheter placement technique The central venous catheter forms a sort of bridge between the outer world and the venous blood system, creating a possible pathway for the infiltration of germs. To avoid infection, strict aseptic practices should be observed when placing the catheter. Skin disinfection of the patient and of the physician inserting the catheter is essential (5). If a central line must be inserted outside of the hospital, for example in an emergency situation, then it is necessary to use a puncture technique that rules out the possibility of a contamination of the catheter. Commercially available catheter-through-cannula systems provide safety sheaths that prevent direct contact between the catheter and the person inserting it. Care should be taken that all other components of the system are also handled under aseptic conditions. In the hospital, there are no restrictions as to the employed puncture technique arising from the surrounding sterile conditions. Central venous puncture is performed using a maximum sterile barrier practice. The physician performing the puncture wears a mask, cap, gloves and gown. In the puncture area, the patient is covered with a large, sterile drape.

Literature
(1) Hope, R. A. et al.: Oxford Handbook of clinical medicine. Bern 1990 3rd edition: 700701 (2) Kirby, R. R. et al.: Clinical Anesthesia Practice. W. B. Saunders Philadelphia 2002, 2nd edition: 531540 (3) Fry, W. R. et al.: Ultrasound guided central venous access. Arch Surg. 1999, 134: 738741 (4) Latto, I. P. et al.: Percutaneous central venous and arterial catheterization. W. B. Saunders London 2000, 3rd edition (5) Pearson, M. L. and the Hospital Infection Control Practices Advisory Committee (HICPAC): Guidelines for prevention of intravascular-device-related infections. Infect Control Hosp Epidemiol 1996, 17: 438473. 25

Catheter Placement with the Seldinger Method

The placement of a central venous catheter using the Seldinger method is easy to learn but requires some manual dexterity. Thanks to modern catheter technology, it is possible to prevent some complications such as incorrect positioning of the catheter already during the placement procedure.

26

Central Venous Catheters 1 2

Central venous puncture usually occurs in the context of a comprehensive anesthesiological intervention with the accompanying preparation of the patient (e.g. Trendelenburg position, sedation, intubation, etc.). Because of the better accessibility it affords, the right internal jugular vein is recommended for right-handed physicians.

2 5 ml of a local anesthetic is injected into the puncture area. With an attached syringe the puncture needle is inserted in a caudal direction at an angle of 30 to the skin between the two bellies of the sternocleidomastoid muscle toward the ipsilateral nipple. The vein is reached at a depth of 2.54.5 cm.

1 The patient is disinfected in the puncture area and amply covered with sterile drapes. The head is turned to the opposite side and slightly extended dorsally. The puncture site is located lateral to the easily felt carotid artery and between the two heads of the sternocleidomastoid muscle. 27

Catheter Placement with the Seldinger Method

3 If the blood flowing back into the syringe is mostly dark red and not flowing with a pulsing rhythm (indicative of arterial blood), then the guidewire can be advanced via the puncture needle. Be sure that there is a secure connection between the needle and the dispenser unit of the guidewire.

4 The guidewire is at first inserted only 56 cm. The puncture needle is removed; the venous position of the guidewire must not be altered during this procedure. The skin directly at the puncture site can be widened with a scalpel (caution: do not damage the guidewire). A dilator that can be threaded over the guidewire and advanced downward to the vein is a safer way of facilitating the subsequent introduction of the catheter. The dilator is then removed. 28

5 The central venous catheter is advanced into the vein over the guidewire. A length marking on the guidewire indicate when the catheter tip has almost reached the tip of the wire but the flexible J-tip remains outside of the catheter. When this point has been reached, the catheter and the guidewire are then advanced together further into the vein.

Central Venous Catheters 6 7 8

6 A universal adapter for conducting an electrical signal from the guidewire is attached to the distal end of the guidewire. The ECG signal is switched over to the guidewire lead. The advancement of the catheter (with the guidewire inside) is continually monitored on the ECG screen.

7 When the catheter is advanced into the right atrium, a pronounced elevation of the P-wave occurs in the electrocardiogram. It must be retracted approximately 2 cm and is now positioned correctly in the superior vena cava.

8 All catheter lumens are checked for possible obstructions using physiological saline solution. 29

Catheter Placement with the Seldinger Method

10

10 Blood on the skin at the puncture site is cleaned away and the site is covered with a transparent dressing. The type of catheter and any complications that may have occurred are noted in the patients file.

9 The sliding fixation wing is brought into position and the clip for catheter fixation is attached. Unintended slippage of the catheter out of the vena cava is ruled out as far as possible by this arrangement. The fixation wing is attached to the skin with purse-string suture. 30

Checking the position of the central venous catheter The correct position of the catheter is in the vena cava directly before the right atrium. If the catheter is too deeply inserted the cardiac muscle can be damaged, which in the worst case can result in the death of the patient (cardiac tamponade). Commonly a chest radiograph is made directly after placement of the catheter. Modern catheter sets, however, make it possible to spare the patient this x-ray exposure by conducting an ECG during the placement procedure. The catheter is initially advanced to the point where an elevated P-wave is visible in the electrocardiogram; then it is retracted 2 cm. The ECG reading returns to normal. The elimination of an elevated P-wave is a clear signal of the catheters position before the right atrium. In some circumstances, a chest radiograph may still be necessary to rule out the occurrence of puncturing errors (e.g. a puncture of the pleural cavity).

Central Venous Catheters

Asepsis during catheter care The puncture site must be examined daily for signs of infection (redness), effluence and pain when pressed, so that any local infection will be quickly recognized. A transparent dressing over the puncture site facilitates this inspection. The dressing should be changed in accordance with the hospital policy for catheter care and if there is any indication of a local infection or contamination of the site. A local infection which is not recognized in time facilitates entry of bacteria and might damage the skin around the puncture site. Depending on the degree of infection, it may be necessary to remove and replace the entire catheter.

Testing catheter function Despite having checked the catheter position using the ECG lead, it is still essential to test that all the catheter lumens are free of obstructions. A syringe filled with physiological saline solution is connected to each of the lumens and blood is briefly aspirated. The aspirated solution is reinjected. If the aspiration or injection is obstructed, then the position of the catheter must be verified with a chest radiograph and corrected if necessary. If a Seldinger system has been used, the repositioning can be done easily. Catheters of the over-the-needle and through-the-cannula types can only be manipulated to a limited degree. If it is not possible to free the catheter lumens, then the catheter must be removed.

Idle catheter lumen Depending on the policy of the particular hospital, unused lumens may be filled with a so-called lock solution. The lock solution is composed of saline solution together with a heparin and/or an antibiotic. The solution in the catheter lumen prevents blood flowing back into the lumen. The heparin additive should help to prevent the deposit of blood platelets and resultant clot formation.

Literature
Kirby, R. R. et al.: Clinical Anesthesia Practice. W. B. Saunders Philadelphia 2002, 2nd edition: 531534 Latto, I. P. et al.: Percutaneous central venous and arterial catheterization. W. B. Saunders London 2000, 3rd edition 31

Catheter Management

Meticulous aseptic technique during catheter placement and catheter care is a prerequisite to avoid catheterassociated infections. The infusion system must be checked in the same careful way as the catheter because of the numerous possibilities for pathogen germs to enter the catheter via the luminal pathway.

32

Central Venous Catheters

Depending on the indication central venous catheter can be used short-term, e.g. for 12 days or up to several weeks. A longer indwelling time increases the risk for the patient to acquire a catheter-associated infection which is one of the most serious complications related to central venous catheterization (1). If clinical signs of a local infection at the puncture site (redness, tenderness, pain, heat) or of a systemic infection (fever, chilling, low blood pressure) occur and blood culture from two different sites show bacteria whereas no second source for a bacteremia is obvious then a catheter-associated infection is proposed (2). patient to become septic if the antibiotic lock method has not worked.

Top priority for the catheter management is to reduce the number of bacteria settling on the catheter's outer surface or invading the bloodstream via the infusion lines. Bacteria can attach to the catheter surface during placement if aseptic technique has not been properly adhered to e.g. during emergency placement. Improper disinfection of the patients skin opens the possibility for bacteria to enter the bloodstream by migrating along the catheter. Clinical studies indicate that meticulous aseptic technique during catheter placement lowers the infection risk. This means mask, cap, glove and gown for the physician and a large sterile dressing around the puncture site (3).

Careful catheter care includes all measures related to the infusion line. Any position in the infusion line that can be opened to the exterior, e.g. a stopcock or any change of the infusion line opens the possibility for bacterial colonization if aseptic techniques are not adhered to. Bacteria, which once have entered the lumen of an infusion line, will migrate into the catheter lumen and proliferate on it. A scheduled change of infusion line has shown some promise to avoid catheter-associated infections. Infusion lines which are used for infusing lipid containing solutions a change after 24 h is recommended. Infusion lines for application of medicines or other infusion solutions can be exchanged after 48 h (3).

The importance of using a good aseptic technique will help to reduce the incidence of catheter-associated infections.

After catheter placement the puncture site is covered by a wound dressing. In principle bacteria can quickly proliferate beneath this dressing and migrate along the catheter into the bloodstream if the catheter surface does not prevent this invasion pathway. Careful, daily control of the puncture site and the wound dressing is necessary to prevent bacterial invasion. Clotted blood or wound secretion at the puncture site must be removed using sterile saline solution. If clinical signs of a local infection are obvious the puncture site must be disinfected. Experts do not recommend the use of topical antibiotics (4). Depending on the recommendations of the hospital the central venous catheter is immediately removed if a catheter-associated infection has been recognized. The central venous catheter can easily be exchanged if a Seldinger guidewire is used. Replacing an infected catheter with a new one at the same site has provoked some discussion because of the risk to contaminate the new catheter (5).

Literature
(1) Raad, I. I. : Intravascular-catheter related infections. Lancet 1998, 351: 893898 (2) Garner, J. S.: CDC definitions for nosocomial infections. Am J Infect Control 1988, 16: 128140 (3) Pearson, M. L. and the Hospital Infection Control Practices Advisory Committee (HICPAC): Guidelines for prevention of intravascular-device-related infections. Infect Control Hosp Epidemiol 1996, 17: 438473 (4) Raad, I. I. et al.: Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiol 1994, 15: 231238 (5) Bach, A. et al.: Infections risk of replacing venous catheters by the guidewire technique. Zbl Hyg 1992, 193: 150159 33

Instead of an immediate replacement one could try to sanitize the infected catheter. A highly concentrated antibiotic lock solution is filled into the lumen for several hours. The antibiotic should kill the bacteria on the catheter surface. The success rate for this method greatly differs leaving a high risk for the

What To Do When Complications Occur

Central venous catheterization requires repeated practice to minimize the risk of complications. A correct estimation of ones own skills and the selection of an appropriate puncture technique for that skill level help to avoid unwanted difficulties for the patient.

34

Central Venous Catheters

Each puncture technique has its own risk profile independent of the users experience. The most important complications of each access method are described in section 2: Criteria for the Selecting of a Puncture Site. The table on the following pages lists the complications that occur most frequently or that may be life threatening (see Literature 17). The second column shows when the first signs of the complication normally become evident (Onset Time). A strict division between early, late and long-term complications is not possible and therefore has not been made. If there are no symptoms of a complication in the first 15 minutes following the puncture, it cannot be assumed that the catheterization is necessarily complication-free. Many injuries that are caused directly during the placement of the central venous catheter (e.g. damage to the inner wall of the vein) first become clinically recognizable some days later. The third column lists the clinical observations that will be made in the event of the respective complications. The fourth column indicates counter-measures that may be taken to limit the effects of the complication. Complications which can be fatal when diagnosed too late are highlighted in red in the table.

Literature
(1) Dailey, R. H.: Late vascular perforations by cvp catheter tips. J Emergency Med 1988, 6: 137140 (2) Gravenstein, N.: In vitro evaluation of relative perforating potential of central venous catheters: Comparison of materials, selected models, number of lumens, and angles of incidence to simulated membrane. J Clin Mat. 1991, 7: 16 (3) Fletcher, S. J. et al.: Safe placement of central venous catheters: where should the tip of the catheter lie? Br. J Anaesth. 2000, 85: 188191 (4) Timsit, J.-F.: Central vein catheter-related thrombosis in intensive care patients. Chest 1998, 114: 207213 (5) Malatinsky, J. et al.: Misplacement and Loopformation of central venous catheters. Acta Anaesth. Scand 1976, 20: 237247 (6) Hennessey, B.: Venous Air Embolism: Keep Your Patient out of Danger. Americ. J Nurs. 1993, 93: 5456 (7) Thomas, C. J., Butler, C. S.: Delayed pneumothorax and hydrothorax with central venous catheter migration. Anaesthesia 1999, 54: 987998 35

What To Do When Complications Occur

Complication Incorrect Puncture

- Into tissue - With perforation of the vessel - With arterial damage - With puncture of pleural cavity

Onset time

Immediately Immediately Immediately In the first 15 minutes, on the same day

- With nerve damage

Immediately, in the first 15 minutes, on the same day

Incorrect catheter position

- in another vein - single lumen openings outside the vein - too deeply inserted in the right atrium - with puncture of the cardiac muscle On the same day Immediately, in the first 15 minutes, on the same day

Immediately On the same day, within one week

Embolism
- Catheter embolism - Guidewire embolism - Air embolism Immediately Immediately Immediately, in the first 15 minutes

Other Disorders
- Dysrhythmia Immediately, on the same day, within one week

- Thrombosis

On the same day, within one week

Infection
- Local infection - Catheter associated infection to the point of sepsis 36 Within one week Within one week

Central Venous Catheters Observation Counter-Measures

No reflux of blood, No other observable damage Initially no reflux of blood; when needle is withdrawn reflux of blood. Swift hematoma formation Blood reflux in synch with pulse, brightly colored blood No reflux of blood through lumen after infusion Breathing problems, Pneumothorax Absent or delayed effect of administered drugs Paresis

New puncture attempt at the same location (up to 3 times) or at a new location Compression bandage, Change of puncture location Compression bandage, surgical closure of vessel Removal of catheter, Pleura drainage if pneumothorax occures wait and see Check with chest radiograph, with ECG

Usually coincidental chest radiograph finding No reflux of blood through lumen, lumen obstructed for infusion After infusion: tissue tender to touch (Hydrothorax) Absent or delayed effect of administered drugs Arrhythmia, extrasystole Pericardium tamponade, falling blood pressure, asystole, cardiac arrest

If possible, repositioning of catheter; if not, removal of catheter, new puncture If possible, repositioning of catheter; if not, removal of catheter, new puncture Repositioning if possible Pericardiocentesis, Resuscitation

Portions of the puncture needle are missing Portions of the catheter are missing when retracted Portions of the guidewire are missing when retracted Oxygen deficiency, gasping breathing Stop of circulation

Radiographic inspection, surgical removal or wait and see Radiographic inspection, surgical removal or wait and see Check of all medical items in the infusion system for air tightness, respiration

Arrhythmia, extrasystole Ventricular fillibration from disturbance of cardiac impulse propogation Vein sensitive to pressure

ECG examination, Drug therapy, Defibrillation

Sonography, Application of anticoagulant drugs, Removal of catheter

Redness, effluence, puncture site sensitive to pressure Fever or shivering, blood culture with detection of bacteria, low blood pressure, oliguria 37

Inspection and disinfection of puncture site Broad-spectrum antibiotic therapy, Removal of catheter

Glossar

Antibiotic lock technique

Instillation of an highly concentrated antibiotic solution in the catheter lumen to eradicate bacteria on the catheter surface Semi-rigid or soft plastic tubing of longer length used for central venous catheterization Technique for cvc placement: catheter is pushed through a needle Technique for cvc placement: needle is surrounded by catheter. After puncture needle is retracted and catheter remains in place Technique for cvc placement: needle is surrounded by cannula and retracted after puncture. Catheter is pushed through the cannula Short and rigid plastic tube, mainly used as intravenous catheter for short-term use Venous catheter which has been placed either via peripheral veins or via large bore veins close to the heart; its tip lies in the vena cava or close to the heart Accumulation of blood beneath the pleura due to simultaneous puncturing of a large blood vessel and the pleura Accumulation of infusion solution beneath the pleura due to malposition of a catheter tip Short venous catheter which is always placed via a peripheral vein Physiological saline solution with or without heparin which is instilled in an idle catheter lumen to prevent clot formation Peripherally inserted venous catheter whose tip doesnt lie in the vena cava superior but more peripherally Metal tube with bevel to puncture tissue and blood vessels Collapse of one or both lungs due to puncturing of the pleura and loss of pressure Peripherally inserted central venous catheter whose tip lies in the superior vena cava Technique for cvc placement: a metal guidewire is advanced through the puncture needle or i.v. catheter into the vein; the central venous catheter is threaded over the wire and after correct placement of the catheter just before the atrium the wire is retracted About 15 inclined position of head and chest to increase blood volume in abdominal veins Exit site of central venous catheter is remote to the venipuncture site in order to prevent fast migration of skin bacteria through the puncture site into the blood vessel Expiration of patient through nose with closed lips, increases blood volume in subclavian vein

Catheter Catheter-through-needle Catheter-over-needle

Catheter-through-cannula

Cannula Central venous catheter

Hemothorax

Hydrothorax Intravenous catheter Lock solution

Midline

Needle Pneumothorax PICC Seldinger technique

Trendelenburg position Tunneled catheter

Valsalva maneuver

Central Venous Catheters

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