Technique of placement of a peripheral venous catheter or a central venous catheter
Peripheral venous cannulation
Indications
The placement of a peripheral venous catheter is indicated when vascular access is required for the administration of intravenous (IV) fluids, blood products or medications that must be administered through the IV route.
Note that when rapid volume resuscitation is needed, short, large-bore peripheral intravenous (IV) catheters can often achieve more rapid flow of fluids than the longer central venous catheters.
Contraindications, cautions and difficulties in inserting a peripheral venous catheter
Εntry through skin with signs of infection should be avoided.
Also avoid using veins previously involved with phlebitis or thrombosis, or extremities with lymphatic insufficiency.
Peripheral venous cannulation is often difficult in patients with obesity, hypovolemia which has resulted in venous collapse or intravenous drug users.
Also avoid using veins previously involved with phlebitis or thrombosis, or extremities with lymphatic insufficiency.
Peripheral venous cannulation is often difficult in patients with obesity, hypovolemia which has resulted in venous collapse or intravenous drug users.
Procedure of peripheral venous cannulation
Prepare the intravenous (IV) infusion setup by attaching the IV tubing to the solution bag. Run a small quantity of solution to fill the tubing.
Place a tourniquet around the upper arm and search for a palpable vein. The tourniquet is placed about 3-4cm proximal to the puncture site. The placement of the tourniquet should be tight enough to impede venous flow, but not so tight as to reduce arterial flow. The tourniquet is tied in a single loop in such a way that it can be released with one hand.
Veins can be usually found in the antecubital fossa, the antibrachium or the dorsum of the hand. Useful maneuvers to distend the veins are the following: opening and closing the fist or tapping over a vein (can cause reflex vasodilatation of the vein). If no veins are apparent, it can be useful to apply a warm towel to the skin, to cause dilation of the veins.
For peripheral venous cannulation it is recommended to choose a straight portion of a vein. Put on gloves, clean the patient’s skin with an alcohol solution and let it dry. Stretch the skin distally to stabilize the vein and inform the patient that they should expect a mild pain. Insert the needle, at an angle with the surface of the skin of about 30 degrees with the bevel of the needle upwards. (The bevel of the needle is the slanted opening of the needle at its tip, which is not straight, but it is inclined to facilitate non-traumatic entry into the tissues). Advance the needle until a flashback of blood is seen in the hub at the back of the IV catheter. Release the tourniquet, hold the needle steady and fully advance the plastic catheter over the needle into the vein. Then remove the needle fully while holding the plastic catheter in position and apply pressure to the vein at the tip of the cannula with your non-dominand hand. Connect the intravenous cannula to the plastic tubing, to start the IV infusion and initiate flow by opening the valve on the tubing.
Apply a sterile dressing and tape the catheter in place. Also tape
the IV tubing to the skin in a U-shaped loop to reduce the likelihood of the catheter being accidentally pulled and dislodged. Carefully dispose of the needle into the sharps bin.
If the cannulation site overlies a joint, it may be useful to affix an
arm board, in order to stabilize the joint.
If the IV catheter (IV cannula) is correctly in position, fluid should flow freely into the vein.
In the case of the appearance of swelling around the catheter site, the cause is extravasation of fluid from the vein. This apart from swelling, also causes pain at the site. This is an immediate complication of venous cannulation. Then stop the infusion, remove the IV catheter and apply pressure over the area and attempt venous cannulation at a different site.
Another possible complication is phlebitis (inflammation of the vein). This is not an immediate complication. It may occur at IV sites utilized for several days. Another delayed complication that may infrequently occur is local subcutaneous infection, but this can be usually prevented by careful skin cleaning with an antiseptic solution (usually an alcohol solution) before performing a venous puncture.
Central venous cannulation
Indications for placement of a central venous catheter
1. Inability to obtain access to a peripheral vein (failed attempts of peripheral venous cannulation or impossible peripheral vein cannulation) in a patient who requires urgent administration of IV fluids or urgent IV medications.
2. When medications that are irritating to smaller peripheral veins need to be infused.
Examples are chemotherapeutic drugs, hyperosmolar saline, 10% calcium chloride (but not calcium gluconate, which can safely be administered from a peripheral vein). It is also better to infuse vasoactive drugs such as norepinephrine or dopamine, through a central venous line, because if extravasation occurs in peripheral veins they can cause soft tissue necrosis.
Examples are chemotherapeutic drugs, hyperosmolar saline, 10% calcium chloride (but not calcium gluconate, which can safely be administered from a peripheral vein). It is also better to infuse vasoactive drugs such as norepinephrine or dopamine, through a central venous line, because if extravasation occurs in peripheral veins they can cause soft tissue necrosis.
3. When temporary transvenous pacing is required.
4. When hemodynamic measurements are required, such as measurement of the central venous pressure or
the insertion of a pulmonary artery catheter (Swan-Ganz catheter) to obtain more complex hemodynamic measurements (pulmonary capillary wedge pressure, etc).
[ Central venous pressure (CVP) measurement is a common measurement that can be obtained with a central venous catheter in the subclavian or internal jugular vein. CVP is approximately the same as right atrial pressure. It can be used in critically ill patients or patients with shock to assess if there is a hypovolemic state (reduced blood volume) or if there is right sided heart failure or hypervolemia due to excessive IV fluid administration. In the first case (hypovolemia) CVP is low, whereas in congestive heart failure or hypervolemia it is high.
CVP values are as follows:
Low: <6 cm H2O
Normal: 6 to 12 cm H2O
High: >12 cm H2O ]
5. To perform urgent hemodialysis for renal failure, life-threatening hyperkalemia, etc
6. For the infusion of hyperalimentation or other
concentrated solutions.
There are no absolute contraindications but the following relative contraindications are generally accepted in the bibliography:
1.A disorder of blood coagulation. This is particularly a factor in subclavian vein cannulation.
2. An overlying skin infection.
3. An uncooperative patient.
General technique of catheterization of a central vein
The Seldinger (catheter over wire) method is used, with a wire inserted through a needle into the vein and then a central venous catheter advanced into the vein over the wire. This allows placement of a large-bore catheter over a wire inserted through a
smaller bore needle.
Identify the appropriate superficial anatomic landmarks, according to the vessel that you intend to catheterize.
For central vein cannulation, a sterile procedure is required. Wear mask and hair covering, and most importantly use sterile gloves and wear a sterile gown. Sterilize the skin of the area around the intended puncture site with a topical antiseptic, such as a povidone-iodine or chlorhexidine solution and surround the field with sterile drapes.
Infiltrate the skin and underlying subcutaneous tissue to be entered with a topical anesthetic solution (1% lidocaine, about 5 ml). Identify the correct puncture site by using the external landmarks and puncture with an 18-gauge (18G), 2.5-inch needle attached to a syringe. While advancing the needle aspirate with the syringe. When blood flows freely into the syringe stop advancing the needle, since this indicates that it has entered the vessel. If no blood is encountered, withdraw the needle to the skin edge, redirect it, and try again.
When blood entering freely the syringe confirms that the syringe has entered the vein, stabilize the needle, remove the syringe and cover the hub of the needle with your thumb, to avoid the entrance of air into the vein. Avoid inadvertent cannulation of the nearby artery, by noticing the type of blood flow from the needle. Venous blood is dark and flows with low pressure, whereas arterial blood is bright red and clearly pulsatile! If you are not sure, take a blood sample from the needle and give it to your assistant for analysis of blood gases or connect the needle to a pressure transducer to ensure that you have entered the vein and after that proceed with the next step, which is the insertion of the guidewire. However, the difference between venous and arterial flow is obvious and you will not usually need any confirmation other than your own eyes.
Introduce the flexible curved end of the J-shaped metal guide wire into the hub of the needle and pass the guide wire through the needle. If the needle tip is in a correct position into the vein the wire should pass smoothly through the needle into the vein without resistance. If you encounter resistance, never force the wire, but withdraw the wire together with the needle and make a new attempt.
Once most of the wire has been passed through the needle, withdraw the needle over the wire, leaving the wire in place. Always maintain a grip on the wire throughout the procedure! ( Be always careful to allow enough of the wire to protrude through the skin to allow passage of the catheter over it and never insert the entire length of the wire through the needle). After removing the needle make a small superficial incision of the skin at the point that the guidewire enters the skin with a scalpel. Then, with a twisting motion, pass the dilator over the wire, being careful to ensure that a portion of the wire protrudes from the dilator and performing every maneuver from now on with one hand holding the wire. (In other words be cautious not to lose the wire into the patient! If this happens you will need to call emergently a surgeon...). Insertion of the dilator will create a passage in the subcutaneous tissue for an easier insertion of a catheter or a sheath. Remove the dilator, leaving the wire in place, paying attention not to move the wire from its position. Pass the central venous catheter (sheath) over the wire in a manner similar to passing the dilator. It is essential that the guidewire protrudes from the hub of the catheter and that the operator grasps it before catheter advancement ! If you have completed the previous steps of the procedure correctly, the catheter or sheath should be able to advance smoothly, requiring no force. Remove the guide wire through the catheter holding the catheter in place. Aspirate and flush all ports of the catheter to confirm catheter function. Attach the tubing of the IV infusion set to the catheter, in order to start an IV infusion.
[ Central venous pressure (CVP) measurement is a common measurement that can be obtained with a central venous catheter in the subclavian or internal jugular vein. CVP is approximately the same as right atrial pressure. It can be used in critically ill patients or patients with shock to assess if there is a hypovolemic state (reduced blood volume) or if there is right sided heart failure or hypervolemia due to excessive IV fluid administration. In the first case (hypovolemia) CVP is low, whereas in congestive heart failure or hypervolemia it is high.
CVP values are as follows:
Low: <6 cm H2O
Normal: 6 to 12 cm H2O
High: >12 cm H2O ]
5. To perform urgent hemodialysis for renal failure, life-threatening hyperkalemia, etc
6. For the infusion of hyperalimentation or other
concentrated solutions.
Contraindications to the placement of a central venous catheter
There are no absolute contraindications but the following relative contraindications are generally accepted in the bibliography:1.A disorder of blood coagulation. This is particularly a factor in subclavian vein cannulation.
2. An overlying skin infection.
3. An uncooperative patient.
General technique of catheterization of a central vein
The Seldinger (catheter over wire) method is used, with a wire inserted through a needle into the vein and then a central venous catheter advanced into the vein over the wire. This allows placement of a large-bore catheter over a wire inserted through a
smaller bore needle.
Identify the appropriate superficial anatomic landmarks, according to the vessel that you intend to catheterize.
For central vein cannulation, a sterile procedure is required. Wear mask and hair covering, and most importantly use sterile gloves and wear a sterile gown. Sterilize the skin of the area around the intended puncture site with a topical antiseptic, such as a povidone-iodine or chlorhexidine solution and surround the field with sterile drapes.
Infiltrate the skin and underlying subcutaneous tissue to be entered with a topical anesthetic solution (1% lidocaine, about 5 ml). Identify the correct puncture site by using the external landmarks and puncture with an 18-gauge (18G), 2.5-inch needle attached to a syringe. While advancing the needle aspirate with the syringe. When blood flows freely into the syringe stop advancing the needle, since this indicates that it has entered the vessel. If no blood is encountered, withdraw the needle to the skin edge, redirect it, and try again.
When blood entering freely the syringe confirms that the syringe has entered the vein, stabilize the needle, remove the syringe and cover the hub of the needle with your thumb, to avoid the entrance of air into the vein. Avoid inadvertent cannulation of the nearby artery, by noticing the type of blood flow from the needle. Venous blood is dark and flows with low pressure, whereas arterial blood is bright red and clearly pulsatile! If you are not sure, take a blood sample from the needle and give it to your assistant for analysis of blood gases or connect the needle to a pressure transducer to ensure that you have entered the vein and after that proceed with the next step, which is the insertion of the guidewire. However, the difference between venous and arterial flow is obvious and you will not usually need any confirmation other than your own eyes.
Introduce the flexible curved end of the J-shaped metal guide wire into the hub of the needle and pass the guide wire through the needle. If the needle tip is in a correct position into the vein the wire should pass smoothly through the needle into the vein without resistance. If you encounter resistance, never force the wire, but withdraw the wire together with the needle and make a new attempt.
Once most of the wire has been passed through the needle, withdraw the needle over the wire, leaving the wire in place. Always maintain a grip on the wire throughout the procedure! ( Be always careful to allow enough of the wire to protrude through the skin to allow passage of the catheter over it and never insert the entire length of the wire through the needle). After removing the needle make a small superficial incision of the skin at the point that the guidewire enters the skin with a scalpel. Then, with a twisting motion, pass the dilator over the wire, being careful to ensure that a portion of the wire protrudes from the dilator and performing every maneuver from now on with one hand holding the wire. (In other words be cautious not to lose the wire into the patient! If this happens you will need to call emergently a surgeon...). Insertion of the dilator will create a passage in the subcutaneous tissue for an easier insertion of a catheter or a sheath. Remove the dilator, leaving the wire in place, paying attention not to move the wire from its position. Pass the central venous catheter (sheath) over the wire in a manner similar to passing the dilator. It is essential that the guidewire protrudes from the hub of the catheter and that the operator grasps it before catheter advancement ! If you have completed the previous steps of the procedure correctly, the catheter or sheath should be able to advance smoothly, requiring no force. Remove the guide wire through the catheter holding the catheter in place. Aspirate and flush all ports of the catheter to confirm catheter function. Attach the tubing of the IV infusion set to the catheter, in order to start an IV infusion.
To stabilize the central venous catheter or sheath suture it to the skin. Before placing the suture, first inject a wheal of topical anesthetic into the area where the suture will be placed.
A general rule is that apart from reading textbooks or internet sites, supervision and guidance from an experienced colleague is very valuable in order to learn these techniques and avoid errors that can lead to complications. Complications of central venous cannulation, although rare, can occur especially if there are errors in the technique of the procedure. Complications can be infection of the puncture site, or systemic infection and endocarditis, inadvertent arterial puncture and hematoma formation, pneumothorax (especially as a complication of subclavian vein cannulation), hemothorax, hemopericardium and tamponade (as a result of injury to the right atrial wall), loss of the guidewire into the vein, air embolism. When there are failed attempts it is better to ask for the help of a more experienced colleague (if available) than to persist. Many attempts greatly increase the likelihood of complications.
Bibliography and links
Intravenous Cannulation- medscape
A general rule is that apart from reading textbooks or internet sites, supervision and guidance from an experienced colleague is very valuable in order to learn these techniques and avoid errors that can lead to complications. Complications of central venous cannulation, although rare, can occur especially if there are errors in the technique of the procedure. Complications can be infection of the puncture site, or systemic infection and endocarditis, inadvertent arterial puncture and hematoma formation, pneumothorax (especially as a complication of subclavian vein cannulation), hemothorax, hemopericardium and tamponade (as a result of injury to the right atrial wall), loss of the guidewire into the vein, air embolism. When there are failed attempts it is better to ask for the help of a more experienced colleague (if available) than to persist. Many attempts greatly increase the likelihood of complications.
Internal jugular vein cannulation
The patient should be lying flat preferably in a Trendeleburg position of the bed (head down to about 15°). This position is useful to distend the vein and also to reduce the risk of air embolism. The patient's head should be resting on one pillow and turned to look to the contralateral side. Place a large absorbent pad under the patient’s head and shoulders to prevent the bedclothes from getting soaked with blood.
There are three main approaches for internal jugular vein cannulation (the anterior, posterior and central approach). Here only the central approach, which is more often used, will be described.
There are three main approaches for internal jugular vein cannulation (the anterior, posterior and central approach). Here only the central approach, which is more often used, will be described.
The puncture site for cannulation of the internal jugular vein is identified as follows: the vein runs directly beneath the apex of the triangle formed by the division of the sternal and the clavicular head of the sternocleidomastoid muscle and it continues to run in that triangle just laterally to the carotid artery. Palpate the internal carotid artery with the one hand and gently lift it medially. Moreover, the venous pulsation of the internal jugular vein may often be visible and it is different from the carotid pulse because it is more complex (consists of more waves), it has a lower amplitude, it is present in diastole and it is not palpable.
Keeping the fingers of one hand on the carotid pulsation, infiltrate the skin with local anesthetic (lidocaine 1%), aiming just lateral to the carotid pulsation and ensuring that you are not injecting the anesthetic into a vessel (eg a vein), by performing gentle suction with the syringe before injecting.
After identifying the above anatomic landmarks which will guide you to the position of the vein, insert the needle at about 1 cm below the apex of this triangle (the triangle formed by the clavicular and sternal head of the sternocleidomastoid muscle and the clavicle) parallel and laterally to the internal carotid artery (which you must continuously palpate during the procedure). The insertion of the needle must be at a 30-45°angle to the skin, with a direction towards the ipsilateral nipple. Successful venous return usually occurs within 1 to 3 cm of needle advancement. In a slim person, the internal jugular vein lies < 1 cm below the skin.
 |
| Central venous cannulation -internal jugular vein catheterization:central approach |
Cannulation of the subclavian vein
Do not use the subclavian approach in patients with coagulopathy or on anticoagulation treatment, because accidental puncture of the subclavian artery is not amenable to direct compression, in order to stop the hemorrhage. In patients with coagulopathy catheterization of the femoral vein is safer, because the femoral artery and vein are both amenable to direct compression.The surface landmark used for the identification of the correct puncture site is the clavicle. Palpate the clavicle along its entire length and locate the point between the medial third and the middle third of the bone.This point lies on the most curved part of the clavicle where it turns to a more posterior direction.
The needle is introduced at this point (between the medial and middle third of the clavicle) and passed under the clavicle. You should try to have a mental image of the location of the needle tip. When the needle tip is under the clavicle, flatten the syringe to
the skin and aim for the suprasternal notch. Direct and advance the needle slowly toward the suprasternal notch at a 10°angle to the surface of the chest. The subclavian vein should be reached when the needle is advanced approximately 4 cm towards the direction of the suprasternal notch.
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| Central venous line: Cannulation of the subclavian vein |
Bibliography and links
Intravenous Cannulation- medscape
http://www.oxfordmedicaleducation.com/clinical-skills/procedures/central-line/
Akaraborworn O. A review in emergency central venous catheterization.
Chin J Traumatol. 2017 ;20:137-140.
Akaraborworn O. A review in emergency central venous catheterization.
Chin J Traumatol. 2017 ;20:137-140.
Paoletti F1, Ripani U, Antonelli M, Nicoletta G. Central venous catheters. Observations on the implantation technique and its complications. Minerva Anestesiol. 2005 Sep;71:555-60.https://www.minervamedica.it/en/journals/minerva-anestesiologica/article.php?cod=R02Y2005N09A0555
Graham AS, Ozment C, et al.Central Venous Catheterization. N Engl J Med 2007; 356:e21 http://www.nejm.org/doi/full/10.1056/NEJMvcm055053
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Graham AS, Ozment C, et al.Central Venous Catheterization. N Engl J Med 2007; 356:e21 http://www.nejm.org/doi/full/10.1056/NEJMvcm055053
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LINK: Emergency medicine book-Table of contents
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