The Central Venous Catheter is inserted peripherally into one of the big veins. Common sites for CVP insertion, the vein used is chosen according to the patient’s needs and suitability. Unit and Physician preference do play a minor role. The following vessels are used most frequently.
Internal Jugular Vein – Site for Insertion
The landmark approach most widely used is between the medial and lateral heads of the sternocleidomastoid muscle and lateral to the carotid artery in most cases.
This site is one of the most frequently chosen because it is easily located and has low probability of complications like pneumothorax. The internal jugular veins (left and right) are short, straight and large. Therefore they facilitate easy insertion of the CVC catheter. Catheter occlusion is the most complication and this is due to head movement. This may cause irritation in the conscious patient.
The capacity to place a line in the IJV is an important skill; this is the preferred vein for placement of a transvenous pacemaker because it is a straight line down the vein to the right side of the heart. Given that it can be compressed, the IJV can be used for central venous access in patients who have impaired blood clotting. However, in such patients, the femoral vein is most often used.
There are three traditional approaches to the IJV:
The central and posterior approaches are most commonly used and are less likely to result in puncture of the carotid artery.
The axillary vein courses medially to become the subclavian vein as it passes anteriorly to the first rib. After crossing the first rib, the vein lies posterior to the medial third of the clavicle at the change in curvature of the clavicle. Deep to the vein is the anterior scalene muscle followed by the subclavian artery.
Left and right. This is the site which is most often used. It is chosen because there are easily recognisable anatomical landmarks which make insertion of the CVC easier. Since the subclavian arteries are located beneath the clavicle the risk of pneumothorax is always present. Subclavian CVCs are most frequently recommended and inserted because they are considered to be more comfortable for the patients
The subclavian veins are reliable access points for temporary and permanent (eg, tunneled central catheters and subcutaneous ports) venous cannulation to support hemodynamic monitoring, fluid and medication administration, and parenteral nutrition. The left subclavian access is particularly well suited for cardiac access, including placement of pulmonary artery catheters, transvenous pacer leads, and implantable defibrillators.
Subclavian venous access may be preferred for subcutaneous port placement due to the short distance between the subclavian vein and chest wall, making the catheter less prone to kinking.
Left and Right Femoral Veins
The femoral vein is located medial to the femoral artery and the femoral nerve below the inguinal ligament. It is important the venipuncture occurs at 1-2 cm below the level of the inguinal ligament and that an assistant pushes aside any significant pannus. US guidance is useful when the femoral arterial pulse cannot be located.
These sites are used because they provide rapid central access in an emergency. A cardiac arrest is one such example. The femoral veins are located in the groin. This site is associated with high bacterial counts and high infection rates. Additionally, the femoral veins are also considered to be uncomfortable for mobility purposes.