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Central Venous Catheter CVP Insertion

How to do Insertion of Central Venous Catheter

What is the Purpose of Insertion of Central Venous Catheter

Central Venous Catheter is to obtain measurements of central venous pressure and administer drug preparations harmful to smaller lumen peripheral vein.

Definition-Insertion of Central Venous Catheter

Insertion of a Central Venous Catheter (IV Catheter designed for the purpose) into a large central vein with the catheter terminus usually near the right atrium.

The placement of a central venous line is an essential technique in the treatment of many hospitalized patients

Uses/Indications

  • IV access (especially if difficult peripheral access)
  • CVP monitoring
  • ScvO2 monitoring/sampling
  • Infusions of irritant substances (e.g. vasoactive agents, chemotherapy or TPN administration)
  • Renal replacement therapy, olasmapheresis and apheresis
  • Transvenous pacing

Large bore peripheral IV lines, RICC lines, Swan sheaths or IO access is preferred for rapid fluid fluid resusciation

Contraindications

  • Coagulopathy
  • Respiratory failure
  • Raised ICP (cannot tilt head down)

Can use femoral approach in all the situations above

  • Obstructed vein (e.g. thrombus, or tumour)
  • Overlying skin infection, burn or other disease process
  • Hemorrhage from target vessel
  • Uncooperative patient

Internal Jugular

Anatomy

  • Course: from jugular foramen -> joins subclavian vein behind sternal extremity of clavicle
  • Medial: internal and common carotid, 9th to 12th cranial nerves above common carotid + vagus
  • Anterolateral: skin, superficial fascia, platysma, cervical fascia, sternomastoid, sternohyoid, omohyoid
  • Posterior: transverse process of the cervical vertebrae, levator scapulae, scalenus medius and anterior, cervical plexus, phrenic nerve, thyrocervical trunk, vertebral vein, 1st part of subclavian artery
  • Tributaries: inferior petrosal sinus, facial, pharyngeal, lingual, superior thyroid, middle thyroid, occipital veins
  • Central approach: find 1cm above the apex of head of SCM and clavicle -> 60 degrees to skin aiming towards ipsilateral nipple (blood should be obtained within 3cm)
  • Lateral/posterior approach: find 2-3 finger breaths above clavicle along posterior border of SCM, direct needle towards jugular notch (blood should be aspirated within 5cm)
  • Anterior approach: identify the carotid and mid point of medial SCM border, aim toward ipsilateral nipple

Subclavian

Anatomy

  • Superior: midpoint of clavicle
  • Anterior: skin, external jugular vein, clavicle
  • Medial: fascia, trachea
  • Posterior: subclavian artery, first rib, scalenus anterior, phrenic nerve and fascia over pleura
  • Approaches: supraclaviclar, infraclavicular and lateral

Femoral

Anatomy

  • NAVEL (nerve – artery – empty space – lymph node (lateral to medial)
  • Boundaries of the femoral triangle are adductor longus and sartorius
  • Approach: slight external rotation of hip, palpate pulse, medial to arterial pulsation

Requirements / Equipments

  • Disinfectant for Hand Hygiene.
  • Sterile Gown Gloves.
  • Sterile Hole Towels / Drape.
  • Spirit, Betadine Solution.
  • Central Line tray containing –
  • Artery Forceps – 1
  • Tooth Forceps – 1
  • Sponge holder – 1
  • Scissors
  • Needle Holder – 1 – For suturing.
  • 3-0 Ethilon.
  • Dressing Towels & Towel Clips.
  • Small Bowl – 2 [Cleaning Solutions].
  • Sterile Gauze Pieces.
  • Syringes 10 ml, 5ml.
  • Sterile Needles 24G 11/2
  • Sterile Blade No. 11
  • Injection Lignocaine – 2%
  • Sterile Central Venous Catheter Pack – Size according to site of insertion (Triple Luman or Double Luman Catheter).
  • Bivalves-3
  • N S 100 ml
  • Suture Material
  • Betadine Ointment & Betadine Solution 10%
  • Tegaderm – Transparent Dressing
  • Kidney Tray and Mackintosh
  • CVP Towel

Procedure

  • Explain procedure to patient and ensure consent.
  • Collect all equipment on a trolley.
  • Wash hands with soap and water.
  • Disinfect hands with disinfectant.
  • Position patient supine with insertion area well exposed. If jugular approach – Head turned to opposite side. If subclavian approach – place towel roll under shoulder.
  • Provide Sterile Gown + Gloves to Physician.
  • Provide Central Line Tray.
  • Provide Betadine for cleaning of site.
  • Provide sterile normal saline.
  • Provide 10 ml. Sterile syringes for flushing of catheter.
  • Clean top of Lignocaine vial with spirit/disinfectant swab. Provide sterile 5 ml. Syringe and 21G needle for withdrawal of Lignocaine.
  • Provide 24G needle for administration of Lignocaine to patient.
  • Open central venous catheter onto sterile towel, provide bivalves.
  • Observe patients cardiovascular status throughout procedure.
  • Provide suture material.
  • Apply Tegaderm dressing after cleaning the site of insertion with Betadine solution or apply Betadine Ointment to puncture site after cleaning with Betadine solution and cover with sterile gauze and apply transparent dressing.
  • Clean patient, position comfortably.
  • Tidy and restock all used equipment.
  • Segregate generated Bio-Medical Waste as per HIC policy.
  • Chest X-ray to be done.
  • Document procedure in Nurses Notes.

Note – No Infusion to be administered via the Central Line Until Correct Positioning is confirmed by Physician on the Chest X-Ray.