Difference between revisions of "Central line: supraclavicular"
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− | + | {{Central line indications}} | |
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− | + | {{Central line contraindications}} | |
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− | {{Central line | + | {{Central line equipment}} |
− | == | + | ==Procedure== |
− | + | ===Landmark Guided Approach=== | |
− | * | + | *Insertion Site - claviculosternocleidomastoid angle |
− | + | **1cm Cephalad and 1 cm lateral to the junction of the lateral margin of the clavicular head and the superior margin of the clavical | |
− | **1 | + | *The needle is advanced in the direction of the line that bisects the claviculosternocleidomastoid angle with elevation of 5-15 degrees above coronal plane |
− | + | **Roughly in the same direction as the contralateral nipple | |
− | + | *Catheter Depth | |
− | * | + | **14 cm on the right side |
− | + | **18 cm on the left side | |
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− | == | + | ===Ultrasound Guided=== |
− | # | + | *Typically done in-plane |
− | # | + | *Provider can visualize where the internal jugular and subclavian vein meet |
− | # | + | *Limited by body habitus |
− | # | + | *Useful in children |
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+ | ===Seldinger Technique=== | ||
+ | #Place sterile drape over target area | ||
+ | #Anesthetize insertion site | ||
+ | #Prepare catheter by flushing each lumen with sterile saline | ||
+ | #Insert needle with syringe while applying negative pressure on the syringe | ||
+ | #Intravascular access will be indicated with free flowing aspiration of blood | ||
+ | #Carefully remove the syringe from needle hub | ||
+ | ##Some syringes allow for placement of wire without removal | ||
+ | #Blood flow should be non-pulsatile (arterial) | ||
+ | #Place finger over needle hub after removing syringe | ||
+ | #Remove finger and introduce guide wire | ||
+ | ##Wire should progress with little resistance | ||
+ | #Remove Needle over guide wire | ||
+ | ##from now on, one hand should always be holding the guide wire | ||
+ | #Using a scalpel make a small incision at the base of the wire | ||
+ | #Thread dilator over wire | ||
+ | #Remove Dilator after advancing it several cm into the vessel | ||
+ | #Pass catheter over wire until wire emerges from uncapped port | ||
+ | ##Do NOT pass catheter into body until wire emerges from opposing end and can be grasped | ||
+ | #After catheter is introduced to correct depth, remove wire and cap free end | ||
+ | #Test each port with withdrawal of blood and flush | ||
+ | #Suture catheter in place | ||
+ | #Secure with tegaderm | ||
==Complications== | ==Complications== | ||
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==See Also== | ==See Also== | ||
− | + | {{Vascular access types}} | |
− | == | + | ==References== |
<references/> | <references/> | ||
[[Category:Procedures]] | [[Category:Procedures]] |
Latest revision as of 22:34, 26 November 2020
Contents
Indications
- Central venous pressure monitoring
- High volume/flow resuscitation
- Emergency venous access
- Inability to obtain peripheral venous access
- Repetitive blood sampling
- Administering hyperalimentation, caustic agents, or other concentrated fluids
- Insertion of transvenous cardiac pacemakers
- Hemodialysis or plasmapheresis
- Insertion of pulmonary artery catheters
Contraindications
Absolute[1]
- Infection over the placement site
- Anatomic obstruction (thrombosis of target vein, other anatomic variance)
- Site-specific
- Subclavian - trauma/fracture to ipsilateral clavicle or proximal ribs
Relative
- Coagulopathy (see below)
- Distortion of landmarks by trauma or congenital anomalies
- Prior vessel injury or procedures
- Morbid obesity
- Uncooperative/combative patient
Central line if coagulopathic
- Preferentially use a compressible site such as the femoral location (avoid the IJ and subclavian if possible)
- No benefit to giving FFP unless artery is punctured[2]
- However, consider giving FFP if patient has hemophilia[3]
Equipment Needed
- CVC kit typically contains:
- Chlorhexidine
- Sterile drape
- 1% lidocaine without epinephrine
- 5 mL syringe (for lidocaine)
- 22-ga and 25-ga needles (for lidocaine)
- 5-10 mL syringe (for venipuncture)
- 18-ga needle (for venipuncture)
- Guidewire
- Scalpel with 11-blade
- Dilator
- Triple-lumen catheter (or introducer catheter/Cordis)
- Catheter clamp
- Silk suture
- Sterile gown, cap, mask, gloves
- Biopatch
- Tegaderm
- Sterile saline flush
- Sterile caps for lumen ports
Procedure
Landmark Guided Approach
- Insertion Site - claviculosternocleidomastoid angle
- 1cm Cephalad and 1 cm lateral to the junction of the lateral margin of the clavicular head and the superior margin of the clavical
- The needle is advanced in the direction of the line that bisects the claviculosternocleidomastoid angle with elevation of 5-15 degrees above coronal plane
- Roughly in the same direction as the contralateral nipple
- Catheter Depth
- 14 cm on the right side
- 18 cm on the left side
Ultrasound Guided
- Typically done in-plane
- Provider can visualize where the internal jugular and subclavian vein meet
- Limited by body habitus
- Useful in children
Seldinger Technique
- Place sterile drape over target area
- Anesthetize insertion site
- Prepare catheter by flushing each lumen with sterile saline
- Insert needle with syringe while applying negative pressure on the syringe
- Intravascular access will be indicated with free flowing aspiration of blood
- Carefully remove the syringe from needle hub
- Some syringes allow for placement of wire without removal
- Blood flow should be non-pulsatile (arterial)
- Place finger over needle hub after removing syringe
- Remove finger and introduce guide wire
- Wire should progress with little resistance
- Remove Needle over guide wire
- from now on, one hand should always be holding the guide wire
- Using a scalpel make a small incision at the base of the wire
- Thread dilator over wire
- Remove Dilator after advancing it several cm into the vessel
- Pass catheter over wire until wire emerges from uncapped port
- Do NOT pass catheter into body until wire emerges from opposing end and can be grasped
- After catheter is introduced to correct depth, remove wire and cap free end
- Test each port with withdrawal of blood and flush
- Suture catheter in place
- Secure with tegaderm
Complications
- Arterial puncture and hematoma
- Pneumothorax
- Hemothorax
- Vessel injury
- Air embolism
- Cardiac dysrhythmia
- Nerve injury
- Infection
- Thrombosis
- Catheter misplacement
See Also
Vascular access types
- Central venous catheterization
- Intraosseous access
- Venous cutdown
- Umbilical vein catheterization
- Ultrasound assisted peripheral line placement
- External jugular vein cannulation
- The "Easy IJ"
- Midlines
References
- ↑ Graham, A.S., et al. Central Venous Catheterization. N Engl J Med 2007;356:e21
- ↑ Fisher NC, Mutimer DJ. Central venous cannulation in patients with liver disease and coagulopathy—a prospective audit. Intens Care Med 1999; 25:5
- ↑ Morado M.et al. Complications of central venous catheters in patients with haemophilia and inhibitors. Haemophilia 2001; 7:551–556