# Central Venous Catheterisation

## Overview

This module describes how to perform central venous catheterisation (CVC) via the subclavian route.

## Indications

## Contraindications

## Patient information and consent

Always verify your patient’s identity and obtain informed consent before proceeding.

### How do I explain this procedure?

“I need to place a thin tube in one of the large veins in your chest. The tube is called a central venous catheter.”

### What can my patient expect?

“I will give you an injection that will stop you from feeling pain at the puncture site. The procedure will take a few minutes. The catheter may need to stay in place for a few days and we will stitch it in place to make sure it doesn't fall out by accident.”

### What is my patient’s role?

“Let me know if you have any allergies or a bleeding tendency, or use blood thinners. Fearing blood or needles is normal, but tell me if you have fainted from it. Keep as still as possible. If you feel strange sensations or severe pain, tell me immediately. Do not fiddle with the stitches or tubing.”

## Preparation

Prepare a trolley with equipment. It is useful to have

ultrasonography

ultrasonography

This might not be readily available, or might take time to procure. Weigh up the risks of delaying the procedure for your patient with your clinical experience and availability of senior assistance should you struggle. If you are using an ultrasound, you need a colleague to hold the ultrasound probe while you perform the procedure.

and a sterile probe sleeve available, as its use decreases the risk of complications. An assistant is required for this procedure. The patient should have ECG, BP and sats monitoring attached.

### Documentation

### Equipment

## Site and Positioning

The CVC may be inserted into the internal jugular, subclavian, or femoral vein. The femoral route is unfavourable due to a high incidence of infections, thrombosis, and arterial puncture. The subclavian route has the lowest risk of infections and arterial puncture, though its rate of haemo-/pneumothorax and thrombosis is higher than that of the internal jugular vein. The subclavian route is preferred in patients who are awake as the approach is not affected by head movement, and in patients in cervical collars. This module will focus on the subclavian route.

Position the patient in the Trendelenburg position. Contrary to popular practice, do not turn the face away from the site of the procedure, and do not place an object between the shoulder blades to retract them.

When inserting a CVC, insert the needle at the junction between the medial and middle thirds of the clavicle, a fingerbreadth away from the clavicle. Aim under the clavicle towards the suprasternal notch—place the index finger of the non-dominant hand here, and the thumb on top of the clavicle at the entry point to keep track of these landmarks.

## Procedure

Follow medical asepsis with sterile gloves.

## Troubleshooting

The wire does not advance smoothly.

Do not force it. Withdraw a few cm, turn it, then advance again. If it still does not advance, withdraw and see if there is still good backflow through the hub of the needle. If not, you’re probably outside the subclavian vein. Connect the syringe again and reposition your needle until you are back in the vein.

The patient has a lot of body hair.

Try to avoid shaving as the skin disruption increases the risk of infection.

The patient is developing an arrhythmia.

Withdraw the tip of the guidewire. You’re probably in the right atrium, irritating the myocardium.

The patient has become unstable.

An air embolism might have occurred, presenting as sudden, acute cardiac output failure. Check for a drop in blood pressure and clinical signs of decreased peripheral and cerebral perfusion. A continuous murmur may be heard over the heart and the jugular veins may be distended. Turn the patient onto their left side, administer 100% oxygen and aspirate the air from the right atrium with the same central line.

The patient is obese.

Consider using ultrasound guidance, or call a senior for assistance.

## Risks

## References