# Central Venous Catheterisation

## Overview

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

## Indications

1. Monitoring central venous pressure (CVP)

2. Delivering caustic medications

3. Emergency resuscitation

4. Haemodialysis

5. Pulmonary artery catheterisation

## Contraindications

1. Infection of the overlying skin

2. Thrombosis of the vein to be catheterised

3. Trauma to, and distortion of the site

4. Weigh up the risks and benefits in patients with coagulopathy

5. Weigh up the risks and benefits in patients with only one functioning lung

## 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

1. Patient notes

### Equipment

1. Sterile gloves and gown

2. Alcohol-based hand rub

3. Sharps container
   Sharps container

   If a sharps container is not within arm's length, use a kidney dish or other hard container to temporarily hold used sharps and to carry them to the sharps container for disposal.

4. Skin disinfectant
   Skin disinfectant

   Commonly used preparations include 0.5-2% chlorhexidine in 70% alcohol (Steriprep), or 10% povidone iodine. There is no consensus on the superiority of one agent above another. Caution: chlorhexidine solutions may be associated with burns and skin breakdown in infants < 2 months old.

5. A central venous catheter pack containing at least:

   1. A central venous catheter
   2. A guidewire
   3. A dilator

6. A suture pack containing:

   1. Sterile drapes
   2. Gauze
   3. A well for skin disinfectant
   4. Forceps and needle holders

7. Three 10 ml syringes

8. An 18 G needle, a blunt fill needle, and one needle of the smallest gauge available

9. 2% lignocaine & an alcohol swab

10. Sterile normal saline

11. A 3-0 non-absorbable suture

12. A scalpel blade

13. An IV giving set and bag of fluid

14. A transparent film dressing

## 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.

1. Perform hand hygiene.

2. Open the suture pack and create a sterile field. Rearrange the items in the suture pack with sterile gauze or spare forceps if necessary. Fill the well with skin disinfectant. Open the needles, syringes, suture, dressing, and blade onto the sterile field. Open the CVC pack.

3. Don sterile gloves and gown.

4. Draw up 5 ml lignocaine in the first syringe with the blunt fill needle. An assistant should clean and hold the vial for you. Remove and discard the blunt fill needle and attach the small gauge needle.

5. Draw up 10 ml normal saline with the second syringe. An assistant should open and hold the vials for you.

   Prime
   Prime

   Inject normal saline into each port until it drips out except the distal (brown) port.

   the CVC ports.

6. Check that the guidewire runs forward in the sheath and retracts smoothly.

7. Attach the 18 G needle to the third syringe.

8. Clean
   Clean

   Clean in concentric circles starting in the middle and working outwards. Clean approximately from the suprasternal notch to the AC joint.

   the skin and allow it to dry. Drape the patient.

9. Anesthetise
   Anesthetise

   Do not use a dental needle for this site, as there are major blood vessels present and it is critical to be able to draw back on the plunger before administering local anaesthetic.

   the target site, including the skin and the subclavicular area. Wait 5-10 minutes.

10. While maintaining gentle suction with the plunger, insert the 18 G needle into the target site aiming at the suprasternal notch. Keep the needle parallel to the ground—do not point it downwards. Once you hit the clavicle, withdraw slightly, depress the syringe and needle as a whole, and advance under the clavicle.

11. Advance until you get flashback of blood into the syringe. The blood should flow freely into the syringe and should be dark in colour i.e. the colour of venous blood.

12. Disconnect the syringe
    Disconnect the syringe

    Some CVP sets contain a syringe with a needle attached. This then contains a port at the back for insertion of the guidewire without having to first remove the syringe.

    and thread the guidewire into the back of the needle, watching the ECG monitor for any disturbances of rhythm.

13. Holding
    Holding

    Never let go of the guidewire; in rare cases guidewires have retracted into patients and required surgical removal.

    on to the guidewire, withdraw the needle over the guidewire and dispose.

14. Make a 2 mm incision at the insertion site. Thread the

    dilator
    dilator

    Hold the dilator halfway down from the hub for better control.

    over the guidewire and insert it with a corkscrew movement. Retract it over the guidewire.

15. Thread the catheter over the guidewire into place to the required

    depth
    depth

    This will usually be between 15 and 20 cm, depending on the patient's height, and the site used. Rather go too deep than too shallow; you can easily retract, but it's harder to advance.

    .

16. Remove the guidewire.

17. Connect the catheter to the intravenous line and lower the vaculitre bag slightly to observe the drainage of blood into the tubing. Hang the bag up immediately.

18. Flush each port to confirm good flow.

19. Suture the CVC into place by the two wings.

20. Apply the transparent film dressing.

21. Dispose of medical waste safely.

22. Record completion of the procedure in patient notes.

23. Order a chest X-ray to confirm positioning.

## 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

1. Local hematoma, pain, or excessive bleeding at the site

2. Arterial puncture with massive haematoma, and/or thrombosis and embolism

3. Haemo/chylo/hydro/

   pneumothorax
   pneumothorax

   30% of CVC complications are pneumothoraces. Avoid advancing too deeply. Never aim your needle downwards. Avoid multiple probing attempts with the needle by keeping landmarks in mind.

4. Air embolism
   Air embolism

   Look for tachypnoea, elevated jugular venous pressure, chest pain, and hypotension. The head-down position and occluding the needle before threading the guidewire reduces this risk.

5. Injury to nerves, including the phrenic nerve, brachial plexus, and vagus

6. Perforation
   Perforation

   This may happen due to erosion of the wall by a catheter tip placed too deeply. Always confirm placement by chest X-ray.

   of major vessels or heart with cardiac tamponade

7. Dysrhythmias
   Dysrhythmias

   Components placed too deeply can irritate the myocardium and cause dysrhythmias.

8. Target vein

   thrombosis
   thrombosis

   Most commonly seen in long-term catheterisation

9. Malpositioned catheter tip (often in the internal jugular vein)

10. Central Line-associated Bloodstream Infection

    (CLABSI)
    (CLABSI)

    Key elements of the CLABSI Bundle:

    - Hand hygiene
    - Sterile field, sterile gloves and gown; face cover;
    - Chlorhexidine skin antisepsis of the site;
    - Optimal site selection (subclavian = lowest risk of infection, femoral = highest)
    - Daily review and prompt removal of unnecessary central lines.

    Additional elements:

    - The type of CV catheter—triple lumen, use of three way taps, multi-flow.
    - Line is secured.
    - Dressing is clean and intact.

11. Catheter embolisation

12. Sharps injury to healthcare personnel

13. Vasovagal response (fainting)

## References

1. Boon JM, van Schoor AN, Abrahams PH, Meiring JH, Welch T, Shanahan D. Central venous catheterization -- an anatomical review of a clinical skill -- Part 1: subclavian vein via the infraclavicular approach. Clin Anat. 2007;20(6):602-611. doi:10.1002/ca.20486

2. Leib AD, England BS, Kiel J. Central Line. [Updated 2021 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519511/

3. Graham AS, Ozment C, Tegtmeyer K, Lai S, Braner DA. Central Venous Catheterization. N Engl J Med. 2007;356:e21. DOI: 10.1056/NEJMvcm055053.

4. Nicol A, Steyn E. Emergency Procedures. Chapter 6. Handbook of Trauma for Southern Africa. 2009. 4th ed. 71-75

5. Department of Health, Republic of South Africa. Practical Manual for Implementation of the National Infection Prevention and Control Strategic Framework. 2020. Available from: https://www.health.gov.za/wp-content/uploads/2020/11/practical-manual-for-implementation-of-the-national-ipc-strategic-framework-march-2020.pdf