CV line

1. Welcome to weekly
Scientific Seminar
Venue: Casualty block 1
Dhaka Medical College Hospital

2. Central Venous Catheterization
&
Venous cut down Technique
Presented by
Dr. Mominul Haider
Resident (Phase A)
Department of Urology
BSMMU

3. Central Venous
Catheterization

4. Introduction
• Central venous access refers to lines placed
into the large veins of the neck, chest, or groin
and is a frequently performed invasive
procedure which carries a significant risk of
morbidity and even mortality.

5. • This procedure should be carried out in
operating theatre or high-dependency care
areas, always using a fully aseptic technique.

6. Indications
• Monitoring of central venous pressure in critically ill
patient and after major surgery
• Infusion of irritant drugs that may damage smaller
veins.
• Insertion of pacing wires.
• Renal replacement therapy.
• Emergency venous access.
• Parenteral feeding.
• Resuscitation of patients who are intravascularly
depleted.

7. Relative Contraindications
• Uncorrected coagulopathy
• Thrombocytopenia
• Skin infection over the site of access
• Obscure anatomical landmarks
• Haemo or pneumothorax on the contralateral
side
• Recent surgery to other structures nearby
such as carotidendartectomy

8. Sites
• Right Subclavian Vein
• Internal Jugular vein
• Femoral Vein

9. Site Advantage Disadvantage
Subclavian •Lower risk of infection
•Does not require
movement of patient’s
head and can be
accessed during c-spine
immobilisation
•Useful in emergencies
•Vein does not collapse
fully in hypovolaemic
states
•Highest chance of
pneumothorax
•Puncture of
tracheostomy or ET tube
cuff
•Cannot apply pressure to
stop bleeding
•Can be painful even with
good skin anaesthesia
•Less easy to visualise
with USG

10. Site Advantaqge Disadvantage
Internal
jugular
•Anatomy readily visible
with ultrasound
•Can be adapted to
accommodate patient
size
and position
•Easily accessed surface
of patient
•Puncture of internal
carotid or misplaced
line in the internal
carotid
•Pneumothorax is a
recognised
complication
•Difficult to nurse long
term.

11. Site Advantaqge Disadvantage
Femoral •Safest vein to place large
lines, for example for
veno–veno
haemofiltration because
there are
fewer important
structures nearby.
•Puncture of femoral
artery can usually be
treated
with pressure
•Femoral artery
puncture leading to
retroperitoneal
bleed
•Femoral nerve
damage
•Difficult to nurse
and keep clean
•Highest likelihood
of infection

12. Central line kit containing: Additional items:
• needle or a cannula over needle
• central venous catheter
• guidewire
• dilator
• anchoring clips.
• suture
• scalpel
• appropriate dressing
• syringes
• blue and green needles
• three-way taps, one for each lumen
• drapes
• cleaning fluid (2% chlorhexidine gluconate in
70% isopropyl alcohol is recommended)
• swabs
• Gallipot or similar
• sterile ultrasound probe sheath
• 0.9% normal saline
Equipments needed

14. Basic Principles
• Must Decide if the line is really necessary
• Should know the anatomy
• Should be familiar with the equipments
• Must obtain optimal patient positioning and cooperation
• Should not try to do it fast
• Must use sterile technique
• Always have a hand on the guide wire
• Should ask for help
• Always aspirate as you advance as you withdraw the
needle slowly
• Always withdraw the needle to the level of the skin before
redirecting the angle
• Obtain chest x-ray post line placement and review it

15. Subclavian Approach
• Positioning
– Right side preferred
– Supine position, head neutral, arm abducted
– Trendelenburg (10-15 degrees)
– Shoulders neutral with mild retraction
– Right side preferred
• Needle placement
– Junction of middle and medial thirds of clavicle
– At the small tubercle in the medial deltopectoral groove
– Needle should be parallel to skin
– Aim towards the supraclavicular notch and just under the
clavicle

17. Internal Jugular Approach
• Positioning
– Right side preferred
– Trendelenburg position
– Head turned slightly away from side of venipuncture
• Needle placement: Central approach
– the triangle formed by the clavicle and the sternal and
clavicular heads of the SCM muscle is located
– three fingers of left hand are gently palced on carotid
artery
– Needle should be placed at 30 to 40 degrees to the
skin, lateral to the carotid artery
– Aim toward the ipsilateral nipple under the medial
border of the lateral head of the SCM muscle
– Vein should be 1-1.5 cm deep, deep probing in the
neck should be avoided.

19. Internal Jugular Central Approach

20. Femoral Approach
• Positioning
– Supine
• Needle placement
– Medial to femoral artery
– Needle held at 45 degree angle
– Skin insertion 2 cm below inguinal ligament
– Aim toward umbilicus

21. Femoral artery
Femoral nerve
Femoral Vein

22. Post-Catheter Placement
• Aspirate blood from each port
• Flush with saline or sterile water
• Secure catheter with sutures
• Cover with sterile dressing (tega-derm)
• Obtain chest x-ray for IJ and SC lines
• Write a procedure note

23. Procedure Note
• Name of procedure
• Indication for procedure
• Comment on consent, if applicable
• Describe what you did, including prep
• Comment on aspiration/flushing of ports
• How did patient tolerate procedure
• Any complications

24. Maintenance of CV line
• Hepsol flush 8 hourly
• Central Short channel is used for measuring
CVP
• Rest two channels are used for medication
and TPN
• The dressing should be changed at regular
interval
• Catheter should not be kept for more tha 3
weeks

25. Ultrasound-Guided Central Venous
Access
• Becoming standard of care
• Vein is compressible
• Vein is not always larger
• Vein is accessed under direct
visualization
• Helpful in patients with
difficult anatomy

26. Needle entering IJ

27. Femoral
Vein
Femoral
Artery
Compression of vein
with US probe

28. Complications
• Vascular
– Air embolus
– Arterial puncture
– Arteriovenous fistula
– Hematoma
– Blood clot
• Infectious
– Sepsis, cellulitis, osteomyelitis, septic arthritis
• Miscellaneous
– Dysrhythmias
– Catheter knotting or malposition
– Nerve injury
– Pneumothorax, hemothorax, hydrothorax,
hemomediastinum

29. Venous cut down

30. • Venous cutdown is a surgical technique by
which a selected vein is exposed and
mobilised and then cannulated under direct
vision.
• It has been largely replaced by central venous
and intraosseous access, but remains a useful
alternative when other methods fail or are not
available.

31. Cutdown sites
• Basilic vein (antecubital fossa)
• Adult: 2–3 cm lateral to the medial epicondyle
of the humerus.
• Child: 1–2 cm lateral to the medial epicondyle
of the humerus.

32. Cutdown sites
Long saphenous vein (groin)
• Adult: 4 cm inferior and lateral to the pubic
tubercle.
Long saphenous vein (ankle)
• Adult: 2 cm anterior and superior to the
medial malleolus.
• Child: 1 cm anterior and superior to the
medial malleolus.

33. Step-by-step cutdown method
• Place a venous tourniquet proximal to
intended cutdown site where possible.
• Identify cutdown site and inject local
anaesthetic along the intended incision line if
the patient is conscious.
• Make a transverse incision through skin being
careful not to damage the underlying vein
• Spread the skin and identify the vein lying at
right angles to the line of the incision.

34. • Mobilise a 2-cm length of vein by blunt
dissection using curved forceps
• Pull a loop of suture (e.g. 2/0 vicryl) under
vein.
• Cut the loop to form proximal and distal
sutures.

35. • Tie off distal suture and transfix vein with a
needle
• Make a vertical stab incision down onto the
transfixing needle to produce a hole
(venotomy) in the anterior vein wall
• Insert a cannula or the cut end of a sterile
giving set through venotomy into vein
• Tie off proximal suture around vein and
inserted cannula.
• Suture and dress wound.

36. Complications of venous cutdown
• Damage to adjacent structures
• Posterior wall perforation
• Haematoma
• Extravasation of fluid or drugs
• Local cellulites
• Phlebitis
• Venous thrombosis
• Scarring