Central Venous Access

How? What? When ? Why & Care ? Of Central Line Catheter. & various types

1. Central Venous Access -Dr Manoj Kumar K (Resident) JLN MEDICAL COLLEGE Underguidance of Respected : Dr Maniram Kumar (HOD & Sr Prof) Dr Munesh Kumar ( Associate Prof ) Dr Ravindra Kumar Tiwari & Dr Harsh Tak ( Assistant Prof ) Dept. of General Medicine

2. Types of Catheters 04 Instruments Table of contents Indications & Contraindications When? Basic Principle of Small vs Large Veins Why central access? What is central venous catheterisation Introduction 03 02 01 5 6 7 08 Complications Prevention Procedure References Various Routes & Insertion Technique Immediate & Late Complications Routine Catheter’s Care & USG Aid

3. Introduction Central Venous Access, which is when a catheter is placed in a large vein, usually the internal jugular or the subclavian vein.  A central access is is usually obtained when peripheral access isn't available, like when an individual is severely hypovolemic, or need iv access for a long period of time for medication delivery such as chemotherapy, then central venous access is a great option to prevent repeated peripheral IV procedures or for those certain intravenous drugs that cause damage to peripheral veins, fluid resuscitation, blood transfusions, central venous pressure monitoring ,giving medications hemodynamic monitoring or plasmapheresis.  It can also be used when emergency dialysis is needed.

4. Why Vein Size Matters Catheters placed in small, peripheral veins have limited durability due to localized inflammation and thrombosis. Inflammation results from mechanical and chemical injury to the vessel, often due to caustic drug infusions. Thrombosis is incited by inflammation and exacerbated by sluggish blood flow in small veins. Blood viscosity increases with reduced flow, increasing the risk of thrombus formation Benefits of Opting for Large Veins Large veins offer a larger diameter, allowing the use of larger bore, multilumen catheters, enhancing vascular access efficiency. Why should we get central venous access?

5. Higher flow rates in large veins reduce the damaging effects of infused fluids, lowering the risk of local thrombosis. Flow rates increase significantly with larger veins. For instance, the subclavian vein’s diameter is about three times greater than the metacarpal veins, yet its flow rates can be up to 100 times highe r This phenomenon adheres to the principles of the Hagen-Poiseuille equation for understanding flow in vessels The Hagen-Poiseuille equation is a fundamental law governing fluid flow in cylindrical tubes. It states that flow (Q) is directly proportional to the fourth power of the vessel radius (r) and the pressure ( Δ P), while inversely proportional to the viscosity of the fluid ( η) and the length of the vessel (l). Mathematically, it can be expressed as: Q = ( π x Δ P x r4) (8 x η x l)

6. Flow Rates

7. Indications Patient refusal Thrombocytopenia Ipsilateral indwelling central venous access device Contralateral haemothorax or pneumothorax Vein stenosis or thrombosis Localized infection at insertion site Contraindications When do we need central venous access? Administration of medications like Vasoconstrictor Drugs (Dopamine,NE) or hypertonic fluids or Chemotherapy or other specialized therapies that may irritate peripheral veins. Difficulty in peripheral venous access or Frequent sampling Administration of parenteral nutrition. (Prolonged) Hemodialysis or plasmapheresis. Need for long-term venous access. Hemodialysis Rapid fluid resuscitation in emergency situations. Invasive hemodynamic monitoring or monitoring of central venous pressure Transvenous cardiac pacing.

8. What do you need ? Instruments

9. Non-Tunneled Catheters Definition: Inserted directly into veins without a tunnel. Characteristics: Temporary access which is Generally short-term use. Examples: Short IV catheters , Midline catheters Tunneled Catheters Definition: Inserted through a tunnel created under the skin. Characteristics: Long-term access. Tunnel prevents infection and increases stability. Examples:Peripherally Inserted Central Catheters (PICCs) , Hickman catheters , Groshong catheters Implanted Ports Definition: Port is placed under the skin with a catheter attached to it. Characteristics:Completely under the skin when not in use. Reduces risk of infection. Examples:Port-a-Cath , MediPort. Types of Catheters

10. Open-ended The catheter is open at the distal tip The catheter requires clamping before entry into the system Clamps are usually built into the catheter Requires periodic flushing Closed-ended A valve is present at the tip of the catheter (eg. Groshong®) or at the hub of the catheter(eg. PAS-V°) Clamping is not required as the valve is closed except during infusion or aspiration Open vs Closed

11. Central Venous Catheters Introduction: Central Venous Catheters are essential for cannulating larger, centrally located veins, ensuring reliable vascular access in critically ill patients. Key Features:Length: Typically 15 to 30 cm (6 to 12 inches). Infusion Channels: Single or Double or Triple Multilumen Advantage: Facilitate delivery of multiple parenteral therapies using a single venipuncture. Triple-Lumen Preferred: Triple-lumen catheters, such as 7 French size, are consensus favorites for central venous access. Types of Catheters (Function)

12. Triple-Lumen Central Venous Catheters : Large bore catheters with three separate infusion channels, typically used for central venous access. Advantages: Multifunctional: Enables the delivery of multiple infusions through a single venipuncture, streamlining therapies in intensive care settings. Reduced Infection Risk: Studies show comparable infection risks to single-lumen catheters, making them a safe choice for various treatments. Efficient Flow Rates: Larger diameters allow for rapid fluid or medication delivery and minimize thrombosis risk due to increased flow. Convenience: Simplifies therapy management for healthcare providers and patients. Size Options: Available in sizes (e.g., 7 French) for adults, offering flexibility. Sizes: Ranging from 4 French to 9 French. 7 French: Popular choice for adults with one 16 gauge and two 18 gauge channels. Flow Rates: Influenced by catheter length ( Hagen-Poiseuille equation). Available Lengths: 16 cm (right-sided), 20 cm, and 30 cm (left-sided). Recommendation: Use catheters no longer than 20 cm to preserve flow. Types of Catheters (Function)

13. Flow Rates of Triple Lumen CVCs

14. Antimicrobial Catheters : Central venous catheters with antimicrobial coatings to prevent infections Types of Antimicrobial Combinations: 1.Chlorhexidine and Silver Sulfadiazine 2.Minocycline and Rifampin. Advantages: Infection Prevention: Release antimicrobial agents to prevent bacterial colonization and reduce infection risk. Reduced Sepsis Risk: Substantially lower the risk of catheter-related septicemia, a life-threatening condition associated with bloodstream infections. Effectiveness: Studies confirm the effectiveness of antimicrobial catheters. Minocycline and rifampin-coated catheters show superior results in infection reduction. Guideline Compliance: Recommended when central venous catheterization exceeds five days and a high infection rate persists despite other control measures. Patient Safety: Enhances patient safety by minimizing infection risks in healthcare settings. Types of Catheters (Function)

15. Peripherally Inserted Central Catheters (PICCs) Introduction: PICCs are inserted in the basilic or cephalic vein in the arm and advanced into the superior vena cava. Use Cases: Used primarily when traditional central venous access sites are considered risky (e.g., severe thrombocytopenia) or difficult to obtain (e.g., morbid obesity). Characteristics:Smaller diameter compared to central venous catheters & Noticeable difference is the length, which is double or more the length of central venous catheters. Types of Catheters (Function)

16. Specialty Catheters Hemodialysis Catheters: Designed for emergent hemodialysis in patients with acute renal failure. Features:Wide-body catheters with large diameters (up to 16 French). Dual 12 gauge infusion channels for high flow rates. Placement typically in the internal jugular vein. Introducer Sheaths: Purpose: Large-bore catheters serving as conduits for temporary vascular devices. Usage: Mainly used for placement of pulmonary artery (PA) catheters. Rapid Infusion: Introducer sheaths can be used for rapid volume infusion for the management of acute blood loss. Flow Rates: When used with pressurized infusion systems, flow rates of up to 850 mL/min have been reported. Pulmonary Artery Catheters: Provide multiple measures of cardiovascular function and systemic oxygenation. Types of Catheters (Function)

17. Implanted Venous Access Devices (IVADs) provide secure and long-term central venous access for various medical treatments. Key Components of IVAD : 1.Catheter: Long, flexible tube inserted into a large vein. Various types: Single or multiple lumens based on medical requirements. 2.Port :Reservoir connected to the catheter. Allows repeated access for medication administration, blood draws, or contrast injection. 3.Subcutaneous Pocket : Space under the skin where the port sits. Minimally invasive implantation. 4.Catheter Tip Position: Typically terminates in the superior vena cava or the junction of the superior vena cava and right atrium. Indications for IVAD Use : 1.Long-Term Medication Administration like Chemotherapy, antibiotics, pain management. 2.Frequent Blood Draws: Minimizes the need for repeated peripheral venipuncture. 3.IV Therapies :Continuous or intermittent infusion of fluids or medications. 4.Radiographic Procedures: Contrast injections for imaging studies. Benefits of IVADs : 1.Reduced Venipunctures 2.Long-Term Access: Suitable for extended treatment courses, reducing the need for device replacement. 3.Improved Patient Comfort: Port remains beneath the skin, reducing visibility and interference with daily activities. 4.Decreased Infection Risk : Lower infection rates compared to external catheters. IVADs

18. Whats inside Central Line Box  Catheter  Nitinol Core J Tip Guide Wire,  Introducer Needle (18 G x 70 mm) Dilator (8 Fr x 90mm) Scalpel - Short Clamp Fastener Suture Wing Swabable Needle Free Connectors Extension Line Clamps Syringe 5 mi ( Luer Lock) Hypodermic Needle Needle Secure Sponge Instructions Booklet For Use How to Insert CVC?

19. CENTRAL VENOUS ACCESS ROUTES Internal Jugular Ve in Anatomy : The internal jugular vein is located under the sternocleidomastoid muscle on either side of the neck. It runs obliquely down the neck along a line from the pinna of the ear to the sternoclavicular joint. The vein is often located just anterior and lateral to the carotid artery in the lower neck region. Preferred Right Side:The right side of the neck is preferred for cannulation due to a straight course to the right atrium. Well-suited for temporary pacer wires, hemodialysis catheters, and pulmonary artery catheters. Positioning :A head-down body tilt of 15° is recommended to distend the internal jugular vein The head should be slightly turned in the opposite direction to straighten the course of the vein. Ultrasound Guidance : Increases success rate, reduces risk of carotid artery puncture. Complications:Accidental puncture of the carotid artery (0.5–11% prevalence). Avoid catheterization of the carotid artery ( consult a vascular surgeon if encountered ) .Other complications: pleural space puncture, septicemia. Where to insert CVC?

20. Subclavian Vein Anatomy:The subclavian vein is a continuation of the axillary vein over the first rib. It runs along the underside of the clavicle, sandwiched between the clavicle and the first rib. It meets the internal jugular vein at the thoracic inlet to form the innominate vein. Positioning:Head-down body tilt distends the subclavian vein. Some maneuvers, like arching shoulders, reduce the cross-sectional area of the vein. Ultrasound Guidance:Less popular due to the clavicle blocking ultrasound waves. Complications:Immediate complications include puncture of subclavian artery, pneumothorax, brachial plexus injury. Complications from indwelling catheters include septicemia and subclavian vein stenosis. Where to insert CVC?

21. Femoral Vein Anatomy :The femoral vein is a continuation of the long saphenous vein in the groin , Located in the femoral triangle, close to the femoral artery and nerve.Easier to locate and cannulate when the leg is placed in abduction Ultrasound Imaging:Ultrasound probe placed over the femoral artery pulse.Cross-sectional view of the femoral artery and vein Landmark Method:Locate femoral artery pulse and insert the probe needle 1-2 cm medial to the pulse. Alternatively, divide a line from the anterior superior iliac crest to the pubic tubercle into three segments to locate the femoral vein. Complications :Major concerns: puncture of femoral artery, femoral vein thrombosis, septicemia. Clinically silent thrombosis from indwelling catheters is common. Where to insert CVC?

22. Peripherally Inserted Central Catheters (PICCs) PICC Placement :PICCs are advanced into the superior vena cava from peripheral veins located just above the antecubital fossa in the arm. Basilic vein preferred for PICC placement due to its larger diameter and straighter course. Distance to the right atrium estimated for catheter tip placement. Portable chest x-ray used to confirm catheter tip position. Complications :The most common complication is catheter-induced thrombosis, often involving axillary and subclavian veins. Septicemia from PICCs occurs at a rate of one infection per 1000 catheter days. Where to insert CVC?

23. Procedure ( Starts after Informed Consent from Patient or Guardian ) 1. Setup of Equipment and Sterile Preparation 2. Landmarking the Access Site 3. Anesthesia 4. Location of the Vein with a Seeker Needle [Optional] 5. Placing the Introducer Needle in the Vein 6. Assessment for Venous or Arterial Placement 7. Insertion of the Guide Wire 8. Removal of the Introducer Needle 9. Skin Incision 10. Insertion of the Dilator 11. Placement of the Catheter 12. Removal of the Guide Wire 13. Flushing and Capping of the Lumens 14. Secure the Catheter Let’s discuss each step in detail How to Insert CVC?

24. Step-1 Setup of Equipment & Sterile Preparation Equipment Assembly:Assemble all necessary equipment for central line insertion. Ensure availability of sterile central line kits and supplies. Sterile Preparation:Ensure the healthcare provider is sterilely gowned and gloved. Open the inner package of the central line kit in a sterile manner. Skin Sterilization:Pour the skin sterilizing solution into the provided container. Apply three coats of the sterilizing solution to a large area surrounding the vascular access site using sponges. Start from the center and work outward in a circular pattern. Creating a Sterile Field:Place a large sterile sheet on the patient. Arrange sterile towels to create a sterile field around the access site. Readiness:After these steps, you are prepared to proceed with the central line insertion. Importance:Proper setup and sterile preparation are crucial to reduce the risk of infection and complications during central line insertion. Step By Step Guide

25. Step -2 Landmarking the access site Variations by Site:Central line landmarking varies based on the chosen insertion site (e.g., internal jugular, subclavian, or femoral). (Discussed in Next Slide) Step 3 - Anesthesia (Optional) :Using a sterile 25-27g needle, infiltrate the skin surrounding the vascular access site with a few milliliters of local anesthetic if the patient is awake and restless. General anesthesia may eliminate the need for local anesthesia. Importance:Proper landmarking and, if needed, anesthesia and vein seeking help ensure a safe and accurate central line insertion process. Now let’s discuss landmarking of various sites Step By Step Guide

26. The internal jugular vein is an attractive central line insertion site due to its predictable course, reduced risk of pneumothorax compared to the subclavian approach, and direct route to the superior vena cava Drawbacks include a slightly higher failure rate compared to the subclavian approach and infeasibility for patients in cervical spine collars. Anatomy :The vein runs lateral to the carotid artery.It consistently relates to the sternocleidomastoid muscle, often located under the triangle formed by the clavicle and the two heads of the sternocleidomastoid muscle. Technique : Step A : Equip and prepare as discussed earlier. Place the patient supine on a stretcher in Trendelenberg position to enlarge the internal jugular vein and minimize air embolism risk. Internal Jugular Vein Insertion

27. Step B : Landmarking the Access Site – Internal Jugular For a medial approach to the right internal jugular: Rotate the patient’s head approximately 15° to the left. Identify the sternal and clavicular heads of the sternocleidomastoid muscle by palpating them along the clavicle. They converge about 5 cm above the clavicle, which is the site for needle placement. Step C : Location of the Vein with a Seeker Needle [Optional] If using a seeker needle:Assemble the seeker needle on a 3 or 5 cc syringe. Place fingers along the sternal head of the sternocleidomastoid muscle, ensuring the carotid pulse is medially located. Insert the seeker needle into the apex of the sternocleidomastoid-clavicular triangle at a 30-40° angle, aiming caudally towards the patient’s nipple. Advance the seeker needle while aspirating on the syringe to locate the vein. Rapid venous blood return confirms vein puncture. Internal Jugular Vein Insertion

28. Step D : Placement of the Introducer Needle Similar to the seeker needle placement but using a larger introducer needle. Position your left 2nd and 3rd fingers along the sternal head of the sternocleidomastoid muscle. Ensure the carotid pulse is located medially to your intended seeker needle placement. Insert the introducer needle into the apex of the sternocleidomastoid-clavicular triangle at a 30-40° angle to the skin. Aim the needle caudally towards the patient’s ipsilateral nipple. Advance the introducer needle while aspirating on the syringe . Typically, the vein is only 2-3 cm deep to the skin’s surface. Upon puncturing the vein, you will experience a rapid return of venous blood into your syringe. Advance the needle about 1⁄2 cm and reaspirate to confirm venous blood flow. This ensures the entire needle tip is within the vein. Internal Jugular Vein Insertion

29. Advantages: The subclavian vein is accessible to patients in cervical spine precautions and less prone to diameter changes in hypovolemia due to its rigid attachments to the costoclavicular ligament. Considerations: However, this procedure has a slightly higher risk of pneumothorax compared to the internal jugular approach and I s not compressible due to its location under the clavicle, which may not be suitable for patients with coagulopathies or bleeding disorders Anatomy of the Subclavian Vein The subclavian vein begins as the axillary vein and becomes the subclavian vein at the outer aspect of the first rib. It runs directly behind the clavicle, held in place by the costoclavicular ligament, making it an ideal site for central line placement. The vein continues to become the innominate vein as it joins the internal jugular vein, eventually leading to the superior vena cava. Subclavian Vein

30. Technique (Different Steps) Setup of Equipment and Sterile Preparation: Position the patient supine with a slight Trendelenberg tilt to prevent air embolism. Place a small towel roll or 1 L IV bag between the patient’s shoulder blades to extend their chest. Don sterile gown, gloves, and mask. Apply sterile skin solution over a wide area from the distal third of the clavicle past the sternum. Drape the patient with a large sterile drape and sterile towels as discussed earlier. 2.Landmark the Access Site: The site of access lies at the junction of the medial and middle thirds of the clavicle. The needle insertion point is about 1 cm caudal to the clavicle to allow passage under the clavicle. 3.Location of the Vein with a Seeker Needle (Optional): Optional but follows the same technique as with the introducer needle. Place the needle at the identified access site (1 cm caudal to the junction of the medial and middle thirds of the clavicle). Direct the needle to a point just above and posterior to the sternal notch. Advance the needle while withdrawing on the syringe until rapid venous blood flow signifies entry into the vessel (usually occurs 3 to 4 cm deep). Subclavian Vein

31. 4.Placing the Introducer Needle in the Vein: Utilize the same technique as with the seeker needle. Use the larger introducer needle, which can be either an angiocath or a steel introducer needle. Place the needle at the previously identified access site (1 cm caudal to the junction of the medial and middle thirds of the clavicle). Direct the needle to a point just above and posterior to the sternal notch. Advance the needle while withdrawing on the syringe until rapid venous blood flow signifies entry into the vessel (usually occurs 3 to 4 cm deep). Advance the needle 1⁄2 cm into the vein and reaspirate to ensure the entire distal portion of the needle is in the vein. Subclavian Vein

32. Advantages : The femoral vein is a favorable site for central vascular access, especially when you want to avoid collapsing lungs or puncturing carotid arteries. Considerations : However, there are a few reasons why you might not choose the femoral vein:Patients with femoral lines cannot get up and walk. Higher risk of infective complications due to challenges in keeping the groin area clean. More difficult to float pacemakers or pulmonary artery catheters from a femoral source . Anatomy of the Femoral Vein Located medial to the femoral artery. Best accessed just distal to the inguinal ligament. To remember the anatomy, use the pneumonic “ NAVLS ” - Nerve, Artery, Vein, Lymphatics, Scrotum. This helps you identify the medial direction. Femoral Vein

33. Technique (Different Steps) Step 1.Setup Equipment and Sterile Preparation :Position the patient supine. Abduct the patient’s leg at the hip and slightly externally rotate the hip. Don sterile gown, gloves, and mask. Prep a large area around the patient’s inguinal ligament. Drape the patient with a large sterile sheet and sterile towels surrounding the access site. Step 2.Landmarking the Access Site : Locate the site for access by palpating the femoral artery’s pulse just distal to the inguinal ligament. The femoral vein lies just medial to this. During CPR, start medial to the palpable pulsation, but be aware the pulse you feel may be a venous pulse generated by CPR. Adjust your catheter placement if needed. Step 3.Local Anesthesia Femoral Vein

34. Step 4 Location of the Vein with a Seeker Needle (Optional): If using a seeker needle, load it onto a 3-5 cc syringe as described previously. Begin by palpating the femoral artery’s pulse just below the inguinal ligament. Place the seeker needle 1-2 cm medial to this. Advance the needle in a cephalad direction with a 45 o angle to the skin while aspirating. Rapid filling of your syringe with venous blood signifies entry into the vein. Step 5 Placing the Introducer Needle in the Vein:Follow the same technique as with the seeker needle. Begin by palpating the femoral artery’s pulse just below the inguinal ligament. Place the seeker needle just medial to this. Advance the needle in a cephalad direction with a 45 o angle to the skin while aspirating. Rapid filling of your syringe with venous blood signifies entry into the vein. Advance the needle 1⁄2 cm into the vein and reaspirate to ensure the entire distal portion of the needle is in the vein. Femoral Vein

35. Observing Blood Flow Upon needle insertion, observe the flow of dark, low-pressure blood from the needle. Venous placement results in a dark, non-pulsatile flow. Bright or highly pulsatile flow may indicate arterial puncture, which should be avoided Simple Testing with Manometer Tubing : Attach sterile manometer tubing to the introducer needle/catheter. Lower the tubing to fill with blood, confirming venous placement. Hold the tubing vertically. In the vein, the blood column equilibrates about 3-10 cm above the right atrium level (in normotensive patients).Venous blood column may vary slightly with respiration but should not be markedly pulsatile. Identifying Arterial Placement Arterial puncture results in a steadily rising blood column. The blood column may rise significantly above the right atrium level. Highly pulsatile nature, correlating with the carotid pulse. Normotensive patients show a marked rise; less so in profoundly hypotensive patients. Alternative Confirmation : if unable to perform manometer tubing test, send a blood gas sample from the introducer needle and another from an arterial site.Compare the two samples:Identical values suggest arterial placement where as Lower pO2 and higher pCO2 in the sample indicate venous placement. Step 6 Assesment of Venous Placement

36. Proper placement of the guide wire into the vein. Guide Wire Assembly: The guide wire is enclosed in a circular tube with a cone-like piece for smooth wire insertion. Insertion Procedure:Attach the guide wire assembly to the introducer needle. Advance the guide wire gently down the needle into the vein. The guide wire should extend approximately 10-15 cm into the vein. Safety Precautions:Ensure smooth and resistance-free wire advancement; never force the wire. Reevaluate needle placement if resistance is encountered. Continuously control the guide wire from start to finish (the “Never let go of the wire” principle). Wire Tip Protection:The folded tip of the guide wire, known as a “J-wire,” safeguards the vein from laceration . Step 7 Insertion of Guide Wire

37. Step 8 - Remove the Introducer Needle Safe removal of the introducer needle while keeping the guide wire in place. Removal Procedure:Carefully withdraw the introducer needle, ensuring that the guide wire remains within the vessel. The “Never let go of the wire” principle continues to apply. Always control the guide wire. Safety Reminder:Maintain control of the guide wire from either above or below the introducer needle during removal. Step 8 Remove the Introducer Needle

38. Skin Incision We need to make a small incision in the skin in order to facilitate the passage of our dilator and line. To do so, take your scalpel and lay it flat along the guide wire. Advance the scalpel along the wire incising the full thickness of the dermis. Step 9 Skin Incision

39. Step 10 Insertion of the Dilator Dilating the pathway around the guide wire to enable smooth passage of the multilumen catheter into the vein. Procedure:Feed the guide wire into the dilator. While controlling the guide wire, advance the dilator until its hub is flush with the skin. Remove the dilator, leaving the guide wire in place. Safety Tip:Maintain control of some part of the guide wire at all times during this step. Step 10 Insertion of Dilator

40. Step 1 1 - Placement of the Catheter Advancing the multilumen catheter down the guide wire and into the vein. Procedure:Once the guide wire is in place, place the multilumen catheter on the guide wire Advance the catheter until its hub is flush with the skin. Remove the dilator, leaving the multilumen catheter in the vein. Safety Tip:Continue holding some part of the guide wire during this step. Step 1 2 - Remove the Guide Wire Removing the guide wire safely. Procedure:Hold the multilumen catheter in place. Carefully remove the guide wire. Ensure all guide wires are completely removed. Safety Tip:Maintain vigilance during guide wire removal to avoid complications. Step 11 – Placement of the catheter

41. Step 1 3 Flushing and Capping the Line P reparing central line lumens for use. Procedure:Allow blood to flow back into the line, clearing any air. Attach an IV cap to a 10cc NS syringe. Flush each lumen of the catheter with normal saline. Repeat for all lumens. Importance:Eliminating air and ensuring lumens are ready for medical use. Step 13 Flushing & Capping the Line

42. Step 14 - Secure the Catheter Ensuring the central line remains securely in place Suture the catheter to the patient, allowing some movement without detachment. Add a large sterile dressing to protect the site. Importance:Preventing accidental dislodgment of the central line & Maintaining cleanliness and sterility around the insertion site. Step 14 Securing the Catheter

43. Summarizing the key steps in central line insertion. Setup and sterile preparation. Landmark the access site. Apply local anesthesia. Use a seeker needle (optional). Cannulate the vein with an introducer needle. Assess for venous or arterial placement. Insert the guide wire. Remove the introducer needle. Make a skin incision. Insert the dilator. Place the catheter. Remove the guide wire. Flush and cap the line. Secure the catheter.

44. Immediate Concerns Venous Air Embolism : Occurs when air enters the venous circulation. Potentially lethal complication. Pathophysiology :Negative intrathoracic pressure during spontaneous breathing creates pressure gradients for air entry. Gravity can aid air movement when the site of air entry is higher than the right atrium. Even small pressure gradients can lead to significant air entrainment. Consequences :Fatal when air entry reaches 200–300 mL in a few seconds. Adverse effects : right heart failure, cardiogenic shock, pulmonary edema, embolic stroke. Prevention :Positive-pressure mechanical ventilation. Trendelenburg position for internal jugular and subclavian vein catheters. Supine/ semirecumbent position for femoral vein catheters. Reduces but doesn’t eliminate risk. Clinical Presentation : Dyspnea, cough, hypotension, oliguria, depressed consciousness. Diagnosis : Clinical with some diagnostic aids (echocardiography, Doppler ultrasound). Management : Prevention of further air entrainment, cardiorespiratory support. Complications

45. Pneumothorax Infrequent complication, often associated with subclavian vein cannulation. Detection: Chest x-ray in upright position and after forced exhalation. Supine Pneumothorax: Challenge for detection, more anterior pleural air in supine position. B-mode ultrasound superior for detecting supine pneumothoraces. Delayed Pneumothorax: May not be evident on immediate post-insertion chest x-rays. Most cases occur in subclavian vein cannulation. Catheter Tip Location Catheter tip should be in the distal one-third of the superior vena cava, 1–2 cm above the right atrium junction.Misplacement found in 5% to 25% of central venous catheter cannulations. Malpositions:Tip Abuts the Wall of the Vena Cava (especially in left-side insertions) , Catheter Tip in Right Atrium. Right atrial malposition risk: right atrial perforation and cardiac tamponade (rare but fatal).

46. Catheter Occlusion Causes: Sharp angles or kinks during insertion, thrombosis, insoluble precipitates from medications, lipid residues (e.g., propofol). Thrombosis is the most common cause (up to 25% of catheters). Restoring patency preferred to catheter replacement, but guidewire advancement risks embolization. Thrombolytic agent ( Alteplase ) used for thrombotic occlusion. Dilute acid (0.1N hydrochloric acid) for non-thrombotic occlusion. 70% ethanol for lipid residues.Venous Thrombosis Common, often clinically silent, particularly in cancer patients. Routine testing may reveal thrombosis in up to 40% of catheters. Most cases are asymptomatic; symptoms more common with femoral vein catheters. Risk factors: Prolonged catheterization, chemotherapeutic agents, hypercoagulable state Non Infectious Complications of CVC

47. Upper Extremity Thrombosis 80% of cases involve central venous catheters. May result in arm swelling, paresthesias, arm weakness. Rarely propagates into superior vena cava, even rarer to cause superior vena cava syndrome. <10% accompanied by symptomatic pulmonary emboli. Diagnosis: Compression ultrasonography (sensitivity 97%, specificity 96%). Removal of catheter not mandatory, anticoagulant therapy if severe or painful symptoms. Non Infectious Complications of CVC

48. Superior Vena Cava Perforation Mostly caused by left-sided catheters that don’t turn downward toward the right atrium. Symptoms: Nonspecific ( substernal chest pain, cough, dyspnea). Pleural effusion may be seen on chest x-ray. Diagnosis: Thoracentesis , pleural fluid analysis, and contrast dye injection for confirmation. Management: Stop infusion, remove catheter, antibiotic therapy if pleural infection present. Ca rdiac Tamponade Rare but life-threatening from catheter-induced perforation of the right atrium. Onset: Abrupt dyspnea, may progress to cardiovascular collapse. Diagnosis: Ultrasound evidence of pericardial effusion with right heart diastolic collapse Immediate pericardiocentesis and potential emergency thoracotomy.

49. Catheter-Related Bloodstream Infections (CRBSIs) pose a potential fatality risk of up to 25%. Incidence Trend : A notable 60% decline in the last decade, attributed to preventive measures. Pathogenesis : Microbial sources: infusates , catheter hubs, skin migration, and secondary seeding from circulating blood. Biofilm Challenge : Microbes form resilient biofilms on catheters, hindering host defenses and antibiotic efficacy. Measurement of Incidence : Expressed as infections per 1,000 catheter-days Culture-Based Diagnosis Semiquantitative culture of catheter tip. Differential quantitative blood cultures. Differential time to positive culture. CRBSIs

50. Effective Management Empiric Antibiotic Therapy : Tailored to common isolates; Vancomycin as a backbone, considering resistant strains and Gram-negative coverage.

51. Culture-Confirmed Infections : Specific antibiotic choices guided by culture results. Catheter Management Decisions : Removal, replacement, or leaving in place based on clinical considerations.Duration of Treatment Varied timelines depending on the involved pathogen, catheter status, and clinical response. Persistent Sepsis : Further evaluation for complications like suppurative thrombophlebitis or endocarditis if signs persist post-72 hours of antimicrobial therapy.

52. Skin Antisepsis : Proper hand hygiene is crucial for infection control. Alcohol-based hand rubs preferred; handwashing with soap and water acceptable. Hand hygiene before and after palpating catheter insertion sites and before/after glove use. Skin decontamination at catheter insertion site just before cannulation. Preferred antiseptic agent: chlorhexidine (superior to other agents). Chlorhexidine’s efficacy due to prolonged residual antimicrobial activity on the skin (at least 6 hours after application). Maximized activity if chlorhexidine is allowed to air-dry on the skin for at least two minutes. Barriers : Full sterile barrier precautions for all vascular cannulation procedures (except small peripheral veins). Includes caps, masks, sterile gloves, sterile gowns, sterile drape head to foot. Peripheral vein cannulation requires gloves, and nonsterile gloves are acceptable if they don’t touch the catheter.Site Selection Recommendations: Avoid femoral vein cannulation; prefer subclavian vein over internal jugular vein. Based on perceived risk of catheter-related infections (highest risk with femoral, lowest with subclavian). Considerations can influence site preference (e.g., hemodialysis catheters). Prevention

53. Routine Catheter Care

54. Resources Want to know more on this topic? Marino, P. L. . Marino’s The ICU Book (4th ed.). Lippincott Williams & Wilkins Medscape .Central Line Insertion: Advances in Procedure (https:// www.medscape.org /sites/advances/central-line-insertion) Central Venous Access in Adults: General Principles. UpToDate . ( June 2023 ). ( https:// www.uptodate.com /contents/central-venous-access-in-adults-general-principles ) Critical Care Medicine. ( 2021 ). Central Venous Access. Queen’s University Critical Care Medicine. ( https:// criticalcare.queensu.ca /sites/ criticalcare /files/inline-files/Central_Venous_Access.pdf ) Practice Guidelines for Central Venous Access 2020:  An Updated Report by the American Society of Anesthesiologists Task Force on Central Venous Access .  Anesthesiology  2020; 132:8–43 doi :  https:// doi.org /10.1097/ALN.0000000000002864 Longo, D. L., Fauci, A. S., Kasper, D. L., Hauser, S. L., Jameson, J. L., & Loscalzo , J. (2018). Harrison’s Principles of Internal Medicine (21st ed.). McGraw-Hill Education.

55. Does anyone have any questions? Please keep this slide for attribution Thanks Thanks for your patience listening.