Central Venous and Arterial Access Procedures

Central Venous Access: General Principles and Preparation

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  Patients in the Cardiac Intensive Care Unit (CICU) require reliable intravenous access.

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  Central venous access is indicated for vasopressor administration, hemodynamic monitoring, temporary transvenous pacing, and hemodialysis.

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  Contraindications are relative, depending on alternative options and clinical urgency.

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  Anatomic distortion, local infection, and existing hardware justify avoiding specific sites when possible.

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  Coagulopathy is not an absolute contraindication, but the risk and benefits should be carefully weighed.

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  Although consent should be obtained prior to attempting central venous access, it is often required emergently and obtaining consent may not be practical.

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    Infection, bleeding, arterial injury, venous thrombosis, and pneumothorax are all important to discuss.

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  Most nonemergent central venous catheters in the CICU are placed in the internal jugular or subclavian vein.

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  Ultrasound guidance is recommended, and the site should be investigated prior to skin preparation and draping.

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  Abnormal vascular anatomy or visible clots may disqualify a preferred site.

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  The Trendelenburg position is recommended for subclavian and jugular access if the patient can safely tolerate repositioning.

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  Once the site is selected and the patient is positioned, the skin should be cleaned, ideally with chlorhexidine-based solutions.

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  Full sterile precautions should be used for all central access procedures.

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  The central line kit should be ergonomically positioned on a large table, but not on the sterile drape, because patients can unexpectedly move.

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  The insertion site should be anesthetized with 1% lidocaine.

Technique

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  The modified Seldinger technique is standard for central access procedures.

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  Vessel puncture is obtained with a large-bore, 18-gauge introducer needle or catheter-over-needle assembly.

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  Needle trajectory and depth should be monitored closely throughout.

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  Continuous negative pressure is applied to the aspirating syringe during needle advancement and withdrawal.

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  Venous puncture confirmation is important for central venous access procedures to avoid inadvertent arterial cannulation.

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  Blood color, pulsatility, and ultrasound visualization may be misleading.

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  A 30-cm length of pressure tubing can be connected to the access needle and used to transduce venous pressure prior to wire introduction.

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  The guidewire is next advanced through the introducer needle to approximately 20 cm.

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  The needle must remain stationary before wire insertion.

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  The guidewire should pass easily with minimal resistance; if not, remove the wire, reconfirm blood aspiration, or reposition the needle trajectory or guidewire J-tip orientation prior to readvancing.

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  With the wire stabilized at 20 cm, the needle is removed and a small stab incision at the guidewire exit site is performed with a No. 11 scalpel.

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  While stabilizing the guidewire, the tissue tract dilator is advanced over the guidewire through the skin and connective tissue to the vessel.

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  Care must be taken to avoid advancing the wire and dilator together because this can bend the wire and damage the vessel.

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  The wire should always slide easily within the dilator.

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  Next, the dilator is removed while keeping the wire stationary and maintaining hemostasis with firm pressure.

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  The vascular catheter is then advanced into position over the guidewire.

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  Finally, the guidewire is removed, the catheter lumens are flushed, and the catheter is secured to the skin at the appropriate depth (usually 15 to 20 cm, depending on access site and patient size).

Internal Jugular Venous Cannulation