Central Venous

Catheterization

Dr. Hiwa Omer Ahmed

Assistant Professor
Indications for central venous
catheter cannulation:
Monitoring of central venous pressures in
shock or heart failure.
management of fluid status.
administration of total parenteral nutrition.
prolonged antimicrobial therapy or
chemotherapy
Location of catheterization site

A. The internal jugular approach should

not be used in patients with a carotid bruit,
carotid stenosis, or an aneurysm.
B. The subclavian approach should be
avoided in patients with emphysema or
bullae.
C. The external jugular or internal jugular
approach by direct cut-down may be
preferable in patients with coagulopathy or
thrombocytopenia.
D. If a chest tube already in place, the
catheter should be placed on the same
side as the chest tube
Internal jugular vein cannulation
The internal jugular vein is positioned
behind the sternocleidomastoid
muscle, lateral to the carotid artery
The catheter should be placed at a
location at the upper confluence of the two
bellies of sternocleidomastoid at the level
of cricoid cartilage.
 Procedure
A. Place the patient in Trendelenburg's position,
and turn the patient's head to the contralateral
side. Choose a location on the right or left. If
lung function is symmetrical and no chest tubes
are in place, the right side is preferred because
of the direct path to the superior vena cava.
Prepare the skin with Betadine solution using
sterile technique and drape the area. Infiltrate
the skin and deeper tissues with 1% lidocaine
B. Palpate the carotid artery. Using a 22-
gauge scout needle and syringe, direct the
needle toward the ipsilateral nipple at a 30
degree angle to the neck. While
aspirating, advance the needle until the
vein is located and blood back flows into
the syringe
C. Remove the scout needle and advance an
18gauge,
thin wall, catheter-over-needle (with an attached
syringe) along the same path as the scout
needle. When back flow of blood is noted into
the syringe, advance the catheter into the vein.
Remove the needle and confirm back flow of
blood through the catheter and into the syringe.
Remove the syringe and cover the catheter hub
with a finger to prevent air embolization
D. With the catheter in position, advance a
guidewire through the catheter. The
guidewire should advance easily without
resistance
E. With the guidewire in position, remove
the catheter and use a No. 11 scalpel
blade to nick the skin. Place the central
vein catheter over the wire, holding
the wire secure at all times. Pass the
catheter into the vein, and suture the
catheter to the skin with O silk suture.
Tape the catheter in place, and connect it
to an IV infusion at a keep open rate
F. Obtain a chest x-ray to rule out
pneumothorax and confirm position.
Subclavian vein cannulation
The subclavian vein is located in the angle
formed by the medial 1/3 of clavicle and
the first rib , At the point of medial 1/3 and
middle 1/3
 PROCEDURE
A. Position the patient supine with a rolled
towel located longitudinally between the
patient's scapulae,
and turn the patient’s head towards the
contralateral
side. Prepare the area with Betadine
iodine solution, and, using sterile
technique, drape the area and infiltrate 1%
lidocaine into the skin and tissues
B. Use a 16-gauge needle, with syringe
attached, to puncture the mid-point of the
clavicle, advancing until the clavicle bone
and needle come in contact
C. Then slowly probe down until the
needle slips under the clavicle. Advance
the needle slowly towards the vein until
the needle enters the vein, and a back
flow of venous blood enters the syringe.
Remove the syringe, and cover the
catheter hub with a finger to prevent air
embolization
D. With the 16-gauge catheter in position,
advance a 0.89 mm x 45 cm guidewire
through the catheter. The guidewire
should advance easily without resistance.
With the guidewire in position, remove the
catheter, and use a No. 11 scalpel blade
to nick the skin. Pass the dilator over the
wire.
E. Place the central line catheter over the
wire, holding
the wire secure at all times. Pass the
catheter into the vein, and suture the
catheter to the skin with 2-0 silk suture,
tape the catheter in place and connect to
IV infusion. Obtain a chest x-ray to confirm
the position of the catheter tip and rule out
pneumothorax