Surgical Critical Care: Central Venous Catheter (CVC)

Central Venous Catheter (CVC) Basics

Anatomy Review

Internal Jugular (IJ) Vein
- Lies Under the Sternocleidomastoid Muscle (SCM)
- Vein Runs Anterior & Lateral to the Carotid Artery
Subclavian (SC) Vein
- Runs Under Clavicle
- Subclavian Artery & Brachial Plexus Are Deep to the Vein
Femoral Vein
- Runs Medial to the Femoral Artery

Types

Non-Tunneled CVC
- Direct Protrusion of Catheter
- Placed at Bedside
Tunneled CVC
- Passed Under Skin to Separate Site
- Placed by IR or in OR
- *Lower Infection Risk
Peripherally Inserted Central Catheter (PICC)
- Longer Line Placed Peripherally in an Arm Vein
- Less Invasive & Lower Infection Risk
- Smaller Caliber Lumens
- Often Used if Anticipating Long-Term Need (TPN or ABX)
Subcutaneous Port
- Completely Tunneled with No Exposed Ports
- Placed Under Anesthesia
- Lower Infection Risk than Tunneled or Non-Tunneled CVC
- Longer Patency – Ideal for Chemotherapy

Choice of Site

Generally Preferred CVC Route: Right IJ
- Straight Path into the SVC – Low Rate of Catheter Malposition
- Able to Provide Compression for Bleeding Easier than SC Vein
If Patient Already Has a Pneumothorax/Chest Tube – Strongly Consider Placing Central Line on the Ipsilateral Side (If Placement is Complicated by Pneumothorax it is Already Treated – “Free Shot”)
Comparison:
- Subclavian
  - Lowest DVT Risk
  - Lowest Infection Risk
  - Highest Mechanical Complication (PTX, etc.) Risk
- Femoral
  - Lowest Mechanical Complication (PTX, etc.) Risk

CVC Flow

Hagen-Poiseuille Equation
- Flow (Q) = ΔP x πr4 / 8 µL
  - P = Pressure, r = Radius, µ = Viscosity, L = Length
- Directly Related to Radius⁴
- Inversely Related to Length¹
Increased Flow with Higher Radius (Strongest Factor) & Lower Length

Internal Jugular Vein & Subclavian Vein ¹

Femoral Vein ¹

Techniques

Blind Placement – Based Solely on Anatomy without US Guidance
Ultrasound Guidance Should be Utilized if Available
- Benefits:
  - Decreased Complication Rate
  - Decreased Failure Rate
  - Increased First-Pass Success
*Either Method Utilizes a Seldinger Technique

Position/Prep

Blind Placement

Internal Jugular (IJ) Vein
- Insertion:
  - Anterior Approach: Along the Medial Border of the SCM, 2-3 Fingerbreadths Above the Clavicle
  - Central Approach: The Apex of the Bifurcation of the SCM Heads
- Angle: 30-45 Degrees
- Aim: Ipsilateral Nipple
- *Palpate the Carotid Artery During Placement (Vein Should be Lateral to Pulse)
Subclavian Vein
- Insert: 2-3 cm Below Midpoint of Clavicle (1-2 cm Lateral of Bend)
- Aim: Just Deep to Suprasternal Notch
  - If Clavicle is Hit, Withdraw and March Down
Femoral Vein
- Insert: 1-2 cm Below Inguinal Ligament & 1 cm Medial to the Femoral Artery Pulse
- Angle: 30-45 Degrees

Seldinger Technique

Puncture Vein with Hollow Introducer Needle
- Attach Syringe with Gentle Negative Pressure During Advancement
- Dark Non-Pulsatile Blood Confirms Venipuncture (Caution: Arterial Blood in Hypoxic Patients May Also be Dark)
Pass Guidewire Through the Needle
- Always Maintain Control of the Guidewire During Placement – Should Never Completely Enter the Vein
Withdraw Needle
Make Small Skin Incision at the Entry Site
Pass Dilator Over the Guidewire & Remove the Dilator
Pass CVC Over the Guidewire
Withdraw Guidewire
Suture CVC to Skin & Place Sterile Dressing
Always Obtain Post-Procedure Chest XR to Confirm Appropriate Positioning & Look for Pneumothorax

Goal Tip Location

CVC: 1-2 cm Above the Right Atrium-SVC Junction
- Seen as Just Above the Carina on CXR
Dialysis Catheter: Right Atrium
- Higher Flow Rate

Insertion Length

Equation Based on Height (cm):
- Right SC: Height/10 – 2 cm
- Right IJ: Height/10
- Left SC: Height/10 + 2 cm
- Left IJ: Height/10 + 4 cm
General Lengths:
- Right SC: 11-14 cm
- Right IJ: 13-15 cm
- Left SC: 15-17 cm
- Left IJ: 17-18 cm

US Guidance Showing Compressibe IJ (White Star) and Noncompressible Carotid (Yellow Star) ²

IJ Insertion (Star), SCM Sternal Head (Yellow), SCM Clavicular Head (Orange), Clavicle (Red) ²

SC Insertion (Star), Bend of Clavicle (Arrow) ²

Carotid Cannulation (Arterial Injury)

Can Cause Life-Threatening Hemorrhage
Reduce Risk by Using Ultrasound-Guidance for Placement
Diagnosis:
- ABG
- Pressure Transducer Showing Arterial Waveform
- CXR Showing Line to the Left of the Spine
Treatment:
- Cannulation with Probe Needle Only: Remove & Hold Pressure for 5-10 Minutes
- Cannulation with Dilator or Catheter: Remove in OR

Malposition

Tip Abutting into the Wall of the Superior Vena Cava
- Risk for SVC Puncture
- Treatment: Retract to the Innominate Vein (Do Not Advance)
Tip in Right Atrium
- Risk for Atrial Wall Puncture
- Treatment: Retract to the Right-Atrium-SVC Junction

Pneumothorax (PTX)

Risk: 1-6.6% (Higher Risk in Emergency Setting or if Multiple Needle Passes are Required to Find the Vein)
*See Trauma: Pulmonary Trauma

Cardiac Tamponade

Thrombosis

*See Vascular: Deep Venous Thrombosis (DVT)
Treatment:
- If Catheter Not Needed: Remove & Heparin
- If Catheter Needed: Systemic Heparin or tPA Down the Line

Air Embolism

Central Line-Associated Bloodstream Infection (CLABSI)

Also Known as Catheter-Related Bloodstream Infection (CRBSI)
Risk Increases with Duration of Placement (However there is No Indication for Routine Catheter Changing Based on the Number of Days)
Most Common Source: Skin Colonization
Most Common Organisms:
- S. epidermidis (Most Common)
- S. aureus (Second Most Common)
- Enterococci
- Candida
Presentation:
- Inflammation & Purulence at the Catheter Insertion Site
- Fever
- Sepsis (Often Sudden Onset)
Complications:
- Septic Thrombophlebitis
- Infective Endocarditis
Treatment: Antibiotics & Catheter Removal
- If Clinically Unable to Remove the Catheter – Consider Exchange Over a Guidewire

CVC in Aorta

Gray H. Anatomy of the Human Body (1918). Public Domain.
Bannon MP, Heller SF, Rivera M. Anatomic considerations for central venous cannulation. Risk Manag Healthc Policy. 2011;4:27-39. (License: CC BY-NC-3.0)