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Trauma Image and Procedure > Volume 7(1); 2022 > Article
Heo: A stepwise “A to Z” central venous catheterization approach: a brief review

Abstract

Central venous catheterization (CVC) is frequently performed in critical care medicine. However, there is a lack of standardized CVC training. The Airway & Catheter Cannulation Education–from Starters to Specialists (ACCESS) course was developed for a systematic airway and catheterization management. A stepwise A to Z approach for safe and successful CVC is the focus of the current review, while providing a guideline for the ACCESS course. In addition, special care for CVC in trauma patients is discussed.

Introduction

Critically ill patient treatment often involves central venous catheterization (CVC). However, CVC has traditionally been taught in an apprenticeship manner and the same is true for the current residency program. Therefore, along with recognizing the need for standard training, a new course titled “the Airway & Catheter Cannulation Education – from Starters to Specialists (ACCESS) course” was designed by the trauma center of Dankook University Hospital in 2022. This review highlights the importance of a standardized protocol and education regarding CVC in critical care, especially in the field of trauma.

Stepwise approach for CVC

Step A: Ask if CVC is needed

CVC is a fairly safe procedure in expert hands, but it is not without complications. Therefore, CVC must be performed only in patients for whom it is indicated while ruling out contraindications. The general CVC indications and contraindications are summarized in Tables 1 and 2 [1-3]. Ultrasound guidance and femoral vein central catheter or peripherally inserted central catheter minimize the risk in severe coagulopathy (platelets <20,000 or INR >3) [1].

Step B: Browse where the optimal site is

“When possible,” special considerations for each central venous access are followed, as conflicts arise among those considerations. Fewer catheter malpositions are associated with a right-sided access. On the contrary, a left-sided access is preferred when cardiac access is needed (i.e., pacer insertion) [2]. The perceived advantages of each site in specific situations are as follows [2-4]:
  • •Coagulopathy: femoral > internal jugular > subclavian

  • •Infection: subclavian > internal jugular > femoral

  • •Hemodialysis: right internal jugular > femoral > left internal jugular > subclavian (dominant side) > subclavian (non-dominant side)

  • •Pneumothorax and chylothorax prevention: right internal jugular > left internal jugular

Step C: Choose the proper catheter

Short and large-bore catheters should be chosen for rapid fluid resuscitation. Flow rate is noted to be proportionately less influenced by the length than by the inner diameter. Multilumen catheters are preferred when a multitude of parenteral therapies are required. However, multilumen catheters create slower flow rates and risk of infection or thrombosis [2,3,5]. Antimicrobial-impregnated catheters are used when they are expected to remain for more than 5 days [2,3].

Step D: Define the anatomy

The pertinent anatomy varies depending on which site of CVC is chosen. Therefore, all relevant landmarks deserve emphasis. Detailed anatomic definitions of different access sites are described in each journal of this issue.

Step E: Equipment preparation

All CVC equipments should be set up before cannulation, especially skin antisepsis and barriers. Any lines placed without strict aseptic technique should be rapidly removed to prevent catheter-related bloodstream infection (CRBSI). CRBSI risk markedly increases after 9 days. CRBSI is associated with a longer hospital stay, increased medical cost, and a 12%-25% mortality rate [5].

Step F: Fluent and flawless cannulation

Ultrasound imaging use in CVC decreases the puncture, insertion time, and complication rate [6-8]. Patency is checked by compression with transducer once the operator determines the location and penetration of the target vessel. Typically, the transverse view (short-axis) makes identification of vessel puncture effortless, whereas the longitudinal view (long-axis) is favorable to localize the wire (Fig. 1). Details of the ultrasound-guided vascular puncture is described in Video 1. The remainder of the procedure is accomplished with the Seldinger technique once the vein is punctured by the needle [5].

Step X: X-ray call, please

In ideal, the tip position should be checked during the insertion, by fluoroscopy or intracavity electrocardiogram. If the position has not been checked intraoperatively, the post-CVC chest X-ray should not be forgotten, especially when blind puncture method was used [9]. Images should be investigated not only for the catheter tip location (Fig. 2), but also for the presence of plero-pulmonary complications (pneumothorax, hemothorax, etc.). A single immediate image is not sufficient, since a pneumothorax may not appear definitely for 12-24 h [9]. Arrhythmia monitoring and ports flushing are also vital post procedure precautions.

Step Y: Yet to remove

Always be cognizant that central venous catheter removal should be done following a standardized protocol to prevent fatal complications, such as air embolism. The patient should be placed in the Trendelenberg position during removal, while the patient takes a deep breath and holds it. Applying an air-tight dressing for 24 h after a 5-min compression secures cutaneous tract occlusion [10].

Step Z: Zero complications

Staffs should exert more effort to avoid making any complications. Early identification of complications and prompt treatment may reduce morbidity. It is extremely important not to force the wire, dilator, and introducer if resistance is felt during the procedure. Using force may result in mechanical complications caused by damage to the surrounding vessels or nearby structures [5]. Post-CVC complications are described in Table 3 [1,2,5].

CVC in trauma

CVC should be used with caution in hypovolemic trauma patients because of the venous collapse associated with hypovolemia. Therefore, CVC success rate is lower and complications are more frequent. Advanced Trauma Life Support guidelines recommend two large-bore intravenous (IV) lines for immediate volume resuscitation. CVC provides rapid and safe venous access in experienced hands if peripheral access is difficult to be achieved. Venous access should not be tried in an injured limb. At least one IV line should be placed toward the superior vena cava when injuries exist below the diaphragm, due to potential inferior vena cava injuries. An IV above the diaphragm and another below the diaphragm are preferred in patients with severe damage in the trunk. The internal jugular vein is a popular site for CVC, however, this is a rather unusual site in trauma patients hindering cervical immobilization [5].

Conclusions

The series of journals of this issue include instructional videos showing the insertion of various vascular catheters using both ultrasound guidance and surface landmarks. The A to Z approach for CVC reminder from this review will ensure safe and successful catheterizations in critical care.
  • •Step A: Ask if CVC is needed

  • •Step B: Browse where optimal site is

  • •Step C: Choose the proper catheter

  • •Step D: Define the anatomy

  • •Step E: Equipment preparation

  • •Step F: Fluent and flawless cannulation

  • •Step X: X-ray call, please

  • •Step Y: Yet to remove

  • •Step Z: Zero complications

Notes

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Supplementary material

Supplementary data including one video can be found with this article online at www.traumaimpro.org.

Video 1.

Ultrasound-guided vascular access. The transverse view (short-axis) is relatively safe for learners as adjacent structures (i.e., artery) are also visible. However, cautions are needed as seeing the needle on the screen does not mean where the tip is. The tip should be tracked by tilting the probe during the whole procedure. The longitudinal view (long-axis) is obtained by rotating the probe 90º from the transverse view, while keeping the vessel in the middle until it is lenghthened out. This view allows watching the entire needle or wire, but the vessel should be straight and higher technique is required than in the transverse view.

Fig. 1.
(A) Ultrasound-guided needle insertion in transverse view (short-axis). The needle tip (arrow) is visualized on the anterior vessel wall. (B) Visualization of the guide wire during the Seldinger technique in longitudinal view (long-axis).
tip-7-1-3f1.jpg
Fig. 2.
The carina and bony structures are reliable landmarks for central venous catheterization. A generally accepted safe zone is described from one rib width above the right main bronchus to two vertebral bodies below the carina. The zone includes the mid to lower superior vena cava, caval-atrial junction, and upper right atrium [11]. Within the zone, the experts recommend that the right-sided catheters be placed above the carina, and the left-sided catheters be placed below the carina due to the angle of abutment [12].
tip-7-1-3f2.jpg
Table 1.
Central venous catheterization indications
Inappropriate volume resuscitation with peripheral access
 Difficult peripheral access
 Severe sepsis or shock
 Intraoperative state
Administration of specific agents
 Vasopressors or inotropes
 Peripheral irritants
 Total parenteral nutrition
 Chemotherapy agents
 Continuous infusion of multiple drugs
 Prolonged antibiotic therapy
Interventional therapy
 Hemodialysis
 Cardiopulmonary resuscitation
 Extracorporeal membrane oxygenation
 Transvenous pacemaker or stent insertion
 Thrombolysis or plasmapheresis
 For hemodynamic monitoring (ScvO2, CVP)
Table 2.
Central venous catheterization contraindications
Absolute contraindications
 None (if experienced or supervised)
Relative contraindications
 Severe coagulopathy or thrombocytopenia
 Local skin infection or burns
 Anatomic abnormalities
 Ipsilateral arteriovenous fistula
 Ipsilateral venous thrombosis
 Inferior vena cava filter
Table 3.
Central venous catheterization complications
Common
 Arrhythmias
 Arterial puncture
 Hematoma
 Catheter malposition
 Venous thrombosis
 Catheter-related blood stream infection
Infrequent
 Pneumothorax
 Hemothorax
 Thoracic duct injury (chylothorax)
 Nerve injury
 Tracheal or laryngeal injury
 Endotracheal tube cuff rupture
 Entanglement of vena cava filter
Rare and fatal
 Air embolism
 Cardiac tamponade

REFERENCES

1. Pepe JL. Central venous catheterization. In: Fink MP, Vincent JL, Abraham E, Moore F, Kochanek P, eds. Textbook of critical care. 7th ed. Philadelphia, PA: Elsevier; 2017. p. e59-61.

2. Chawla R, Varma V, Kansal S, Bali RK. Central line placement. In: Chawla R, Todi S, eds. ICU protocols: a step-wise approach, vol II. 2nd ed. Singapore: Springer Singapore; 2020. p. 383-95.

3. Marino PL. Marino’s the ICU book. 4th ed. Philadelphia: Wolters Kluwer Health; 2013.

4. Karkar A, Ronco C. Prescription of CRRT: a pathway to optimize therapy. Ann Intensive Care. 2020;10(1):32.
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5. Feliciano DV, Mattox KL, Moore EE. Trauma. 9th ed. New York: McGraw-Hill Education; 2020.

6. Miller AH, Roth BA, Mills TJ, Woody JR, Longmoor CE, Foster B. Ultrasound guidance versus the landmark technique for the placement of central venous catheters in the emergency department. Acad Emerg Med. 2002;9(8):800-5.
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7. Milling TJ, Rose J, Briggs WM, Birkhahn R, Gaeta TJ, Bove JJ, et al. Randomized, controlled clinical trial of point-of-care limited ultrasonography assistance of central venous cannulation: the Third Sonography Outcomes Assessment Program (SOAP-3) Trial. Crit Care Med. 2005;33(8):1764-9.
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8. Leung J, Duffy M, Finckh A. Real-time ultrasonographically-guided internal jugular vein catherization in the emergency department increases success rates and reduces complications: a randomized, prospective study. Ann Emerg Med. 2006;48(5):540-7.
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9. Pittiruti M, Hamilton H, Biffi R, MacFie J, Pertkiewicz M, ESPEN. ESPEN guidelines on parenteral nutrition: central venous catheters (access, care, diagnosis and therapy of complications). Clin Nutr. 2009;28(4):365-77.
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10. Bernard LA, Katzman A, Mathew DK, Oller KL. Prevention of central venous catheter removal-associated air embolization. Am J Med. 2018;131(3):e123.
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11. Johnston AJ, Bishop SM, Martin L, See TC, Streater CT. Defining peripherally inserted central catheter tip position and an evaluation of insertions in one unit. Anaesthesia. 2013 May;68(5):484-91.
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12. Stonelake PA, Bodenham AR. The carina as a radiological landmark for central venous catheter tip position. Br J Anaesth. 2006 Mar;96(3):335-40.
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