A stepwise “A to Z” central venous catheterization approach: a brief review

Article information

Trauma Image Proced. 2022;7(1):3-7

Publication date (electronic) : 2022 June 30

doi : https://doi.org/10.24184/tip.2022.7.1.3

¹Department of Medicine, Dankook University Graduate School, Cheonan, Korea

²Department of Trauma Surgery, Trauma Center, Dankook University Hospital, Cheonan, Korea

Correspondence to Yoonjung Heo Department of Trauma Surgery, Trauma Center, Dankook University Hospital, 201 Manghyang-ro, Dongnam-gu, Cheonan 31116, Korea Tel: +82-41-550-3040 Fax: +82-41-550-0039 E-mail: serapinaoliv@gmail.com

Received 2022 June 12; Revised 2022 June 24; Accepted 2022 June 26.

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.

Keywords: Central venous catheterization; Central venous catheters; Intensive care units; Critical care; Ultrasonography

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].

Table 1.

Central venous catheterization indications

Table 2.

Central venous catheterization contraindications

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].

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).

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.

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].

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].

Table 3.

Central venous catheterization complications

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.

tip-7-1-3-v1.mp4

References

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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 edth ed. Singapore: Springer Singapore; 2020. p. 383–95.

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

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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.

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.

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.

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.

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.

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.

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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Fig. 1.

Fig. 2.

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