Page 276 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

180 PART 2: General Management of the Patient

PLACEMENT OF CENTRAL VENOUS CATHETERS a steep angle toward the underlying visceral pleura of the lung while
attempting to locate the posterior border of the clavicle. Once the needle
The clinical presentation often dictates the type of catheter to be inserted. is “walked down” the bone and is positioned underneath the clavicle, it
For example, a patient with a hemodynamically significant gastrointes- is then redirected toward the sternal notch and advanced slowly while
tinal hemorrhage may only require a single lumen, large bore CVC for applying backpressure to the syringe (Fig. 27-1).
volume resuscitation in addition to a peripheral IV, whereas a neutropenic
patient with septic shock may require a triple lumen CVC in order to
simultaneously administer vasoactive drugs and antibiotics. Importantly, CENTRAL INTERNAL JUGULAR APPROACH
most evidence suggests that the number of catheter lumens does not affect If the patient’s anatomy (scar from previous vascular access) or coagula-
the rate of CVC infectious complications. Once the type of catheter has tion disorder prevents the use of the subclavian vein, then the internal
2,3
been selected, an anatomic site for insertion needs to be determined. The jugular vein should be utilized for placement of a CVC. The central
optimal anatomical location for insertion of CVCs has been a matter of approach to placing an internal jugular catheter uses the triangle formed
debate for many years. In 2001, Merrer and colleagues published a study of by the two heads of the sternocleidomastoid muscle and the medial por-
289 patients who were randomized to have their CVCs inserted in either tion of the clavicle as the anatomic landmark. Most commonly (though
the femoral or subclavian vein. Patients with femoral vein catheters had not always), the internal jugular vein is lateral to the carotid artery and
4
a dramatically higher incidence of infectious complications (19.8% vs both vessels run through the triangle beneath the sternocleidomastoid
4.5%; p < 0.001) as well as thrombotic complications (21.5% vs 1.9%; muscle. After the patient has been sterilely prepped/draped and local
p < 0.001) as compared to patients with subclavian catheters. The overall anesthesia has been administered, the patient is placed in Trendelenburg
sum of mechanical complications (arterial puncture, pneumothorax, position and the head is rotated slightly toward the contralateral side
hematoma or bleeding, air embolism) was similar between the two groups. such that the carotid artery can be palpated in the apex of the triangle.
To date, there are no randomized trials comparing subclavian versus The nondominant hand is used to lightly palpate the carotid artery with
internal jugular catheters with regard to infectious complications, though careful attention not to place too much pressure on the skin as this can
observational studies suggest a lower rate of infectious com plications with alter the position of the internal jugular vein. A smaller (eg, 21-gauge)
subclavian catheters and a similar rate of mechanical complications. “finder needle” is often used to locate the vessel prior to using the
5,6
A recent Cochrane review on comparison of central venous access sites in introducer needle (18-gauge). This “finder needle” should enter the skin
2007 did suggest that subclavian catheters had lower rates of colonization at the apex of the triangle and be advanced at an angle of 60° above the
(defined as culture tip with >103 colony-forming units) and major infec- plane of the skin. If the nondominant hand is able to delineate the course
tious complications (ie, clinical sepsis with or without bacteremia) when of the common carotid artery, then the needle should be advanced along
compared to the femoral site. As a result of these and other studies, the a similar line just lateral to the carotid artery as both vessels are contained
7
8
CDC recommends that, if not contraindicated, the subclavian vein should within the carotid sheath. If the carotid artery cannot be palpated with the
be used for the insertion of nontunneled CVCs in adult patients in an effort nondominant hand, then the needle should enter the skin at the apex of
to minimize infection risk. the triangle at a 60° angle to the skin and be advanced in the direction
of the ipsilateral nipple. If the needle is inserted to a depth of 3 cm
without achieving good blood return, then the needle should be pulled
INFRACLAVICULAR SUBCLAVIAN APPROACH back slowly while applying constant backpressure to the plunger of
Prior to the insertion of an infraclavicular subclavian CVC, a small the syringe and redirected more medially before slowly advancing the
rolled up towel should be placed between the shoulder blades to move needle again. After the vessel has been cannulated the modified-Seldinger
the vascular structures more anterior. After the subclavian area has been technique is utilized to complete insertion of the CVC (Fig. 27-2).
sterilely prepped and draped (see below) and local anesthesia
has been administered, the patient should be placed in Trendelenburg POSTERIOR INTERNAL JUGULAR APPROACH
position. The arm should be positioned at the patient’s side so that the
shoulder, clavicle, and sternal notch are aligned and perpendicular to The posterior internal jugular approach is an alternative to the central inter-
the sternum. The subclavian vein arises from the axillary vein and nal jugular approach that may be used if there is concern that the patient
travels beneath to the clavicle and inferior to the subclavian artery prior would not be able to tolerate a procedure-related pneumothorax (high posi-
to joining the internal jugular vein and forming the brachiocephalic tive end-expiratory pressure and/or high Fi O 2 requirements). The puncture
vein. Thus, the clavicle provides a good anatomic landmark for the site is posterolateral to the sternocleidomastoid muscle, immediately cepha-
insertion of a subclavian CVC. The skin should be entered with an lad to where the sternocleidomastoid is crossed by the external jugular vein.
18-gauge introducer needle 1 to 2.5 cm below the inferior edge of the The needle should be directed beneath the muscle and advanced in an
clavicle and 2 to 4 cm lateral to the midpoint of the clavicle. Once anterior and inferior direction toward the sternal notch. If blood return is
the needle is directly underneath the clavicle, it should be advanced not obtained, the needle should be pulled back and redirected slightly more
toward the sternal notch making sure that the needle remains in the posterior until venous blood is obtained. Because unintentional carotid
plane immediately below the clavicle. If no blood return is obtained, artery puncture is more likely with this approach, a “finder” needle should
then the needle should be pulled back and directed more cephalad. Slight be used prior to cannulation with a large bore needle.
backpressure should be placed on the plunger of the syringe any time the
needle is advanced or withdrawn so that blood return can be visualized ULTRASOUND-GUIDED PLACEMENT
when the vessel is cannulated. After the vessel has been accessed, the
modified-Seldinger technique is utilized to complete insertion of the CVC. Ultrasound guidance to assist in the placement of CVCs is a strategy with
Inexperienced operators often have difficulty knowing when the needle growing interest. Early studies did not suggest that ultrasound guidance
is directly underneath the clavicle and are appropriately fearful of punc- for placement of CVCs improved outcomes. For example, Mansfield and
turing the visceral pleura. Thus, we often utilize a slightly different colleagues reported that ultrasound guidance did not impact the rate of
approach when supervising an inexperienced operator. Once the skin is complications or failures in 821 patients randomized to standard inser-
entered, the operator is instructed to find the clavicle with the tip of the tion procedures with anatomic landmark guidance versus ultrasound
introducer needle. After the edge of the clavicle is reached, and more guidance for subclavian vein catheterization. It is noteworthy that this
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local anesthesia is given in the area, the introducer needle is retracted study used ultrasonography to locate the subclavian vein, but did not use
slightly (1 cm) and redirected in a more posterior direction by pushing real-time ultrasound guidance for the actual venipuncture. In contrast,
down on the syringe and needle as a unit with the nondominant hand. several more recent studies have compared the use of real-time ultra-
This prevents the inexperienced operator from advancing the needle at sound with the use anatomic landmarks during the insertion of both

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