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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3892_Библиотеки_им_академика_М_И_Перельмана
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219
What are general
indications for the
different categories
of central venous
catheters?
PICCs:
Short-term, inpatient or outpatient
access
Medications, commonly outpatient
antibiotics
Centrally inserted central venous
catheters
Non-tunneled:
Inpatient only
Short-term, temporary access,
including for ICU care, or need for
dialysis expected to resolve
Unstable patients who cannot
travel or receive sedation
Patients requiring a tunneled
catheter but currently with
contraindications
Tunneled
Longer-term access (weeks to
months, possibly years) in inpatient
and/or outpatient settings
Small bore (usually < 7 Fr):
general durable central venous access,
fluids, most medications including
pressors and shorter-term antibiotics
Large bore (7 Fr or >): higher
viscosity or vesicant fluids like TPN
and ionotropic medications, better for
blood products, sometimes used for
longer-term medications including
antibiotics
Subcutaneous port
Longer-term access (months to
years), mostly in outpatient settings,
chemotherapy being the most
common indication
What indications
distinguish types of
non-tunneled central
venous catheters?
Number of lumens needed
Need for performance of HD
(continued)
24 Central Venous Access
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What are
contraindications to
non-tunneled central
venous catheters?
Absolute:
Cellulitis at insertion site
Choose another site.
Allergy to catheter material
Rare, find a catheter with another
material.
Relative:
Central venous thrombosis/occlusion
Uncorrectable coagulopathy
What are
contraindications for
placement of tunneled
central venous
catheters?
Absolute:
Sepsis or bacteremia
Cellulitis at insertion site
May choose another site, or place
temporary line at another site until
treated and resolves
Allergy to catheter material
Relative:
Venous stenosis
Central venous thrombosis/occlusion
Uncorrectable coagulopathy
Hyperkalemia
Is there any indication
for an emergent
tunneled line?
No, a temporary non-tunneled catheter
can be placed for emergent indications.
What are indications
for removal of a central
venous catheter*?
Completion of therapy
Malfunction (can try to treat issue or
exchange, discussed below)
Catheter access or exit site infection
(can exchange or re-site, discussed
below)
Bacteremia (can exchange, discussed
below)
Sepsis
Possible emergent indication for
removal
*Note: A temporary non-tunneled
line or PICC can be placed at the
time of removal if needed for clinical
management (e.g., for pressors, etc.)
G. Gadodia
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221
Relevant Anatomy
What vein is preferred for
central venous access and
why?
Internal jugular (IJ) due to lower risk
of complications (both immediate
and delayed)
Which side of internal
jugular vein (IJV) is
preferred for central
venous access and why?
Right is preferred over left, as it
offers a more direct route to the right
atrium and does not need to cross the
left brachiocephalic vein
Lowers risk of complications (no
kink, less risk of fracture)
Where does the common
carotid artery normally
run in relation to the
IJV?
Medial
Where should the IJV
be punctured for central
venous access?
1–5cm above the clavicle, ideally at
the apex of the triangle formed by
the sternal and clavicular heads of the
sternocleidomastoid muscle, and the
clavicle
Why is lower venous
access preferred in
tunneled lines placed in
the IJV?
Less chance of kinking or occlusion
What are options if the
jugular vein is occluded?
Recanalization of the occluded
jugular veins, access via nearby
collateral veins including the (often
enlarged) external jugular vein, or
choosing another site for access
(continued)
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222
What vein is often
preferred if the jugular
veins are contraindicated?
Why is it less preferred
than the jugulars?
Subclavian vein, less preferred than
jugulars because:
Higher risk of immediate
complication, especially
pneumothorax
Higher risk of delayed
complication, especially subclavian
stenosis causing arm swelling/pain
and possible loss of ability to place
future AV grafts of fistulae in that
arm
Where is the subclavian
vein in relation to the
subclavian artery?
Anterior and inferior to the artery at
the level of the first rib
How should the
subclavian vein be
accessed?
Over the anterior aspect of the first
rib, lateral to the clavicle.
The underlying bone protects against
pneumothorax.
Infraclavicular approach accesses the
vein at the junction of the medial and
middle thirds of the clavicle.
If a patient has an upper
extremity AVG or AVF,
which side should jugular
and subclavian central
venous catheters be
placed?
On the side contralateral to the AVG/
AV F
Where are PICCs placed? In the upper arm, usually in the
brachial, basilic, or cephalic vein
What is the ideal final
location for the tip of a
central venous catheter,
and why?
High-flow (dialysis/pheresis)
catheters:
Proximal right atrium
Low-flow catheters (all others,
including PICCs):
Cavoatrial junction
The goal is to place the tips at the
locations with the highest flow rates
and largest lumen, making clot and
occlusion less likely.
G. Gadodia
https://t.me/med1917
223
What is the approximate
location of the cavoatrial
junction on AP
radiographs?
Two vertebral body units below the
carina
In general, how can veins
reliably be distinguished
from nearby arteries?
Veins are compressible, while arteries
retain their rounded shape.
What other veins outside
the chest can be used for
central venous access, and
what are risks associated
with each?
Femoral
Higher rate of infection and
occlusion than chest, meaning more
frequent interventions for catheter
maintenance
May result in IVC occlusion
Direct IVC (translumbar)
Malfunction more than chest
catheters
But similar infection rates
IVC occlusion also a possibility
Transhepatic IVC or hepatic venous
catheters
High malfunction rate due to
respiratory motion causing liver
and thus catheter movement
Transrenal
Direct right atrial (surgically placed)
Does not allow for over the wire
catheter exchange
Many of these alternate routes also
pose increased risk of injury to major
surrounding structures due to difficult
and deep placement.
What structures form the
common femoral vein?
Deep femoral and superficial femoral
vein
Where should the
common femoral vein be
accessed?
Proximal to the saphenofemoral
junction, over the femoral head
(continued)
24 Central Venous Access
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224
Where is the common
femoral artery in relation
to the CFV?
Lateral and superficial
How is the IVC accessed
via a translumbar
approach?
Posterior approach in a prone patient,
to the right of the spine (same side as
the IVC/away from the aorta) with a
low entry (often through the inferior
endplate of L3; A balloon or wire
may be inserted into the IVC as a
target.)
What anatomic obstacles
and issues may be present
with translumbar IVC
access?
Presence of an abdominal aortic
aneurysm
Anomalous left IVC
Right renal artery, which often is
posterior to the IVC at the level of
L2
Relevant Materials
In general, what is the
ideal catheter to use?
The smallest bore (lowest risk of
venous stenosis), least lumen (lower
risk of occlusion as lumens often
get smaller in diameter as more are
added), and most temporary device
possible for the needed indication is
the best
What materials come in a
standard micropuncture
kit used to initiate
most venous access
procedures?
21-gauge micropuncture needle
0.018-in. guidewire
Micro-introducer dilator
What type of catheter
tips exist?
Open tip (end hole)
Groshong tip (side hole)
Staggered tip
G. Gadodia
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What are examples of
common tunneled central
venous catheters?
Small bore:
Hohn
Broviac (mostly used for pediatric
patients)
Large bore:
Hickman:
Single lumen: TPN, ionotropic
medications, blood products and
draws
Triple lumen/Trifusion: Stem cell
transplant
Leonard
What are examples of
common temporary
non-tunneled dialysis
catheters?
Quinton: Two lumens with staggered
tips
Trialysis: Three lumens (two for HD,
one power injectable lumen) with
staggered tips
What types of tunneled
dialysis catheters exist?
Shape:
Pre-curved
Straight
Side hole design:
Staggered tips are more common:
Help to avoid recirculation, but
may be prothrombotic
Multiple brands
At least two lumens
Large outer diameter: up to 15.5–16
Fr
Length measured “tip-to-cuff”: 15, 17,
19, 23, or 28cm
Flow rate > 400mL/min
Coating:
Antibiotic-impregnated catheters
(minocycline, rifampin)
Significantly reduced infection
Chlorohexidine and silver
impregnated
Slight reduction in infection
Which patients may
antibiotic-impregnated
catheters indicated for?
ICU patients
(continued)
24 Central Venous Access
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What are the
specifications of most
port catheters?
Usually single lumen, can be double
lumen
Open or Groshong tip
6.6–9 Fr
What does it mean for
a catheter to be “power
injectable” and why is
this important?
Allows for flow of 5cc/s (pressures up
to 600psi)
Can be used for contrast injection
for imaging studies
What kinds of catheters
have Dacron retention
cuffs?
Tunneled central venous catheters,
including for dialysis
Not non-tunneled catheters or ports
What are the advantages
of valved PICCs and
ports?
Lower incidences of infection
What valve placement
(proximal or distal)
is associated with the
lowest incidence of
infection and occlusive
complications?
Proximal
General Step by Step
Are pre-procedural
prophylactic antibiotics
generally recommended for
placement of tunneled or
temporary lines?
No
When are pre-procedural
antibiotics indicated?
Line exchanges, especially if done
for bacteremia
Port placements
What kind of anesthesia
or sedation is generally
recommended for each
type of procedure?
Local anesthesia only:
PICCs and midlines
Non-tunneled CVCs
Moderate sedation and local
anesthetic:
Tunneled CVCs
Port catheters
G. Gadodia
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227
How long should
common anticoagulation
medications be held
prior to CVC placement,
especially for tunneled
catheters or ports?
Clopidogrel (Plavix): 5days
Aspirin 81mg: No need to hold
Heparin drip (gtt): 2hours
Lovenox:
Prophylactic (daily): 12hours
Therapeutic (BID): 24hours
Apixaban (Eliquis): 48hours
Rivaroxaban (Xarelto): 24hours
What should be done prior
to patient positioning to
confirm site selection?
Physical exam of the site for
cellulitis, other devices, or other
issues
Ultrasound the site to ensure vessel
patency and favorable anatomy
What is ideal patient
positioning for attempted
IJ and subclavian access?
Supine and slightly Trendelenburg
(head down) or legs up
Helps increase central venous
pressure, distending veins
and lowering risk of some
complications
Head turned to contralateral side.
Use of a roll or pillow under the
ipsilateral shoulder can help expose
the area.
How can venous access be
confirmed?
Fluoroscopically: The wire should
pass below the diaphragm.
Ideal, most reliable method
Ultrasound: Longitudinal views
to ensure placement within the
compressible venous system
May be inaccurate in patients
with aberrant anatomy
Pressure manometry
May be inaccurate in certain
patient positions or in a patient
with low pressures (such as in
shock)
What can make venotomy
dilation easier?
Small dermotomy
(continued)
24 Central Venous Access
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228
For tunneled lines and
ports, what is the ideal site
for the catheter to exit/port
pocket?
Approximately 2–3 fingerbreadths
(3–6cm) inferolateral to the clavicle
What is the “over-the-
wire” method to measure
appropriate catheter
length?
Place initial guidewire tip in the
desired location via fluoroscopy.
Clip the wire at the level where it
emerges from the sheath.
Remove the initial wire with clip
in place, ensuring no air embolus
can enter the sheath (using a cap or
syringe, thumb, or the new wire).
Measure from the clip to the end of
the removed guidewire, taking into
account the amount that was within
the sheath outside of the vein,
and distance to tunnel exit site as
appropriate.
Select the catheter of the closest
length or trim the catheter to this
length, as appropriate.
For tunneled catheters,
how far into the tunnel
should the cuff be placed?
At least 1cm
After tunneling the
catheter, what are methods
to prevent significant
bleeding or air emboli
while inserting it into the
venotomy sheath?
Use of a peel-away sheath catheter
with a valve.
If there is no valve:
Keep finger on the top of the
remaining peel-away sheath while
quickly removing the inner dilator
and guidewire.
Pinch the sheath while inserting
the catheter, and have the patient
hum to avoid deep inspiration.
G. Gadodia
https://t.me/med1917
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