In this modern era of USG, you will hardly attempt Central lines blindly. So when your USG machine breaks down, how will you resuscitate the patient? Know your basics about Central venous catheterization.

1. Central Venous Catheterization
(without USG)
Runal Shah
3rd year MEM
Kokilaben Dhirubhai Ambani Hospital.

2. Objectives
• Indications
• Contraindications
• Anatomy
• Complications
• Videos

3. Central Venous Catheterization
• Indications
1) CVP monitoring
2) High-volume/flow resuscitation
3) Emergency venous access
4) Inability to obtain peripheral venous access
5) Repetitive blood sampling
6) Administering hyperalimentation, caustic agents, or other
concentrated fluids
7) Insertion of transvenous pacemakers
8) Hemodialysis or plasmapheresis
9) Insertion of PA cath

4. Central Venous Catheterization
• Contra-indications
1) Infection over the placement site
2) Distortion of landmarks by trauma or congenital anomalies
3) Coagulopathies, including anticoagulation and thrombolytic
therapy
4) Pathologic conditions, including superior vena cava
syndrome
5) Current venous thrombosis in the target vessel
6) Prior vessel injury or procedures
7) Morbid obesity
8) Uncooperative patients

5. Anatomy

7. Internal Jugular Vein cannulation
Pros:
• Good external landmarks
• Improved success with USG
• Less risk for pneumothorax
than with SV access
• Can recognize and control
bleeding
• Malposition of the catheter is
rare
• Almost a straight course to
the SVC on the right side
• Carotid artery easily
identified
Cons:
• More difficult and
inconvenient to secure
• Possibly higher infectious
risk than with SV access
• Possibly higher risk for
thrombosis than with SV
access

8. Right IJV cannulation

9. Right IJV cannulation

10. Right IJV cannulation

11. Anatomy

12. Subclavian venous cannulation
• Pros:
– Good external
landmarks
• Cons:
– “Blind” procedure
– Unable to compress
bleeding vessels

13. Anatomy

14. Femoral Venous Cannulation
• Pros:
– Good external landmarks
– Useful alternative with
coagulopathy
• Cons:
– Difficult to secure in
ambulatory patients
– Not reliable for CVP
measurement
– Highest risk for infection
– Higher risk for thrombus

15. Complications

16. Complications

17. Caveats & Helpful hints
• If there is a concern about possibility of bleeding – avoid
Subclavian approach, as direct compression is difficult and
surgical exploration is required.
• If anticipating Transvenous Pacemaker or PA catheter insertion,
use either Right IJV or Left Subclavian approach, as this aligns
catheter trajectory with SVC and RA.
• The catheter tip should be positioned in the SVC and not the
right atrium. In most adults, the right atrium is 10–15 cm from
the subclavian vein. Be sure that the catheter is not inserted
deeper than this.

18. Caveats & Helpful hints
• If pneumothorax occurs and central access remains a priority,
subsequent attempts should be made on the same side of the
thorax as the pneumothorax to prevent the development of
bilateral pneumothorax.
• If the pulse cannot be palpated (e.g., cardiac arrest), divide the
distance from the anterior superior iliac spine to the symphysis
pubis into thirds. The artery typically lies at the junction of the
medial and the middle thirds and the vein is 1 cm medial to this
location.
• Excessive contralateral head rotation increases overlap of the
carotid by the internal jugular and may increase the risk for
arterial injury.

19. Reference:
Roberts and Hedges’ Clinical Procedures
in Emergency Medicine Expert Consult –
5th & 6th Edition