CENTRAL VEIN /ARTERY CANNULATION

 

INTERNAL  JUGULAR  VEIN:

 

Anterior approach:

 

  1. Place patient in  Trendelenburg position. Turn  patient's head to the contralateral side.
     
  2. Prep with iodine solution (Betadine). Inject 1% lidocaine subcutaneously to numb the area.
     
  3. The catheter is placed  at the apex of the two bellies of SCM, at the level of  the cricoid cartilage. Direct finder needle  towards ipsilateral nipple. Vein should  be cannulated within  2cm of skin. Insert 18 gauge needle over finder needle .  Once vein is accessed, remove finder needle.
     
  4. Thread the guidewire. Remove needle.  With a #11 scalpel,  enlarge incision.
     
  5. Enlarge tract with dilator. Now place the central line. The wire  will exit via middle (distal) port. Line is advanced 15cm when placed on R side and 17 cm when placed on  L side.
     
  6. Access all ports. Secure to skin. Attach lines.
     
  7. Obtain CXR.

 

Posterior approach:

 

    1. Place pt in Trendelenburg and move to step #2 above.
       
    2. The needle is placed at posterior border of the SCM about 2-3 fingers above its insertion at the clavicle,  or at  the junction of the EJV and SCM.
       
    3. Direct needle to suprasternal notch. Vein should be cannulated within 5cm.
       
    4. Other steps are as above in steps 4 - 7
       
    5. Advance catheter to 10 cm mark when placed on the R and 13 cm when placed on the L.

       

SUBCLAVIAN  VEIN

 

  1. The subclavian vein is located at  the angle formed by the middle third of the clavicle and 1st rib.
     
  2. Place  rolled  towel (or 1L IV bag) between the patient's scapulae.
     
  3. Apply traction to ipsilateral arm.
     
  4. Sterile prep and drape anterior chest.
     
  5. Infiltrate 1% Lidocaine. With 16 gauge catheter-over-needle at  the site described above, direct  needle towards the clavicle until the bone is felt.
     
  6. Slowly probe down with the needle until it slips below the clavicle
     
  7. Direct needle towards sternal notch.
     
  8. Advance until flow of venous blood is seen. Remove syringe.  If flow is absent, slowly angle needle more cephalad and re-attempt puncture.
     
  9. Follow steps 4-7 as described for IJ cannulation above. Line is advanced to the 15 cm marker if inserted on  the R and 17-18 cm if  L subclavian is used.

 

    **Complications: Tension pneumothorax, chylothorax (with  L subclavian cannulation), phrenic nerve injury (when R or L subclavian is used).  Brachial plexus injuries have also been reported when close attention to landmarks has been avoided.

 

FEMORAL  VEIN

 

  1. The vein is located 1cm ( 1 finger  width ) medial to femoral artery.
     
  2. Another landmark in case of a poor pulse exam is to use the imaginary line  between the pubic tubercle and the anterior iliac crest. The vein is between these two.
     
  3. Apply iodine solution (Betadine). Inject local anesthetic.
     
  4. Advance needle with syringe until venous blood return is appreciated. Remove syringe.
     
  5. Follow steps 4 - 7 as described for IJ (above).
     
  6. Advance line to catheter hub.

 

ARTERIAL  LINE:

Radial Artery:

 

  1. Prepare Angiocath, A-line setup kit, tubes, pressure bag, armboard, Lidocaine.
     
  2. Prep with iodine solution.
     
  3. Perform Allen's Test.
     
  4. Hyperextend the wrist on roll of gauze.
     
  5. Cannulate with 20 gauge angiocath over distal artery. When arterial blood return is seen ( you will see pulsating  blood ), advance the catheter.
     
  6. Remove the wire. Attach tubing and secure.

 

Femoral Artery:

 

  1. Prepare assembly as above
     
  2. Use landmarks as in FV (above).  Pulse should be palpable.
     
  3. Prep and drape with sterile technique.
     
  4. Cannulate artery with 20 gauge needle as above. 
     
  5. Once pulsatile return is appreciated, insert wire as per Seldinger technique.
     
  6. Pass dilator per subcutaneous tissues only.
     
  7. Thread long catheter into artery to its hub.
     
  8. Remove wire, attaching tubing, and secure to skin as above.

 

    **Other arterial cannulation sites to consider:  Axillary artery, Dorsalis pedis (although this is not commonly performed in ED setting).

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