see also: [[MAC line]], [[Invasive devices CXR]] see: [Robert Hedges - Central venous catheterization](x-devonthink-item://31ACDC98-D2CC-48C5-BE69-E9B37E53FA8C?page=491), [Deranged physiology - Central Venous access insertion](https://derangedphysiology.com/main/required-reading/intensive-care-procedures/Chapter-211/central-venous-access-device-insertion), [Oh's - CVC](x-devonthink-item://49C9C33E-BFC4-4CAE-99BB-110FA7246880?page=169), [Marino's - Central Venous Access](x-devonthink-item://82A334A0-2166-466B-B59F-64C76CCF073F?page=34), [ETM - large bore vascular access devices](https://etmcourse.com/large-bore-vascular-access-devices/) #incomplete ## Overview of non-CVC catheter options > Poiseuilles formula: > **Flow** = (π × pressure gradient × radius4) / ( 8 × viscosity × length of tubing) > > ∴ , for every doubling of the radius, flow rate ↑ by the fourth power (16x) ! There are some misconceptions about the actual flow rate of different catheters. See this table from [Marino's chapter 1](x-devonthink-item://82A334A0-2166-466B-B59F-64C76CCF073F?page=19) about the relative size and flow rate of different catheters: ![[Pasted image 20250206002615.png]] And this comparison of peripheral cannula sizes and flow rates (by mL/min) ![[Pasted image 20250206003018.png]] Other options: - **RIC line** (rapid infusion catheter) - 7 Fr (internal diameter) x 2 inch (5.08cm) or 8.5 Fr (internal diameter) x 2.5 inch (6.35cm) - likely **fastest flow rates** of any peripheral access device - can convert a 20g cannula to a RIC - prob too short to use in deep veins - **[[MAC line]]** (multi-lumen access catheter) - 9Fr large lumen (brown), 12 gauge line, introducer sheath you can put a CVC in - **flow rate** through the 12 gague port ~11 L/h ; 29+ L/h via the 9Fr port - ==are NOT pressure rated for CT contrast== (risk of line fracture) - can place pressure-rated CVC in sheath to give contrast, put through a peripheral line, or in an emergency, through the brown 9 french lumen at discretion of senior emergency doctor - midline catheter - Available in lengths of 15 cm and 20 cm, and can have one to three infusion channels. - The increased length of the midline catheter is correlates with a decrease in flow capacity; the gravity-driven flow rate in each lumen of the midline catheter is only about 20% of the flow rate in the short peripheral catheter. - **flow rate** >1L/hour per lumen - PICC - essentially a longer midline - length ~3x of midline - ∴ , flow rate ~20% of midline - The compromised flow capacity in PICCs may explain the relatively high incidence of occlusions in these catheters ![[Pasted image 20250206003716.png]] ![[Pasted image 20250206003743.png]] 4 lumen central line flow rates (cc=mL): ![[Pasted image 20250206014500.png]] > **takeaway:** > - a large bore, short peripheral cannula is superior to a central line for volume resuscitation ## Indications Overall, indications are diminishing due to alternatives (eg peripheral low-dose vasopressors, midlines) *Textbook answer:* - Central venous pressure monitoring - High-volume/flow resuscitation - Emergency venous access - Inability to obtain peripheral venous access - Repetitive blood sampling - Administering hyperalimentation, caustic agents, or other concentrated fluids - Insertion of transvenous cardiac pacemakers - Hemodialysis or plasmapheresis - Insertion of pulmonary artery catheters ## Contraindications - Infection or burn over the placement site - Distortion of landmarks by trauma or congenital anomalies (eg clavicle fracture and subclavian line) - severe coagulopathies, including anticoagulation and thrombolytic therapy - not absolute contraindication, but generally want INR <3 and platelets > 20k - consider safe compression site for coagulopathic patient needing a central line (eg femoral) - Pathologic conditions, including superior vena cava syndrome - Current venous thrombosis in the target vessel - Prior vessel injury or procedures - Morbid obesity - Uncooperative patients - elevated ICP (IJ) ## Alternatives - midline or PICC ## Complications (structure as procedure complication, post-procedure, equipment, late complication) - Arterial puncture and haematoma - Pneumothorax (subclavian and internal jugular approach) - Haemothorax (subclavian and internal jugular approach) - [[Procedures#procedures and specific anatomical considerations|vessel or nerve injury]] - Air embolism - Cardiac dysrhythmia from wire or catheter itself - Infection / catheter-related sepsis (*CLABSI* audited by the government so major QI target) - Thrombosis - Catheter misplacement **arteries:** - carotid, innominate (brachiocephalic), aorta, femoral, subclavian **Nerves:** - femoral, laryngeal, phrenic **aerodigestive:** - pneumothorax, trachea, oesophagus, bowel **Other:** - hernial contents, thoracic duct | Complication | management | prevention | | ------------------------------ | ------------------------------------------------------------------------------------------ | ----------------------------------------------------------------------------------------------------------------------------------- | | failure of insertion | - appropriate training and credentialing<br>- USS guidance<br>- appropriate site selection | | | air embolism | - position patient left lateral<br>- 100% O2<br>- CPR as needed | - flush catheters with sterile saline prior to procedure<br>- | | cardiac dysrhythmia | - remove catheter or withdraw wire | - continuous cardiac monitoring | | wire fracture, damage, or loss | | - care with insertion<br>- handle wire with hand at all times<br>- confirmation of complete wire removal at completion of procedure | | malposition | - don't use line until position confirmed (eg ABG, CXR) | - appropriate catheter length<br>- confirmation during insertion | | infection | - remove lines <br>- aseptic technique<br>- line surveillance | - remove lines when no longer needed<br>- aseptic technique | | | | | ## Internal Jugular Procedure see [[MAC line#subclavian procedure|Subclavian procedure]] in MAC line article for subclavian approach - Apex of the triangle formed by the clavicle, and the sternal and clavicular heads of SCM - Insert the needle at angle 30-40 degrees to skin - Place Left index finger in sternal notch and thumb at costoclavicular junction - Nb: Ultrasound should be used in all cases where it is available and the needle should be visualised throughout the procedure ### 1. Depth | location | depth | | ---------------- | ---------- | | Right IJ | 15 cm | | Right subclavian | 13 - 14 cm | | left IJ | 17 - 20 cm | | left subclavian | 17 cm | ### 2. surface anatomy ![[F42E4A51-689F-4103-9E96-842145167947.jpeg]] Source: [deranged physiology - CVC](https://derangedphysiology.com/main/required-reading/intensive-care-procedures/Chapter-211/central-venous-access-device-insertion) ![[ED2F8DDA-D0EF-4662-9953-7FC5331E8006.jpeg]] ![[Pasted image 20250223175655.png]] **Anterior approach** ![[Pasted image 20250223174146.png]] Insert needle along the medial edge of the sternocleidomastoid, 2-3 fingerbreadths above the clavicle. Entry angle = 30° to 45°. Aim toward the ipsilateral nipple. Note: palpate the carotid artery during venipuncture. The artery may be slightly retracted medially. **Central approach (classical teaching)** ![[Pasted image 20250223173102.png]] Insert needle at the apex of the triangle formed by the heads of the sternocleidomastoid muscle and the clavicle. Entry angle = 30°. Aim toward the ipsilateral nipple. Note: estimate the course of the IJ vein by placing three fingers lightly over the carotid artery as it runs parallel to the vein. The vein lies just lateral to the artery, albeit often minimally so. ### 3. Secure the line ![[Pasted image 20250223174515.png]] “Roman sandal” securing technique: ![[Pasted image 20250426184028.png]] ### 4. catheter tip position see: [[Invasive devices CXR]] - above the cephalic limit of the pericardial reflection, which is - at a ==level corresponding to the carina on a chest radiograph== ![[Pasted image 20250223175317.png]] ![[Pasted image 20250223175924.png]]