|Year : 2017 | Volume
| Issue : 3 | Page : 66-70
Central venous catheterization: An updated review of historical aspects, indications, techniques, and complications
Rafael Cardoso Pires1, Noslen Rodrigues1, Jonathan Machado1, Ricardo Pedrini Cruz2
1 Department of General Surgery, Hospital Nossa Senhora da Conceição de Porto Alegre, Porto Alegre, Brazil
2 Department of Oncogynecologyc Surgery, Hospital Nossa Senhora da Conceição de Porto Alegre, Porto Alegre, Brazil
|Date of Submission||13-Apr-2017|
|Date of Acceptance||15-Jul-2017|
|Date of Web Publication||15-Sep-2017|
Ricardo Pedrini Cruz
Department of Oncogynecologyc Surgery, Hospital Nossa Senhora da Conceicao de Porto Alegre, Avenida Francisco Trein, 596, Porto Alegre 91350-200, RS
Source of Support: None, Conflict of Interest: None
Central venous catheterization has become an indispensable procedure in various situations in the intensive care unit, emergency room and operation room. There are many applications such as invasive hemodynamic monitoring, parenteral nutrition support, dialysis, chemotherapy, fluid resuscitation and drug administration, though there are some complications associated with catheter placement. There are some articles that discuss the security and advantages of the anatomic landmark technique and ultrasound (US) guidance technique. In this non-systematic review article we searched the current data in Pubmed library.
Keywords: Central access, central venous access complications, central venous access techniques, central venous catheter, venous catheter
|How to cite this article:|
Pires RC, Rodrigues N, Machado J, Cruz RP. Central venous catheterization: An updated review of historical aspects, indications, techniques, and complications. Transl Surg 2017;2:66-70
|How to cite this URL:|
Pires RC, Rodrigues N, Machado J, Cruz RP. Central venous catheterization: An updated review of historical aspects, indications, techniques, and complications. Transl Surg [serial online] 2017 [cited 2019 Nov 17];2:66-70. Available from: http://www.translsurg.com/text.asp?2017/2/3/66/214805
| Introduction|| |
Werner Forssmann, in 1929, was the first physician to introduce venous devices for central vein catheterization. The applications and techniques have been improved progressively since then. Dr. Sven-Ivar Seldinger introduced the central venous puncture technique known as “Seldinger technique” in the 1950s, and nowadays, it is the main method in use. The use of central venous catheters (CVCs) became a routine procedure in the emergency rooms, Intensive Care Units (ICUs), and operation rooms, despite the evolution of central venous access techniques and the CVCs. A thorough knowledge of anatomy is required by the physician to reduce complications.
| Literature Search Strategy|| |
The mesh terms “central venous access,” “central venous access” and “complications,” “central venous access” and “ultrasound” (US) and “central venous access” and “landmark techniques” were searched in PubMed library. Original, meta-analysis and review articles were included without considering the publication date. The total number of articles appeared was 1,664, details of which are summarized in [Table 1]. Other articles were found by searching the references of the selected articles. After analyzing the titles and abstracts, 38 articles were selected to be read in full.
| Results|| |
The most common indications of the central venous line include invasive hemodynamic monitoring (central venous pressure, pulmonary artery pressure), parenteral nutrition support, dialysis, chemotherapy, temporary pacemaker, venous line for caustic solutions, venous line for rapid fluid resuscitation, and inadequate peripheral veins. Contraindications include infection of the puncture site and blood dyscrasia, and relative contraindication includes anatomic variations. Subclavian, internal jugular, and femoral veins are the main sites for central venous access puncture. The techniques of which are described below.
- The position of the patient is the principal step in central venous catheterization. In general, to access subclavian, jugular or femoral veins, supine position is recommended
- Antisepsis and careful aseptic protection with sterile fields are mandatory.
Internal jugular vein
Trendelenburg position, contralateral rotation of the neck and extension of the ipsilateral arm is advised for jugular catheterization.,, The internal jugular vein is found anterolaterally to the internal carotid artery. The distal half is located in the triangle formed by the clavicular and sternal heads of sternocleidomastoid muscle, and the upper border of the clavicle [Figure 1]. The jugular veins drain to the subclavian vein in the proximal third of the clavicle.
Anatomical landmarks are important to internal jugular vein catheterization. The apex of the jugular triangle is the puncture landmark point. Internal vein catheterization is achieved using the ipsilateral nipple to guide the needle. Maintaining negative pressure on the syringe, the needle is inserted about 2–3 cm deep into the skin. It is important to alleviate the skin pressure and recede the needle to avoid vein from collapsing. After confirmation of venous reflux, the passage of the guidewire is performed. Skin dilation must be performed by the appropriate cannula, inserting not more than 1–2 cm through the skin.
Unfortunately, in some patients, the anatomical landmarks are difficult to identify, as in obese patients. A tip to internal vein cannulation in such patients is to prepare the patient as previously describe, and imagine a line between ipsilateral mastoid and sternal furcula. Then, this line must be divided into three regions; superior, middle, and inferior. The needle must be inserted in the junction of middle and inferior regions, with the same needle guidance.
Trendelenburg position, contralateral rotation of the neck and extension of the ipsilateral arm are advised for subclavian catheterization. Some physicians use a cushion placed between shoulder blades to facilitate the access to the subclavian vein, though it reduces the cross-sectional area of the vein hindering the needle insertion. The subclavian vein originates from the axillary vein, extends from the side edge of the first rib to the sternal end of the clavicle, joining the internal jugular vein to form the brachiocephalic vein.
The preferred anatomical landmark for subclavian vein catheterization is 1 cm caudal to the junction of the medial and middle thirds of the clavicle, directing the needle to sternal furcula. A tip to subclavian vein catheterization is to identify the triangle formed by applying a gentle digital pressure on the inferior border of the clavicule [Figure 2]. The puncture site (the apex of this triangle) and the patient position are illustrated in [Figure 3]. The needle and syringe should be parallel to the bed. Vein is accessed when the venous reflux is achieved by maintaining a negative pressure on the syringe. After the introduction of the guidewire, the skin dilation is performed with the appropriate cannula dilator to enable catheter insertion as previously described.
Little abduction, external rotation of the ipsilateral leg and inverse trendelenburg position is advised for femoral vein catheterization. The femoral vein is the most medial structure of the femoral canal. It starts at the hunter canal, formed by the popliteal vein, and receives various tributary muscle veins; the deep femoral vein and great saphenous vein. It ends at the bottom of the inguinal ligament, becoming the external iliac vein.
The femoral artery pulse serves as a landmark to femoral vein identification, being just medial to it. After identifying the femoral pulse below the inguinal ligament, the needle is inserted about 0.5 cm medially to it and directed cranially in a 45° angle. Maintain negative pressure on the syringe until the venous reflux is achieved. Complete the procedure with guidewire passage, skin dilatation, and catheter introduction.
Ultrasound guidance technique
Internal jugular vein
An assistant may be necessary to handle the probe (preferably a 7.5–9 MHz vascular transducer). Using sterile cover for the probe, the major vessels can be identified as two circles when the probe is used in a transverse position in relation to the neck [Figure 4]. The artery appears as a pulsatile hypoechoic circle, and the jugular vein can be safely differentiated when external pressure is applied, being collapsed [Figure 5]. The syringe is advanced (maintaining negative pressure until venous reflux is achieved) under ultrasound guidance.,
The probe must be positioned inferiorly to the inguinal ligament. The femoral vein is identified medially to the femoral artery. Valsalva maneuver can be used to enlarge the vein diameter and the vein can be collapsed applying external pressure. After the syringe is advanced (maintaining negative pressure until venous reflux is achieved) under ultrasound guidance.,
The static technique is advised for subclavian vein instead of dynamic US guidance technique due to the clavicular acoustic shadow.
Complications of CVC can be classified into three categories: mechanical (hematoma, arterial puncture, pneumothorax, hemothorax, catheter misplacement, and stenosis), infectious (insertion site infection, CVC colonization, and bloodstream infection) and thrombotic (deep vein thrombosis). These three categories occur in 5%–19%, 5%–26% and 2%–26% of patients, respectively., Complications vary according to insertion route [Table 2], technique used number of attempts and personal experience.
|Table 2: Complications of central venous catheterization using anatomical landmark technique|
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In a prospective study conducted in the ICU with 707 patients submitted to subclavian placement of CVC, arterial punctures were reported in 7.8% of patients, while pneumothorax and misplacements of the catheter tip were 3.1% and 4.2%, respectively. A systematic review including 17 prospective trials that compared jugular and subclavian access concluded that arterial puncture is more common in jugular access, while misplacement of the catheter tip was less common in the jugular CVC. This study did not find differences in pneumothorax and hemothorax incidences between puncture sites.
The femoral access technique is associated with a higher risk of catheter-related thrombosis., A randomized controlled trial involving 289 ICU patients, compared femoral and subclavian catheterizations and evidenced 21.5% of catheter-related thrombosis in the femoral venous line, whereas only 1.9% in the subclavian venous line (P < 0.001). A systematic review compared the use of heparin and 0.9% sodium chloride flushing to prevent catheter thrombosis and showed no statistically significant difference.
Infection of CVC leads to increased morbidity and costs in health-care systems. According to Graham et al., infection with subclavian, jugular and femoral approach is associated to 4, 8.6, and 15.3/1,000 catheter-days, respectively. Femoral access has been shown to be associated with an increased risk of infection,,, but some authors suggest that there is no difference among the three puncture sites when the strict sterile technique is followed., Many types of dressing (gauze, transparent material, frequency of change) and care systems are described,, although the optimal type cannot be recommended due to the lack of evidence. The use of medication-impregnated dressing (chlorhexidine gluconate and silver-alginate) reduces catheter colonization and catheter-related bloodstream infection, however, further research is necessary to assess the impact of these measures in CVC infectious complications.,,
Surgical experience is inversely proportional to the number of attempts of vein catheterization. Some authors have shown that more than two attempts for central vein catheterization are associated with higher complication rates. Other authors demonstrated 50% reduction in the risk of mechanical complications after fifty or more catheterizations performed.
The use of the US to guide central vein catheterization has become popular among physicians. A systematic review showed that US is associated with lower complication rates, higher success rates and lesser attempts. A meta-analysis conducted by Hind et al., showed that the use of US for jugular vein catheterization is associated with lower failure rate (hazard ratio [HR] 0.14, 95% confidence interval [CI] 0.06–0.33) and success on the first attempt (HR 0.59, 95% CI 0.39–0.88). The landmark technique was shown to be more successful for subclavian vein catheterization than the US-guided approach (1.48, 95% CI 1.03–2.14). A prospective randomized trial comparing the US guidance and the landmark technique for internal jugular vein catheterization evidenced success rates of 93.9% and 78.5% (P = 0.009, 95% CI 3.8%–27.0%), and complications rates of 4.6% and 16.9%, respectively (95% CI 1.9%–22.8%). Although they demonstrated a tendency of lower complication rates in the US technique, no significant difference was found.
Keenan et al. conducted a systematic review with 18 trials and found that US guidance reduced the number of attempts (risk reduction, 1.41, 95% CI, 1.15–1.67) and arterial puncture rates (risk difference, −0.07, 95% CI, −0.10–−0.03). Some studies have shown a reduction in the procedural time required for US-guided central venous catheterization.,,, However, these studies did not evaluate the time necessary to prepare the equipment.
| Conclusion|| |
Central vein catheterization is an important invasive procedure often performed to administer the medication, hemodynamic monitorization, and total parenteral nutrition. It can be associated with significant mechanical complication rates, which can be reduced by considering appropriate indications, knowledge of anatomical landmarks and personal experience in central venous catheterization. Complications vary according to the puncture site chosen. The subclavian route is associated with highest rates of mechanical complication, while femoral route with thrombotic complication.
US guidance for CVC is becoming more popular in the medical practice because of its advantages, such as lower complication rates and higher rate of successful attempts, safety in patients with disorders of hemostasis and the possibility of not performing routine chest radiography after the procedure., Even with the US popularization, the anatomic landmark technique can be safely taught in teaching hospitals, with acceptable complication rates.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]