Central Venous Access

APPENDIX APPENDIX: I TITLE: CENTRAL VENOUS ACCESS PROCEDURES REVISED: 15 April 2006

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I. BACKGROUND Placement of central intravenous lines allows for rapid access to the central circulation.

II. INDICATIONS: 1. Rapid fluid replacement for traumatic exsanguination 2. To gain venous access in the presence of symptomatic hypotension and venous collapse

III. CONTRAINDICATIONS: None IV. COMPLICATIONS: 1. Hemotoma with airway compromise 2. Inadvertent extravenous placement causing: • pneumothorax • hemothorax • hydrothorax • hydromediastinum 3. Major vessel laceration of the: • femoral artery • subclavian artery • carotid artery 4. Air embolus 5. Sepsis

V. PROCEDURE: Physician Comments: The medical director preference is that the femoral site be considered before the internal jugular, and the internal jugular site before the subclavian.

CENTRAL VENOUS ACCESS

CENTRAL LINE PLACEMENT SHALL ONLY BE ATTEMPTED WHEN PERIPHERAL VENOUS ACCESS IS NOT POSSIBLE, OR WHEN THE ANTICIPATED DELAY IN ESTABLISHING A PERIPHERAL ROUTE MAY RESULT IN INCREASED MORTALITY OR MORBIDITY.

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I Femoral approach Special Considerations: Medications given via the femoral route in second and third trimester may not be distributed effectively. Consider other sites.

CENTRAL VENOUS ACCESS

Procedure 1. Prepare equipment in advance. 2. Identify the anatomical landmarks • Locate the femoral arterial pulse 1 cm caudad of the inguinal fold. The puncture site for femoral vein catheterization is just MEDIAL and parallel to the artery. 3. Using aseptic technique, prepare the insertion site. 4. Palpate the femoral pulse. Using a long 14 or 16-gauge over-theneedle catheter with an attached 10-12 cc syringe, insert the needle and advance cranially at a 450 angle to the skin, parallel to the arterial pulse. Continually aspirate the syringe during insertion. 5. Upon free aspiration of blood, advance the catheter over the needle. 6. Attach the infusion set to the catheter, observe for free flow of solution and blood return when the infusion set is lowered below the level of the patient’s heart. 7. Secure the catheter and place an occlusive dressing over the insertion site.

Internal Jugular approach Special Considerations Care should be taken when accessing the internal jugular vein because of the proximity of adjacent structures. Procedure 1. Prepare equipment in advance. 2. Place the patient in the Trendelenburg position with the face rotated away from the side of insertion. 3. Identify the anatomical landmarks: • Locate the triangle formed by the sternal and clavicular head of the sternocleidomastoid muscle. 4. Using aseptic technique, prepare the insertion site. 5. Using a long 14 or 16-gauge over-the-needle catheter with an attached 10-12 cc syringe, insert the needle into the apex of the triangle formed by the three heads of the sternocleidomastoid muscle. Direct the needle on a 45-60 degree angle, laterally toward the ipsilateral nipple. Continually aspirate the syringe during insertion. 6. Upon free aspiration of blood, advance the catheter over the needle. 7. Remove the stylet on exhalation and immediately occlude the catheter with a gloved finger to reduce the risk of air embolism.

APPENDIX 8. Attach the infusion set to the catheter during exhalation, observe for free flow of solution and blood return when the infusion set is lowered below the level of the patient’s heart. 9. Confirm equal breath sounds and observe for respiratory difficulty. 10. Secure the catheter and place an occlusive dressing over the insertion site. 11. Secure site well.

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1. Prepare equipment in advance. 2. Place the patient in the Trendelenburg position with the face rotated away from the side of insertion. 3. Identify the anatomical landmarks, specifically the clavicle and the suprasternal notch. 4. Using aseptic technique, prepare the insertion site. 5. Establish a point of reference by placing a fingertip into the suprasternal notch to locate the deep side of the superior aspect of the clavicle. 6. Using a long 14 or 16-gauge over-the-needle catheter with an attached 10-12 cc syringe, introduce the needle approximately 1 cm below the junction of the middle and medial thirds of the clavicle. 7. Apply negative pressure to the syringe and direct the insertion medially and slightly cephalad toward the posterior and superior aspect of the sternal end of the clavicle, aiming slightly behind the fingertip in the suprasternal notch. 8. Upon free aspiration of blood, advance the catheter over the needle. 9. Remove the stylet and immediately occlude the catheter with a gloved finger to reduce the risk of air embolism. 10. Attach the infusion set to the catheter during exhalation, observe for free flow of solution and blood return when the infusion set is dropped below the level of the patient’s heart. 11. Confirm equal breath sounds and observe for respiratory difficulty. Secure the catheter and infusion device and place an occlusive dressing over the insertion site.

Central Venous Access Device (CVAD) Special Considerations Arterial bleeding will result if the needle is dislodged from a dialysis graft or fistula. Dialysis fistulas and grafts (located under skin of arm) may have high back pressure and require positive pressure to infuse. When attempting to insert a needle into a dialysis fistula, avoid the scar line or any lumpy areas in the graft or fistula. Follow the track marks that are present from previous use of the site for dialysis. When in doubt, aspirate first PRIOR TO FLUSHING the line. The heparin in some catheters is an extremely high concentration that will be harmful if it enters central circulation.

CENTRAL VENOUS ACCESS

Subclavian approach

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CENTRAL VENOUS ACCESS

Devices Indwelling Catheter(s) - Venous access devices whose ports are Luerlocked or capped. Tip of the catheter is located in large vein or superior vena cava. Available brands include Hickman, PICC Line, and Midline. Implanted Ports - Single or double (oval) reservoir located under skin on chest or forearm. To access, one must insert a needle through skin into the rubber septum. The catheter tip is located in large vein or superior vena cava. Available brands include Port-a-Cath. These typically require a special needle to access (with a 90 degree bend, called a “Huber” method), although in an emergency a straight needle, such as that used to give an IM injection, may be used. Simply limit the depth of needle inserted. Aphoresis or Hemodialysis Accesses • Indwelling Catheters - Large bore, short length double or triple catheters . “Arterial” and “venous” lumens are actually side by side in subclavian, internal jugular, or femoral vein. Available brands include Quinton and Perma Cath. CAUTION: These devices contain very high concentrations of heparin. It must be aspirated and discarded prior to use. • Gortex Graft or AV Fistula - Natural or plastic connection between vein and artery usually located under skin on arm. The examiner may feel a “thrill” or auscultate a bruit. These sites have high back pressure due to arterialization of vessel. Procedure for accessing CVAD 1. Prepare equipment in advance. 2. Identify if CVAD is accessible by standard prehospital equipment. (Implanted ports, AV fistulas, and grafts should be accessed by special, non-coring [Huber-type] needles.) 3. Identify shut-off, clamps, caps, heparin/saline lock, etc., and clamp line if disconnecting or opening. 4. Access the device after cleansing with betadine prep. 5. Aspirate with 10-20 cc syringe until blood returns, but site may be functional without return. Only use venous access devices that have a blood return unless the patient or family can verify that the device is functional despite the lack of blood return. 6. Discard aspirated fluid. 7. Flush lumen or port with 10 cc saline, avoiding excessive pressure. 8. Establish IV connection, avoiding air entry. 9. Secure connections with Luer lock or tape.

APPENDIX 1. “Intravenous Techniques”, Textbook of Advanced Cardiac Life Support, American Heart Association, 1994. 2. “Central Line Placement”, Policy and Procedure. St. Alphonsus Life Flight, Boise, Idaho. St. Alphonsus Regional Medical Center, 1987. 3. Niemeyer, Cheryl, “Written C.E.: Central Lines, PICC lines, and Dialysis Fistulas”, Internal Educational Document, Ada County Paramedics, Boise, Idaho, 2004

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VI. REFERENCES:

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