1. CENTRAL
VENOUS LINES
AND THEIR
PROBLEMS
By
Sunil Agrawal
1st
yr Resident
Pediatrics, IOM

2. CONTENT
 Introduction
 Indications and Contraindications
 Access to Different Great Vessels
 Complications
 Summary
 References

3. INTRODUCTION
 Central venous access is defined as placement of
a catheter such that the catheter is inserted into
a venous great vessel.
 The venous great vessels include the superior
vena cava, inferior vena cava, brachiocephalic
veins, internal jugular veins, subclavian veins,
iliac veins, and common femoral veins.
2012, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins.
Anesthesiology 2012; 116:539–73

4. INDICATION FOR USE
 Limited vascular access
 Administration of highly osmotic or caustic fluids
or medications
 Frequent administration of blood and blood
products
 Frequent blood sampling
 Measurement of CVP
 Hemodialysis
 Hemofiltration
 Apheresis

5. CONTRAINDICATIONS
 Distorted Anatomy
 Infection at the Site of Access
 Proximal Vascular Injury
 Bleeding Disorders or Anticoagulation
 Combative Patients

6. CONTENTS OF THE TRIPLE LUMEN CENTRAL
LINE KIT.

7. STERILE TECHNIQUE
 We will not review sterile technique in depth here
 For the physician, sterile technique means wearing a
surgical cap, procedure mask, sterile gown and sterile
gloves.
 Sterile setup for the patient should begin with
adequate skin preparation with a sterilizing solution
(proviodine, chlorhexidine, etc.) in a large area
surrounding your procedure site.
 Place a large sterile sheet on the patient following this
and then isolate the procedural field with four to six
sterile towels.
 This will minimize infective complications of the
procedure.

10. SELDINGER TECHNIQUE
1. Setup of Equipment and Sterile Preparation
2. Landmarking the Access Site
3. Anesthesia
4. Location of the Vein with a Seeker Needle [Optional]
5. Placing the Introducer Needle in the Vein
6. Assessment for Venous or Arterial Placement
7. Insertion of the Guide Wire
8. Removal of the Introducer Needle
9. Skin Incision
10. Insertion of the Dilator
11. Placement of the Catheter
12. Removal of the Guide Wire
13. Flushing and Capping of the Lumens
14. Secure the Catheter

11. ACCESS TO DIFFERENT GREAT
VESSELS
 Internal jugular vein
 Subclavian vein
 Femoral vein
 Umbilical vein

12. INTERNAL JUGULAR VEIN
 The right internal jugular vein (IJV) is the most
common site chosen for central venous access in
pediatric cardiac surgery.
 It is large, and runs in close proximity superficial
to the carotid artery along most of its length.
 The primary advantage of using the IJV is that it
provides a direct route to RA.

13. CATHETERIZATION: INTERNAL
JUGULAR APPROACH

15.  The primary disadvantage comes from difficulty
in cannulation in small infants, who have large
heads and short necks, and thus difficulty in
obtaining the shallow angle of approach
necessary to access the vessel.
 This site is also not comfortable for some awake
infants

16. TECHNIQUE
 Placing a small roll under the shoulders, using
steep Trendelenburg position, and rotating the
head no more than 45◦ to the left.
 Recent studies have demonstrated that liver
compression and simulated Valsalva maneuver
also increase the diameter of the IJV, possibly
increasing the success rate of cannulation.
 An ultrasound technique should be used to
clearly identify the course of the vessel

17. SUBCLAVIAN VEIN
 The subclavian vein is positioned immediately
behind the medial third of the clavicle.
 Advantages of this route include the subclavian
vein’s relatively constant position in all ages in
reference to surface landmarks and the site is
comfortable for awake patient.
 Disadvantages include an incidence of
pneumothorax is high. Also in 5–20% of patient,
subclavian catheters will enter the contralateral
brachiocephalic vein or ipsilateral IJV, instead of
the SVC

18. CATHETERIZATION: SUBCLAVIAN
APPROACH

20. TECHNIQUE
 Small rolled towel is positioned vertically between
the scapulae, steep Trendelenburg position used, and
the arms are restrained in neutral position at the
patient’s sides.
 The right subclavian vein should always be the first
choice.
 Turn the head toward the side being punctured.
 The puncture site that is most successful is 1–2 cm
lateral to the midpoint of the clavicle, directly lateral
from the sternal notch, with the needle directed at
the sternal notch.
 Advancing the needle only during expiration is
recommended to minimize the risk of pneumothorax.

21.  Complications during subclavian catheterization
occur when a needle angle of incidence is too
cephalad, resulting in arterial puncture, or too
posterior, resulting in pneumothorax.
 Advancing the needle too far in infants may
result in puncture of the trachea.

22. FEMORAL VEIN
 The femoral vein has long been used for central
venous catheterization in pediatric patients, with
no greater infection or other complication rate
compared to other sites.

24. TECHNIQUE
 the patient is positioned with a rolled towel
under the hips for moderate extension.
 The puncture site should be 1–2 cm inferior to
the inguinal ligament, and 0.5–1 cm medial to
the femoral artery impulse, with the needle
directed at the umbilicus.

25. UMBILICAL VEIN
 The umbilical vein in the fetus is a conduit to carry
oxygenated and detoxified blood from the placenta, through
the abdominal wall, the liver, and patent ductus venosus to
the inferior vena cava (IVC) and the right atrium (RA).
 This vessel can usually be cannulated at the umbilical
stump for the first 3–5 days of postnatal life.
 Passage into the IVC depends on the patency of the ductus
venosus, which often exists for the first few days.
 Sterile technique without a guidewire is used to pass the
catheter blindly a premeasured distance. If no resistance to
passage is met and free blood return is achieved, the
catheter tip is usually in the high IVC or RA, and functions
as a CVC.

26.  Catheter tip position must be determined by
radiography as soon as possible to determine if it is
through the ductus venosus into the IVC or the RA.
Often the ductus venosus is not patent, and the
catheter tip passes into branches of the hepatic veins,
and is visible in the liver radiographically.
 A UVC can be left in place for as long as 14 days if no
complications are suspected.

28. COMPLICATIONS
1. Acute Procedural
2. Sub-acute Infection
3. Chronic
Infection
Thrombosis

29. COMPLICATIONS:
ACUTE
1. Local Hematoma 4. Pneumothorax,
Hemothorax, Chylothorax
2. Local Cellulitis 5. Malposition
3. Arterial puncture 6. Air embolus

30. AIR EMBOLUS
SYMPTOMS
1. Respiratory distress
2. Increased heart rate
3. Cyanosis
4. Decrease level of consciousness

31. AIR EMBOLUS:
TREATMENT
1. Left lateral decubitus Position
2 100% O2
3. Vasopressin if necessary
4. Chest compression
5. Aspiration through catheter

32. COMPLICATIONS:
CHRONIC
1. Infection
2. Thrombosis

33. TYPES OF INFECTION
1. Cutaneous - pain, erythema, swelling,
+/- exudate
2. Bacteremia - fever, leukocytosis and
positive blood cultures
3. Septic thrombophlebitis - bacteremia,
thrombosis and purulent discharge

34. INFECTION
CAUSATIVE ORGANISMS
Staph epidermaidis 25-50%
Staph aureus 25%
Candida 5-10%

35. INFECTION TREATMENT
1. Septic thrombophlebitis - remove catheter
2. Cutaneous - local treatment
3. Bacteremia -
1. IV antibiotics 48 -72 hours
if improved - keep catheter
if no change, worse or recurs
remove catheter
or
2. Exchange catheter over wire,
85% cure with treatment

36. INFECTION: THE USE OF
ANTIMICROBIAL-IMPREGNATED
CATHETERS
Maki, D. G. et. al. Ann Intern Med 1997;127:257-266

37. INFECTION: THE USE OF
ANTIMICROBIAL-IMPREGNATED
CATHETERS
 Use of these catheters decreases blood stream
infection:
4.6% regular catheter
1.0% antibiotic impregnated catheters
 Chlorhexidine-Silver sulfadiazine and Minocycline-
Rifampin impregnated catheters
 The Use of antibiotic impregnated catheters should
be considered at all circumstances!
 The emergence of resistance is certainly of concern.
N ENGL J MED 348; 12, 2003

38. INFECTION: INSERTION OF
CATHETERS AT THE
SUBCLAVIAN VENOUS SITE
 The risk of catheter-related infection is lower with
subclavian catheterization than with internal jugular
or femoral catheterization

39. INFECTION: AVOIDING THE USE
OF ANTIBIOTIC OINTMENTS
 The Use of ointments such as bacitracin,
mupirocin, neomycin, and polymyxin to catheter
insertion sites show:
 Increase the rate of colonization by fungi
 Promote bacterial resistance
 Has not shown to affect the risk of catheter related
bloodstream infection.
N ENGL J MED 348; 12, 2003

40. INFECTION: ROUTINE
CATHETER CHANGES?
 Scheduled, routine replacement of central
venous catheters at a new site does not
reduce the risk of catheter related infection.
 Scheduled, routine exchange of cathetres
over guide wire is associated with a trend
toward increased catheter related infections
and mechanical complications.
 META analysis of 12-RCTs do not support.
 CVC should not be replaced on a
scheduled basis.
N ENGL J MED 348; 12, 2003

41. INFECTION: REMOVE WHEN NO
LONGER NEEDED.
 The
probability
of
colonizatio
n and
catheter-
related
bloodstrea
m
infection
increases
over time.
Collin, G. R. Chest 1999;115:1632-1640
Antiseptic Impregnated
catheter
NON-Antiseptic
Impregnated catheter

42. THROMBOSIS
 Intermittently used catheters need to be replaced
frequently due to obstruction and/or infection.
 Clot formation is a major source of obstruction

43. THROMBOTIC: INSERTION OF THE
CATHETER AT THE SUBCLAVIAN
SITE
 Subclavian catheterization carries a lower risk of
catheter related thrombosis than femoral or internal
jugular catheterization.
N ENGL J MED 348; 12, 2003

44. KEEPING CENTRAL VENOUS
LINES OPEN
 The use of anti-obstructive flushes such as heparin,
citrate and Vitamin C (Germans), have associated
complications:
 Bleeding,
 Thrombocytopenia-heparin induced
 Arrhythmia (citrate)
Intensive Care Med. 2002; 28:1172-6

45. KEEPING CENTRAL VENOUS LINES OPEN: A
PROSPECTIVE COMPARISON OF HEPARIN,
VIT. C, AND NACL BLOCKS
 Signif. longer patency with
heparin(5000IU/ml)
 Vitamin C ineffective
 Group of 25 low dose
heparin flushes(200IU/ml)
flushes showed catheter
survival closer to saline
group.
 So, high concentration of
heparin flushes
recommended.
Intensive Care Med. 2002; 28:1172-6

46. SUMMARY
 Central venous access is defined as placement of
a catheter such that the catheter is inserted into
a venous great vessel.
 Three sites are commonly used for pediatric CVC
placement: femoral, internal jugular, and
subclavian.
 Should be done under sterile condition to
minimize infection related complication .
 Seldinger Technique is used for insertion of
CVC.

47. SUMMARY.
 Use antimicrobial-impregnated catheters
 Avoid antibiotic ointments
 Do not schedule routine catheter changes
 Remove catheter when no longer needed

48. REFERENCES
 Roger's Textbook of Pediatric Intensive Care, 4th
Edition 2008 Lippincott Williams & Wilkins
 The American Society of Anesthesiologists, Inc.
Lippincott Williams & Wilkins. Anesthesiology
2012; 116:539–73
 Anesthesia for Congenital Heart Disease Edited
by Dean B. Andropoulos, Stephen A. Stayer,
Isobel Russell and Emad B. Mossad © 2010
Blackwell Publishing Ltd. ISBN: 978-1-405-
18634-6
 N Engl J Med 2003;348:1123-33. 2003
Massachusetts Medical Society.

49. Thank You