PROCEDURE Central Venous Catheter Insertion (Perform)

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PROCEDURE

82

Central Venous Catheter Insertion (Perform) Susan Yeager

PURPOSE: Central venous catheters (CVCs) are inserted for measurement of central venous pressure (CVP) with jugular or subclavian catheter placement. Clinically useful information can be obtained about right-ventricular preload, cardiovascular status, and fl uid balance in patients who do not need pulmonary artery pressure monitoring. CVCs also are placed for infusion of vasoactive medications and to provide access for pulmonary artery catheters and transvenous pacemakers.

PREREQUISITE NURSING KNOWLEDGE

• Knowledge of the normal anatomy and physiology of the cardiovascular system is needed.

• Knowledge of the anatomy and physiology of the vascu-lature and adjacent structures of the neck, groin, and chest is needed.

• Knowledge of the principles of sterile technique is essen-tial.

• Clinical and technical competence in central line insertion and suturing is essential.

• Competence in chest radiographic interpretation is neces-sary.

• Advanced cardiac life support (ACLS) knowledge and skills are needed.

• Knowledge of potential complications and associated interventions/consultations for addressing issues is neces-sary.

• Follow guidelines regarding institution credentialing. • Knowledge of ultrasonography technique is needed. • Indications for CVC placement may include the follow-

ing: ❖ Severe blood loss ❖ Hemodynamic instability ❖ Administration of vesicant irritant medications ❖ Administration of total parenteral nutrition ❖ Lack of peripheral venous access ❖ Assessment of hypovolemia or hypervolemia ❖ Monitoring of CVPs ❖ Placement of pulmonary artery catheters or placement

of transvenous pacemakers ❖ Hemodialysis access

• The normal CVP value is 2 to 8 mm Hg. • The CVP waveform is identical to the right-atrial wave-

form.

• Interpretation of right-atrial/CVP waveforms including identifi cation of a, c, and v waves is important. The a wave refl ects right-atrial contraction. The c wave refl ects closure of the tricuspid valve. The v wave refl ects passive fi lling of the right atria during right-ventricular systole.

• The CVP provides information regarding right-heart fi lling pressures and right-ventricular function and volume.

• The CVP is commonly elevated during or after right-ventricular failure, ischemia, or infarction because of decreased compliance of the right ventricle.

• The CVP can be helpful in the determination of hypovo-lemia. The CVP value is low if the patient is hypovolemic. Venodilation also decreases the CVP value.

• Electrocardiographic monitoring is essential in the accu-rate interpretation of the CVP value.

• Some contraindications of CVC insertion include ana-tomical problems, venous obstructions, and coagulopa-thies. The subclavian site should be avoided in hemodialysis patients and patients with advanced kidney disease to avoid subclavian vein stenosis. 5

• It is important to weigh the risks and benefi ts of placing a CVC against the risk for mechanical complications (e.g., pneumothorax, vein laceration, thrombosis, air embolism, misplacement). 5,6

• A subclavian site is recommended rather than a jugular or femoral site to minimize the risk of infection. 5

• The internal jugular site is recommended to minimize catheter cannulation-related risk of injury or trauma. 6

• Ultrasound guidance is recommended to place CVCs if the technology is available to reduce the number of can-nulation attempts and mechanical complications. 4,5,7

• Regardless of the site selected, complications may occur during or after insertion of a central venous catheter ( Table 82-1 ).

EQUIPMENT

• CVC insertion kit • CVC of choice (single, dual, or triple lumen) usually

supplied with insertion needle, dilator, syringe, and guidewire.

• Full sterile drapes

This procedure should be performed only by physicians, advanced practice nurses, and other healthcare professionals (including critical care nurses) with additional knowledge, skills, and demonstrated competence per professional licensure or institutional standard.

82 Central Venous Catheter Insertion (Perform) 715

Complication Clinical Manifestation Treatment Prevention

Pneumothorax • Sudden respiratory distress • Chest pain • Hypoxia/cyanosis • Decreased breath sounds • Resonance to percussion

• Confi rmation with chest radiograph

• Symptomatic treatment • Small pneumothorax:

❖ Close monitoring ❖ Daily chest radiograph ❖ O 2

• Large pneumothorax: ❖ Chest tube ❖ Cardiopulmonary

support

• Proper patient preparation • Sedation as necessary • Proper patient positioning • Technique and angle of the needle/

catheter on insertion • Avoidance of multiple passes with the

needle • Healthcare provider is skilled and

experienced in insertion technique • Direct visualization with bedside

ultrasonography for internal jugular placement.

Tension pneumothorax

• Most likely to occur in patients on ventilator support

• Respiratory distress • Rapid clinical deterioration:

❖ Cyanosis ❖ Jugular venous distention

(may not be present with severe hypovolemia)

❖ Hypotension ❖ Decreased cardiac output

• Treatment must be rapid and aggressive

• Immediate air aspiration followed by chest tube

• Cardiopulmonary support

• Proper patient preparation • Sedation as necessary • Proper patient positioning • Reduction of positive end-expiratory

pressure to ≤ 5 cm H 2 O at the time of venipuncture

• Technique and angle of the needle/catheter on insertion

• Avoidance of multiple passes with the needle

• Healthcare provider is skilled and experienced in insertion technique

• Use of peripherally inserted central venous catheter

Delayed pneumothorax

• Slow onset of respiratory symptoms

• Subcutaneous emphysema • Persistent pleuritic chest or

back pain • Insidious increase in peak

airway pressures in ventilated patients


• Chest tube • Cardiopulmonary support




experienced in insertion technique • Use of peripherally inserted central

venous catheter

Hydrothorax hydromediastinum

• Dyspnea • Chest pain • Muffl ed breath sounds • High glucose level of chest

drainage • Low-grade fever

• Stop infusion • Confi rmation with chest

radiograph • Cardiopulmonary support




experienced in insertion technique • Use of peripherally inserted central

venous catheter • Placement of catheter tip in lower

superior vena cava • Aspiration of blood before catheter

use to confi rm vascular placement

TABLE 82-1 Complications of Central Venous Catheter Insertion

Continued

716 Unit II Cardiovascular System

Complication Clinical Manifestation Treatment Prevention Hemothorax • Respiratory distress

• Hypovolemic shock • Hematoma in the neck with

jugular insertions


• Chest tube • Thoracotomy for arterial

repair if indicated

• Correction of coagulopathies before insertion


• Evaluation with Doppler scan studies or venogram of suspected thrombosis from prior cannulation before insertion

Arterial puncture/laceration

• Return of bright red blood in the syringe under high pressure

• Pulsatile blood fl ow on disconnection of the syringe

• Arterial waveform/pressures when the catheter is connected to the transducer system

• Arterial saturation of sample sent for blood gas analysis

• Deterioration of clinical status: ❖ Hemorrhagic shock ❖ Respiratory distress ❖ Bleeding from catheter site

may or may not be observed

• Deviation of trachea with large hematoma in the neck

• Hemothorax may be detected on chest radiograph

• Application of pressure for 3–5 minutes or as needed to promote hemostasis after removal of the needle

• Elevate the head of the bed if condition is hemodynamically stable

• Chest tube as indicated • Thoracotomy for arterial

repair if indicated



• Evaluation with Doppler scan studies or venogram of suspected thrombosis from prior cannulation before insertion

• Use of small-gauge needle to fi rst locate the vein

• Direct visualization with bedside ultrasonography for femoral vein placement.

Bleeding/hematoma; venous or arterial bleeding

• Bleeding from insertion site • Hematoma formation not likely

to be seen with subclavian approach

• Bleeding may occur internally without visible evidence

• Tracheal compression • Respiratory distress • Carotid compression • Pain at insertion site

• Application of pressure to the insertion site

• Thoracotomy for arterial repair

• Tracheostomy for tracheal deviation from hematoma

• With the femoral approach, manual pressure slightly above the inadvertent arterial puncture site (see Procedure 76 for femoral sheath removal)

• If retroperitoneal bleeding occurs, external signs may not be apparent except for signs of hypovolemia. Computed tomography (CT) scan of the abdomen may be required for diagnosis.


• Avoidance of multiple passes with the needle at venipuncture

• Use of a small-gauge needle to fi rst locate the vein

• Immediate control of femoral bleeding may prevent large blood loss or hematoma formation

Cardiac dysrhythmias

• Premature atrial complexes • Atrial fi brillation or fl utter • Premature ventricular

complexes • Supraventricular tachycardia • Ventricular tachycardia • Sudden cardiovascular

collapse

• Withdraw the guidewire or catheter from the heart; dysrhythmias should stop if the cause was mechanical in nature

• Pharmacological treatment of persistent dysrhythmias

• Avoidance of entry into the heart with the guidewire

• Observation of cardiac monitor; tall, peaked P waves can be identifi ed as the catheter tip enters the right atrium

TABLE 82-1 Complications of Central Venous Catheter Insertion—cont’d


Complication Clinical Manifestation Treatment Prevention Air embolism • Symptoms depend on amount

of air drawn in, especially with patients who are spontaneously breathing

• Sudden cardiovascular collapse

• Tachypnea, apnea, tachycardia

• Hypotension, cyanosis, anxiety • Diffuse pulmonary wheezes • “Mill wheel” churning heart

murmur • Neurological defi cits, paresis,

stroke, coma • Cardiac arrest

• Stop airfl ow • Position patient on left side

in the Trendelenburg position

• Oxygen administration • Air aspiration;

transthoracic needle or intracardiac catheter

• Cardiopulmonary support

• Adequate hydration status • Head-down tilt or the Trendelenburg

position during catheter insertion • Use of small-bore needle for insertion • Application of thumb over needle or

catheter hub during ventilation; needle or hub should not be exposed longer than 1 second

• Advancement of catheter during positive-pressure cycle in patients on ventilatory support

• Avoidance of nicking of catheter with careful suturing technique

• Avoidance of catheter exchange from large-bore catheter (pulmonary artery) to smaller catheter

• Use of Luer-Lok connections • Minimal risk with peripherally inserted

central venous catheter

Catheter malposition • Pain in ear or neck • Swishing sound in ear with

infusion • Sharp anterior chest pain • Pain in ipsilateral shoulder

blade • Cardiac dysrhythmia • Observation on chest

radiograph • Signs or symptoms may be

absent • No blood return on aspiration

• Ensure that the bevel of the insertion needle is positioned downward (toward feet of patient) before placing guidewire

• Repositioning of catheter with guidewire or new venipuncture

• Catheter removal

• Proper patient positioning • Avoidance of use of force when

advancing the catheter • Use of a guidewire or blunt-tipped

stylet

Catheter embolism • Cardiac dysrhythmias • Chest pain • Dyspnea • Hypotension • Tachycardia • May be clinically silent

• Location of fragment on radiograph

• Transvenous retrieval of catheter fragment

• Thoracotomy • Interventional radiology

retrieval

• Use of “over a guidewire” (Seldinger) insertion technique

• Extreme caution with use of through-the-needle catheter designs; never withdraw a catheter through the needle

• Use of guidewire or stylet within a catheter that is inserted through a needle

Cardiac tamponade • Retrosternal or epigastric pain • Dyspnea • Venous engorgement of face

and neck • Restlessness, confusion • Hypotension, paradoxical pulse • Muffl ed heart sounds • Mediastinal widening • Pleural effusion • Cardiac arrest

• Treatment must be rapid and aggressive

• Discontinuation of infusions through the central line

• Aspiration through the catheter

• Emergency pericardiocentesis

• Emergency thoracotomy

• Catheter tip position: Parallel to the walls of the superior vena cava 1–2 cm above the junction of the superior vena cava and right atrium

• Use of soft, fl exible catheters • Minimal risk with peripherally inserted

central venous catheter

Tracheal injury • Subcutaneous emphysema • Pneumomediastinum • Air trapping between the chest

wall and the pleura • Respiratory distress with

puncture of endotracheal tube cuff

• Emergency reintubation (for punctured endotracheal tube cuff)

• Aspiration of air in mediastinum

• Physician, advanced practice nurse, or other healthcare professional is skilled and experienced in insertion technique

• Use of peripherally inserted central venous catheter


Continued


Complication Clinical Manifestation Treatment Prevention Nerve injury • Patient has tingling/numbness

in arm or fi ngers • Shooting pain down the arm • Paralysis • Diaphragmatic paralysis

(phrenic nerve injury)

• Remove catheter if brachial plexus injury is suspected

• Physician, advanced practice nurse, or other healthcare professional is skilled and experienced in insertion technique

• Minimal risk with peripherally inserted central venous catheter

Sterile thrombophlebitis

• Potential complication of the peripherally inserted central venous catheter

• Redness, tenderness, swelling along the course of the vein

• Pain in the upper extremity or shoulder

• Application of heat for 48–72 hours

• Removal of catheter

• Strict aseptic technique during catheter insertion

• Adequate skin preparation

Pulmonary embolism • Potential complication of catheter exchange

• Often clinically silent • Chest pain, dyspnea,

coughing, tachycardia, anxiety, fever

• Spiral chest CT scan • Lung perfusion scan • Cardiopulmonary support

with large pulmonary embolism

• Avoidance of catheter exchange in veins with thrombosis


• 1% lidocaine without epinephrine • One 25-gauge 58 -inch needle • Large package of 4 × 4 gauze sponges • Suture kit (hemostat, scissors, needle holder) • 3-0 or 4-0 nylon suture with curved needle • Syringes: one 10- to 12-mL syringe; two 3- to 5-mL

syringes; two 22-gauge, 112 -inch needles

• Masks, head coverings, goggles (shield and mask combi-nation may be used), sterile gloves, and sterile gowns

• No. 11 scalpel • Roll of 2-inch tape • Dressing supplies • Waterproof pad • Chlorhexidine-impregnated sponge • Antiseptic solution (e.g., 2% chlorhexidine-based prepa-

ration) • Nonsterile gloves • Normal saline fl ush syringes or 0.9% sodium chloride

vials, 10- to 30-mL • Bedside ultrasound machine with vascular probe • Sterile ultrasound probe cover Additional equipment, to have available as needed, includes the following: • Hemodynamic monitoring system (see Procedure 75 ) • Sutureless catheter securement device • Intravenous (IV) solution with Luer-Lok administration

set for IV infusion • Luer-Lok extension tubing • Bedside monitor and oscilloscope with pulse oximetry • Supplemental oxygen supplies • Emergency equipment • Package of alcohol pads or swab sticks • Package of povidone-iodine pads or swab sticks • Heparin fl ushes • Sterile injectable or noninjectable caps • Skin protectant pads or swab sticks

PATIENT AND FAMILY EDUCATION

• Explain the need for the CVC insertion and assess patient and family understanding. Rationale: Clarifi cation and understanding of information decrease patient and family anxiety levels.

• Explain the procedure and the time involved. Rationale: Explanation increases patient cooperation and decreases patient and family anxiety levels.

• Explain the need for sterile technique and patient position-ing, and that the patient ’ s face may be covered. Rationale: The explanation decreases patient anxiety and elicits coop-eration.

• Explain the benefi ts and potential risks for the procedure. Rationale: Information is offered so that the patient and/or family can make an informed decision.

PATIENT ASSESSMENT AND PREPARATION Patient Assessment • Determine the patient ’ s medical history including neck,

chest, and groin surgeries and previous vascular access devices. Rationale: Data obtained will assist with site selection.

• Determine the patient ’ s medical history of pneumothorax or emphysema. Rationale: Patients with emphysematous lungs may be at increased risk for puncture and pneumo-thorax, depending on the approach.

• Determine the patient ’ s medical history of anomalous veins. Rationale: Patients may have a history of dextroacardia or transposition of the great vessels, which leads to greater dif-fi culty in catheter placement.

• Assess the intended insertion site. Rationale: Scar tissue may impede placement of the catheter. Permanent pacemakers or


implantable cardioverter defi brillators may preclude place-ment. Previous surgery and previous placement of a CVC may cause a thrombus to be present or there may be stenosis of a vessel.

• Assess the patient ’ s neurological, cardiac, and pulmonary status. Rationale: Aids in determining whether the patient can tolerate Trendelenburg position.

• Assess vital signs and pulse oximetry. Rationale: Baseline data enable rapid identifi cation of changes.

• Assess electrolyte levels (e.g., potassium, magnesium, calcium). Rationale: Electrolyte abnormalities may increase cardiac irritability.

• Assess for a coagulopathic state and determine whether the patient has recently received anticoagulant or throm-bolytic therapy. Rationale: These patients are more likely to have complications related to bleeding. Therefore site selection and the need/ability to provide interventions before insertion of the CVC can be determined prospec-tively. 3

Patient Preparation • Verify that the patient is the correct patient using two

identifi ers. Rationale: This increases patient safety by ensuring correct identifi cation of the patient for the intended intervention.

• Ensure that the patient and family understand preproce-dural teaching. Answer questions as they arise, and rein-force information as needed. Rationale: Understanding of previously taught information is evaluated and rein-forced.

• Obtain informed consent. Rationale: Informed consent pro-tects the rights of the patient and makes a competent decision possible for the patient; however, in emergency circum-stances, time may not allow for this form to be signed.

• Perform a preprocedure verifi cation and timeout, if non-emergent. Rationale: Ensures patient safety.

• Prescribe sedation or analgesics as needed. Rationale: The patient may need sedation or analgesics to promote comfort and to ensure adequate cooperation and appropri-ate placement.

• Place an order for patient restraints and apply if needed. Rationale: In patients with cognitive impairment, restraints may be needed to ensure maintenance of patient positioning and equipment and access site sterility. During the proce-dure, restlessness and an altered level of consciousness may represent a pneumothorax, hypoxia, or placement in the carotid artery.

Procedure continues on following page

Steps Rationale Special Considerations

1. Review indications, contraindications, and potential complications.

Enables appropriate site selection and preprocedural intervention if needed.

2. Obtain ultrasound equipment if time is available to determine the most appropriate approach.

Prepares equipment. Assistance may be needed from radiology.

3. HH 4. PE All physicians, advanced practice

nurses, and other healthcare professionals in the room should have on protective equipment including head coverings and masks. 5 Persons inserting the catheter or assisting should use face shields or googles.

5. Place a waterproof pad beneath the site to be accessed.

Avoids soiling of bed linens.

6. Assist the patient to a position that will optimize access to the site selected.

Proper positioning increases vessel access and optimizes comfort of patient and physician, advanced practice nurse, or other healthcare professional throughout the process.

7. Determine the anatomy of the access site. (Level E * )

Helps ensure proper placement of the CVC and guides the area to be prepped. 5,6

Ultrasound guidance to place CVCs (if the technology is available) should be used to reduce the number of attempts and complications. 5,6

* Level E: Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations.

Procedure for Performing Central Venous Catheter Insertion


Figure 82-1 Area of skin preparation for central venous catheter insertions. A, Subclavian inser-tion: scrub from shoulder to contralateral nipple line and neck to nipple line. B, Jugular insertions: scrub mid clavicle to opposite border of the sternum and from the ear to a few inches above the nipple. (Courtesy of Suredesign.)

A

B

* Level A: Meta-analysis of quantitative studies or metasynthesis of qualitative studies with results that consistently support a specifi c action, intervention, or treatment (including systematic review of randomized controlled trials).


8. Prepare skin with an antiseptic solution (e.g., 2% chlorhexidine-based preparation). 5,6 (Level A * ) A. Subclavian vein: scrub from

shoulder to contralateral nipple line and neck to nipple line ( Fig. 82-1A ).

B. Internal jugular vein: scrub midclavicle to opposite border of the sternum and from the ear to a few inches above the nipple ( Fig. 82-1B ).

C. Femoral vein: scrub the anterior and medial surface of the proximal thigh to the inguinal ligament.

Limits the introduction of potentially infectious skin fl ora into the vessel during the puncture.

If there is a contraindication to chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol can be used as alternatives. 5

9. Discard used supplies, perform hand hygiene, and apply sterile gown and gloves.

Minimizes the risk of infection and maintains standard and sterile precautions.

10. Place the full drape over the patient with exposure of only the insertion site.

Prepares sterile fi eld. All physicians, advanced practice nurses, and other healthcare professionals in the room should have on protective equipment including head coverings and masks. 5

Procedure for Performing Central Venous Catheter Insertion—Continued



Figure 82-2 Anatomy of the jugular vein. A, Anatomy of the internal jugular vein showing its lower location within the triangle formed by the sternocleidomastoid muscle and the clavicle. B, Triangle drawn over the clavicle and sternal and clavicular portions of the sternocleidomastoid muscle is centered over the internal jugular vein (inset). (From Dailey EK, Schroeder JS: Techniques in bedside hemodynamic monitoring . St Louis, 1994, Mosby and redrawn from Daily PO, Griepp RB, Shumway NE: Percutaneous internal jugular vein cannulation, Arch Surg 101:534–536, 1970. Copyright 1970, American Medical Association.)

Sternocleidomastoidmuscle

External jugularvein

Internal jugularvein

Subclavian vein

Carotid artery

Innominatevein

1st rib

Sternocleidomastoid

Internal jugular vein

Innominatevein

A B


11. Ask critical care nurse or provider assisting to open the CVC insertion kit and drop the sterile items onto the sterile fi eld.

Maintains aseptic technique and prepares the work area.

12. Check landmarks again for the intended catheter insertion site.

Ensures proper placement of the catheter.

Site Specifi c: Internal Jugular Vein ( Fig. 82-2 ) See steps 1–12 above. 1. Locate the carotid artery. Helps prevent placing the catheter in

the carotid artery. 2. Identify the jugular vein and

mark it if necessary. Identifi es the intended insertion site. Localization of the vessel may occur

with palpation; however, real-time ultrasound should be utilized with the internal jugular approach if equipment and a trained physician, advanced practice nurse, or other healthcare professional are available. 7

3. Instruct the patient to turn his or her head slightly away from the insertion site.

Helps identify the landmarks. Ensure that there are no contraindications to neck mobility. If there are no contraindications to neck mobility, the critical care nurse or another physician, advanced practice nurse, or other healthcare professional assisting with the procedure may need to assist the patient to turn his or her head.



*Level E: Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations


4. Ensure that the patient is in the Trendelenburg position (i.e., 15 to 25 degrees). 1,2 (Level E * )

Minimizes the risk for venous air embolus by increasing the pressure in the large veins above atmospheric pressure thus reducing the risk of air aspiration. The patient should be positioned so that the intended puncture site is at or below the level of the heart. 1,2

Most patients can tolerate Trendelenburg positioning but intracranial, respiratory, or cardiac compromise may occur. Therefore evaluation for the need for alternative sites and close monitoring are necessary.

5. Identify the internal jugular vein from the triangle between the medial aspect of the clavicle, the medial aspect of the sternal head, and the lateral head of the sternocleidomastoid muscle (see Fig. 82-2 ).

A high entry can be made from a posterior approach, a lateral approach, an anterior approach, or a central approach.

The midanterior approach may be preferred in an obese patient. The posterior approach may present a slightly higher risk.

The internal jugular vein is 3–4 cm above the medial clavicle and 1–3 cm within the lateral border of the sternocleidomastoid muscle.

6. Administer an anesthetic: A. Attach a 3- or 5-mL syringe

with 2 or 3 mL of 1% lidocaine (without epinephrine) to an 18-gauge needle.

B. Align the needle with the syringe parallel to the medial border of the clavicular head of the sternocleidomastoid muscle.

C. Aim at a 30-degree angle to the frontal plane over the internal jugular vein, toward the ipsilateral nipple.

D. Instill the lidocaine.

Promotes patient comfort during the procedure. Helps to anesthetize below the subcutaneous tissue.

7. Prepare the catheter: A. Place sterile injectable or

noninjectable caps. B. Flush the catheter and ports

with normal saline.

Removes air from the catheter and prepares for insertion.

8. Place the sterile probe over the ultrasound equipment and locate the vessel.

Maintains sterility. Another physician, advanced practice nurse, or other healthcare professional in sterile attire may assist with this step.

9. Use Seldinger ’ s technique for placement of the catheter ( Fig. 82-3 ).

This technique is the preferred method of CVC placement; it uses a dilator and guidewire.

A. Puncture the skin and advance the needle while maintaining slight negative pressure within the syringe until free-fl owing blood is obtained.

Slight negative pressure helps to ensure placement into the vein and decreases the risk for air embolism and pneumothorax.

Without slight negative pressure, penetration into the vein will go unrecognized.

Insert at a 45-degree angle to prevent pneumothorax. Avoiding a too-lateral or too-deep needle insertion can reduce the risk for pneumothorax. Lateral movement of an inserted needle can lacerate vessels and should not be done.




B. After a free fl ow of blood is returned, turn the bevel to the 3 o’clock position. Once in the vein, have the patient hold his or her breath while the syringe is detached and insert the soft-tipped guidewire 20–25 cm through the needle.

A free fl ow of blood indicates a vessel has been entered.

When preparing the syringe and needle, line the bevel up with the numbers on the syringe so that you know where the bevel is regardless of how the syringe is manipulated during placement.

C. Remove the needle. D. Wipe the guidewire with the

sterile 4 × 4 gauze. E. Instruct the patient to breathe

normally.

Wiping the guidewire dry may ease manipulation.

The guidewire should always pass easily without resistance.

10. With a No. 11 blade, knife edge up, make a small (2–3-mm) stab wound at the insertion site.

Eases the insertion of the dilator through the skin.



Figure 82-3 Basic procedure for Seldinger ’ s technique. A, The vessel is punctured with the needle at a 30- to 40-degree angle. B, The stylet is removed, and free blood fl ow is observed; the angle of the needle is then reduced. C, The fl exible tip of the guidewire is passed through the needle into the vessel. D, The needle is removed over the wire while fi rm pressure is applied at the site. E, The tip of the catheter or sheath is passed over the wire and advanced into the vessel with a rotating motion. (From Dailey EK, Schroeder JS: Techniques in bedside hemodynamic monitoring . St Louis, 1994, Mosby.)

D

C

A

B

E


Figure 82-4 Anatomical location of the subclavian vein and surrounding structures. The subcla-vian vein joins the internal jugular vein to become the innominate vein at about the manubriocla-vicular junction. The innominate vein becomes the superior vena cava (SVC) at about the level of the mid manubrium. (From Dailey EK, Schroeder JS: Techniques in bedside hemodynamic monitor-ing , St Louis, 1994, Mosby.)

Carotid artery


Subclavian artery

Subclavian vein

Innominate vein

SVC


11. Insert the dilator through the skin, over the guidewire, until 10–15 cm of wire extends beyond the dilator, then remove the dilator while maintaining the position of the guidewire.

The dilator enlarges the subcutaneous tissue and vessel, easing the insertion of the catheter and preventing the formation of a false channel.

Control of the guidewire should be maintained at all times to avoid wire embolization.

12. Advance the catheter over the guidewire until 10–15 cm of the guidewire extends beyond the catheter and then remove the guidewire.

Places the catheter. Cover the needle hub between manipulations to avoid air embolization.

13. Suture the catheter in place. Secures the catheter. A sutureless catheter-securing device may be used to stabilize the CVC.

14. Apply an occlusive, sterile dressing (see Procedure 66 ).

Reduces the risk for infection. Consider use of a chlorhexidine-impregnated sponge dressing. 5,6 Follow institutional standards.

15. Return the patient to a neutral, or head-up, position.

Promotes comfort.

16. Assess lung sounds and peak airway pressures (in ventilated patients), and obtain a chest radiograph.

Assesses for placement and complications.

The radiograph needs to be read before utilization of the catheter for administration of IV fl uid and medications.





17. Remove PE and discard used supplies in appropriate receptacles.

Reduces the transmission of microorganisms and minimizes exposure to contaminated sharps.

18. HH Specifi c Site: Subclavian Vein ( Fig. 82-4 ) See steps 1–12 above. 1. Identify the junction of the

middle and medial thirds of the clavicle. The needle insertion should be 1–2 cm laterally.

Identifi es the landmarks for catheter placement.

Access from the right side is preferred to avoid inadvertent puncture of the thoracic duct.

2. Depress the area 1–2 cm beneath the junction with the thumb of the nondominant hand and the index fi nger 2 cm above the sternal notch.

Helps identify the landmarks. To avoid the subclavian artery, select a puncture site away from the most lateral course of the vein and do not aim too posteriorly.

3. Identify the subclavian vein. May aid in identifying the intended insertion site.

Utilization of real-time ultrasound should be considered with the subclavian approach if equipment and a trained physician, advanced practice nurse, or other healthcare professional are available. 7

4. Instruct the patient to turn his or her head away from the insertion site.

Helps identify the landmarks. Ensure that there are no contraindications to neck mobility. If there are none, the critical care nurse or another physician, advanced practice nurse, or other healthcare professional assisting with the procedure may need to assist the patient to turn his or her head.

5. Position the patient for optimal vein access. A. Ensure that the patient is in

the Trendelenburg position (i.e., 15–25 degrees).

B. Adduct the patient ’ s arms. C. Consider placing a rolled

towel between the patient ’ s shoulder blades.

Minimizes the risk for venous air embolus by increasing the pressure in the large veins above atmospheric pressure thus reducing the risk of air aspiration. The patient should be positioned so that the intended puncture site is at or below the level of the heart. 1,2

Most patients can tolerate the Trendelenburg positioning but intracranial, respiratory, or cardiac compromise may occur. Therefore evaluation for the need for alternative sites and close monitoring are necessary.

6. Administer a local anesthetic. A. Attach a 3- or 5-mL syringe


B. Inject the lidocaine into the area surrounding the intended insertion site.


7. Prepare the catheter: A. Flush the catheter and ports

with normal saline. B. Place sterile injectable or

noninjectable caps.






Figure 82-5 Puncture of the subclavian vein with the needle inserted beneath the middle third of the clavicle at a 20- to 30-degree angle aiming medially. (From Dailey EK, Schroeder JS: Techniques in bedside hemodynamic monitoring . St Louis, 1994, Mosby.)

Clavicle

Subclavianvein



9. Use Seldinger ’ s technique for placement of the catheter (see Fig. 82-3 ).


A. Insert the needle under the clavicle and “walk down” until it slips below the clavicle and enters the vein while maintaining negative pressure within the syringe until free-fl owing blood is returned ( Fig. 82-5 ).

Slight negative pressure helps to ensure placement into the vein and decreases the risk for air embolism and pneumothorax. Without slight negative pressure, penetration into the vein will go unrecognized.

Insert at a 45-degree angle to prevent pneumothorax. Avoiding a too-lateral or too-deep needle insertion can reduce the risk for pneumothorax. Lateral movement of an inserted needle can lacerate vessels and should not be done.

B. After a free fl ow of blood is returned, have the patient hold his or her breath while the syringe is detached and insert the soft-tipped guidewire 20–25 cm through the needle under constant manual control.







sterile 4 × 4 gauze. E. Instruct the patient to breathe

normally.

Wiping the guidewire dry may ease manipulation.

10. With a No. 11 blade, knife edge up, make a small (2-mm to 3-mm) stab wound at the insertion site.


11. Insert the dilator through the skin, over the guidewire, advancing under the clavicle until 20–25 cm of wire extends beyond the dilator, then remove the dilator while maintaining the position of the guidewire.



12. Advance the catheter over the guidewire until 20–25 cm of the guidewire extends beyond the catheter and then remove the guidewire.

Places the catheter. Cover the needle hub between manipulations to avoid air embolization.


14. Apply an occlusive, sterile dressing to the site (see Procedure 66 ).

Provides a sterile environment. Consider use of a chlorhexidine-impregnated sponge dressing. 5,6 Follow institutional standards.

15. Return the patient to a neutral or head-up position.

Promotes comfort.

16. Assess lung sounds and peak airway pressures (in ventilated patients) and obtain a chest radiograph.

Assesses for placement and complications.




18. HH Specifi c Site: Femoral Vein (see Fig. 81-2 ) See steps 1–12 above. 1. Assist the patient to a supine, fl at

position with the intended leg extended.

Prepares for the procedure.

2. Locate the femoral artery and mark it if necessary.

Identifi es the intended insertion site. Localization of the vessel may occur with palpation; however, real-time ultrasound should be utilized with the femoral approach if equipment and a trained physician, advanced practice nurse, or other healthcare professional are available. 5–7

3. Administer a local anesthetic. A. Attach a 3- or 5-mL syringe


B. Inject the lidocaine into the area surrounding the intended insertion site.





4. Prepare the catheter: A. Flush the catheter and ports

with normal saline. B. Place sterile injectable or

noninjectable caps.




6. Use Seldinger ’ s technique for placement of the catheter (see Fig. 82-3 ).


A. Insert the needle at a 20–30 degree angle 1–2 cm inferior to the inguinal ligament and just medial to the femoral artery. Maintain slight, continuous, negative pressure during insertion and advance the needle until free-fl owing blood is returned.

Slight negative pressure helps to ensure placement into the vein.

Lateral movement of an inserted needle can lacerate vessels and should not be done.

Without slight negative pressure, penetration into the vein will go unrecognized.

B. After a free fl ow of blood is returned, detach the syringe and insert the soft-tipped guidewire 25 cm under constant manual control.



sterile 4 × 4 gauze. Wiping the guidewire dry may ease

manipulation. 7. With a No. 11 blade, knife edge

up, make a small (2-mm to 3-mm) stab wound at the insertion site.


8. Insert the dilator through the skin, over the guidewire, until 25 cm of wire extends beyond the dilator, then remove the dilator while maintaining the position of the guidewire.



9. Advance the catheter over the guidewire until 25 cm of the guidewire extends beyond the catheter and then remove the guidewire.

Places the catheter.


11. Apply an occlusive, sterile dressing to the site.

Decreases the risk for infection. Consider use of a chlorhexidine-impregnated sponge dressing. 5,6

Follow institutional standards. 12. Return the patient to a neutral

position with the head of the bed slightly elevated.

Facilitates comfort.

13. Obtain an x-ray. Assesses for placement and complications.





Steps Rationale Reportable Conditions

These conditions should be reported if they persist despite nursing interventions.

1. Perform respiratory, cardiovascular, peripheral vascular, and hemodynamic assessments immediately before and after the procedure and as the patient ’ s condition necessitates.

Determines whether signs or symptoms of complications are present, for example, an air embolism may present with restlessness.

• Abnormal level of consciousness • Abnormal vital signs • Abnormal waveforms or pressures • Declining oxygen saturation • Increasing peak airway pressures

2. If the catheter was placed for CVP measurement, assess the waveform.

Ensures that the catheter is in the proper location for monitoring. Allows assessment of a , c , and v waves and measurement of pressure.

• Abrupt and sustained changes in CVP

• Abnormal waveform

3. Assess the insertion site for presence of a hematoma or hemorrhage.

Determines the presence of complications.

• Bleeding that does not stop • Hematoma or expanding

hematoma 4. Assess heart and lung sounds

before and after the procedure. Abnormal heart or lung sounds may

indicate cardiac tamponade, pneumothorax, chylothorax, or hemothorax.

• Diminished or muffl ed heart sounds

• Absent or diminished breath sounds unilaterally

5. Assess the results of the chest radiograph.

Ensures accurate placement and may aid in identifi cation of complications.

• Abnormal radiograph results

6. Monitor for signs of complications. May decrease mortality and morbidity if recognized early.

• Signs and symptoms of complications




15. HH


Expected Outcomes • Successful placement of the CVC • If infusing IV solution, the solution infuses without

problems • The a , c , and v waves are identifi ed if hemodynamic

monitoring is used • CVP measurements are obtained

Unexpected Outcomes • Failure to place catheter • Arterial puncture • Catheter embolization • Vascular injury • Pain or discomfort during the insertion procedure • Pneumothorax, tension pneumothorax, hemothorax,

or chylothorax • Nerve injury • Sterile thrombophlebitis • Infection • Cardiac dysrhythmias • Malposition • Inadvertent lymphatic or thoracic duct perforation • Hemorrhage • Hematoma • Venous air embolism • Cardiac tamponade

Patient Monitoring and Care


References and Additional Readings For a complete list of references and additional readings for this procedure, scan this QR code with any freely available smartphone code reader app, or visit http://booksite.elsevier.com/9780323376624 .

Documentation Documentation should include the following: • Patient and family education • Completion of informed consent • Preprocedure verifi cations and timeout • Insertion of central venous catheter • Insertion site of central venous catheter • Date and time of procedure • Catheter type • Lumen size

• Right-atrial pressure and CVP waveform in the event of pressure monitoring

• Centimeter marking at the skin • Patient response to the procedure • Pain assessment, interventions, and effectiveness • Confi rmation of placement (e.g., chest radiograph) • Occurrence of unexpected outcomes • Additional nursing interventions

Patient Monitoring and Care Steps Rationale Reportable Conditions

7. Follow institutional standards for assessing pain. Prescribe analgesia as needed.

Identifi es need for pain interventions. • Continued pain despite pain interventions

8. If signs and symptoms of venous air embolus are present, immediately place the patient in the left-lateral Trendelenburg position. (Level E * )

Venous air embolus is a potentially life-threatening complication. The left-lateral Trendelenburg position prevents air from passing into the left side of the heart and traveling into the arterial circulation. 1,2

• Respiratory distress • Dyspnea • Coughing • Tachypnea • Altered mental status (agitation,

restlessness) • Cyanosis • Gasp refl ex • Sucking sound near the site of the

catheter insertion/air entrainment • Petechiae • Cardiac dysrhythmias • Chest pain • Hypotension

—Continued

* Level E: Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations.

PROCEDURE Central Venous Catheter Insertion (Perform)

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