CVP Insertion

NEJM video

CVP indication
1. monitor CVP (eg EGDT)
2. Deliver of caustic or critical meds
3. Emergency Resusciation
4. Haemodialysis
5. PA catheterisation

C/I
1. Operator Inexperience unless supervised2. Uncooperive/combative2. Infection on site
3. IJ thrombosis
4. Coagulopathy (relative)
- uncorrected coagulopathy in a stable patient (absolute)

- Plt ct (150-420 K/cu mm)
- APTT (26-36 secs)
- INR (0.9-1.2)
- Fibrinogen (200-450 mg/dL)

Steps:
1. Explain and consent
2. C/I
3. Landmarks
*IJV
- at the apex of the triangle formed by clavicular and sternal head of SCM
- lateral to carotid artery

Equipment:
1. sterile gown, gloves, cap, mask and face shield
2. Skin prep and drape or towels
3. Lignocaine, sterile gauze
4. Syringes (non Luer-lock, to easily remove)
5. Scalpel (11), saline and heparin flush
6. Needle, guide wire, Dilator, Triple lumen
7. Suture and needle holder

Procedure (R IJV is preferred cuz it's more direct approach to SVC)
Landmarks:
1. Position: 10-15 deg Trendelenberg (decreases air embolism; engorges the vein), turn head opposite
2. Identify: Sternal head of SCM, Clavicular head of SCM, clavicle; IJ is lateral to carotid pulse
3. Aim needle toward apex of the triangle, lateral to carotid pulse and aimed at ipsilateral nipple

Sterilize:
4. U/S: IJ is collapsible, more lateral and superficial vs Carotid A
5. Sterilize with chlorhexidine x 60 seconds
6. Drape (explain to patient that his face may be covered but can breathe, if needs help raise hand)

Prep:
7. Flush/Prime all lumens with saline and heparin: lock all except the brown longer port/lumen
8. Make sure guidewire threads easily thru needle
9. U/S probe: gel inside, sterile sleeve, sterile gel

Enter
10. Lignocaine if awake
11. Needle with syringe and saline, 45 degrees along skin, side of sternal head, pointing to apex of triangle, directed at ipsilateral nipple
12. U/S guidance: if needle nears vein, wiggle needle a little bit upon entering (about 1-2 cm)

Vein
13. While inserting the needle (retracting the plunger), IJ is entered if blood return noted
14. Remove U/S probe
15. Remove the syringe, no pulsatile blood flows

Wire
16. Insert guidewire, if arrythmia is noted on monitor, withraw a little bit
17. Withraw the needle, leaving the guidewire in place
18. 11 blade scalpel, small superficial skin incision with sharp pointing up, away from guidewire; to facililate dilator
19. dilator over guidewire, make sure guidewire is grasp (to avoid guidewire embolism), advance 1-2 cm rotating it
20. Remove dilator, leaving the wire, expect blood = gauze
21. Insert catheter over wire; MAKE SURE THE EXTERNAL END OF WIRE IS GRASPED BEFORE CATHETER ENTERS THE SKIN
22. Grasp wire, insert the catheter thru skin rotating fashion, if resistance, may need to redilate tract
23. Once catheter is at the junction of SVC and RA
24. Remove the wire and check for blood return for all ports, flush with saline all ports
25. Secure with non absorbable stitches, dressing

CXR:
- assess proper placement (junction)
- make sure no pneumothorax, hemothorax, line not irritating the heart

Troubleshooting
1. Arterial: pulsatile (don't insert wire); pulsatility may be hard to recognize if hypotensive
- may connect to transducing system = pulsatility
- don't insert wire, remove needle, firm press on the site x 10 minutes
2. Air is aspirated into syringe (connected to transducer or catheter)
- remove needle or catheter (may have pneumothorax, especially if patient is more distress)
- CXR: chest tube as necessary
3. Persistent bleeding at failed site
- direct pressure, check coagulation studies, replace blood products as necessary
- if still bleeding, may have vascular laceration, refer to surgeon
= DON'T ATTEMPT TO INSERT CVP at the other site = may have contralateral pneumothorax
4. Arrythmia: line may be abutting the heart
- cxr, withraw
5. Cannot advance guidewire thru needle
A. Rotate the wire while introducing
B. Withdraw the needle a little bit and re-aspirate, then introduce wire again (needle might have gone thru and thru the vein)
C. Alway flush needle with saline/heparin as blood clot might have formed



Catheters
7 Fr 15 or 20 cm Triple Lumen: most commonly used in adults
11.5 Fr 20 cm double lumen: large bore for resuscitation or dialysis
5 Fr 8 cm Triple lumen or 4 Fr 8 cm double lumen = kids or small adults

Remember that large bore peripheral IV is better than CVP for rapid fluid resuscitation

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Stanford Page

Knowledge base: http://medresidents.stanford.edu/cvc/CVCknowledgeBase.html

CVC page: http://medresidents.stanford.edu/cvc/

Index

I Indic and C/I
II Selecting the Location
III Risks and complications
IV Using U/S
V Procedure of U/S guided CVC using IJ
VI A Word about Confirmation of placement
VII Mx of Complications

I. Indications and Contraindications
A. Indications
• Inability to achieve adequate peripheral venous access
• Delivery of substances not safely given via peripheral IV (TPN, vasopressors, etc.)
• Hemodialysis, CVVH, plasmapheresis
• Measurement of cardiac filling pressures
• Placement of pulmonary artery catheter
• Placement of transvenous pacer
• Access for frequent blood sampling
• Remember that triple lumen catheters are less useful than large bore IV’s for rapid volume administration – unless introducer catheter placed.
Catheter Size & Color
Length (inches)
Gravity Assisted
Flow rate (ml/min)
8.5 french (introducer)
3.50
160
14 gauge (orange)
2.00
93
16 gauge (gray)
2.00
75
18 gauge (green)
2.00
62
Triple Lumen CVC 18 gauge
(distal port)
57
20 gauge (pink)
2.00
42
22 gauge (blue)
2.00
34
Triple Lumen CVC 16 gauge
(proximal port)
32
Triple Lumen CVC 16 gauge
(medial port)
30
24 gauge (yellow)
0.75
14
• Even if running fluids through all three ports of your CVC simultaneously, you would get a flow rate of only 119 ml/min!
• Two 18 gauge peripheral IV’s would run fluid in at 124 ml/min. A better choice.
B.Contraindications
• Absolute:
•
o Operator inexperience
o Uncooperative/combative patients
o Uncorrected coagulopathy in a stable patient
• Relative:
•
o Uncorrected coagulopathy in an unstable patient
o Cellulitis over anticipated insertion site
o Injury or previous surgery to SVC (prior XRT, prior long term venous cannulation at site.
o Inability to tolerate pneumothorax (femoral vein should be considered)
o Ability to provide adequate care via peripheral access
o Morbid obesity. Consider placement of line in cephalic vein on upper outer chest using ultrasound guidance beyond the rib edges.
o Vasculitis
o COPD/bullous lung disease (subclavian lines)
o Congenital heart disease (Glenn or Fontan anastamoses). These patients have increased risk of clotting with upper body central lines. Consider a femoral approach.
o Presence of a pacemaker or ICD – especially relevant for subclavian lines, pulmonary artery catheters, and right IJ lines. The more recently placed the device, the more likely lead dislodgement becomes. Consider having devices interrogated following placement/removal of CVC’s.
KEY POINTS: Indications/Contraindications:
• A central line is NEVER indicated if peripheral IV's would suffice.
• Operator inexperience is an ABSOLUTE contraindication to central line placement unless appropriate supervision is available.
• In the case of volume resucitation, a 14 or 16 gauge peripheral IV is more effective than a triple lumen CVC. If a central line is necessary, an introducer must be placed.







II. Selecting the Location
• Right IJ:
•
o Lower risk of pneumothorax than subclavian
o Compressibility of the vessel in the event of bleeding or arterial puncture
o Straight path from the right IJ to the superior vena cava
o Facilitates the passage of pulmonary artery catheters and temporary pacemakers into the heart.
o Less comfortable and more difficult to keep clean than a SC (especially in patients with tracheostomies
♣ Subclavian:
♣
o More easily identified bony landmarks
o Improved patient comfort
o Ease of dressing and maintenance
o Lower incidence of catheter colonization and bacteremia.
o Not as compressible as IJ
o Increased risk of pneumothorax as compared with IJ.
o Avoid subclavian site, if possible, in patient with severe renal disease as repeated subclavian punctures can lead to subclavian stenosis and subsequent difficulty in placing appropriate access for dialysis in such patients.
♣ Femoral:
♣
o No risk of pneumothorax
o Will not interfere with (CPR).
o If done below inguinal ligament, minimal risk of peritoneal perforation or perforation of pelvic vessels.
o Easily compressible
o Possibly unreliable drug delivery to the heart in low flow states
o Poor patient mobility
o Higher rate of catheter colonization and clinical sepsis (19.8 versus 4.5 percent with SC catheters in a randomized trial of 289 patients receiving a first CVC. (Merrer et al, 2001)
o Unreliable central venous pressure monitoring.


KEY POINTS: Selecting the Location:
• Right IJ placement with ultrasound guidance has a lower risk of pneumothorax than subclavian line placement.
• Central line placement in the femoral veins carries a higher risk of thrombotic and infectious complications.







III. Risks and Complications
Complication
Internal Jugular
Subclavian
Femoral
Arterial puncture
6.3-9.4%
3.1-4.9%
9.0-15.0%
Hematoma
<0.1-2.2%> arterial (via septal defect or AVM)
• 50-100 mL of entrained air can be fatal via “air lock” or obstruction of the pulmonary outflow tracts.
• Higher risk in patients spontaneously breathing with large negative intrathoracic pressures, low CVP.
• Minimize risk by placing patients in Trendelenberg, quick insertion of guidewire through needle, asking patient to valsalva, clamping all but proximal (brown) ports during insertion, hum/exhalation with removal of central lines.
B. Arrhythmia
• Usually associated with malpositioned catheter tip within right atrium or ventricle and resolves with pulling back of guidewire or catheter.
• If unstable arrhythmia, proceed with ACLS algorithm
C. Arteriovenous fistula formation
• Most commonly seen when vein is reached through punctured artery creating track.
D. Central Vein perforation
• Ensure appropriate placement of catheter tip via chest x-ray following procedure
E. Clot embolization
F. Chylothorax
• Due to injury of thoracic duct
• Right IJ preferred side to avoid such injury
G. Guidewire embolization
• Keep your eye on the wire!
• Make sure that the guidewire is exiting the proximal (brown) port BEFORE threading the catheter through the skin.
• When possible, keep a hold on the guidewire.
H. Hemothorax
• Seen most commonly with arterial puncture
• Suspect with development of post procedure effusion/drop in hematocrit
I. Hydrothorax
J. Hemomediastinum
K. Hydromediastinum
L. Infection (insertion site, thrombophlebitis, bacteremia, sepsis, cellulitis, osteomyelitis)
• Minimize risk with wide sterile barrier precautions – drape should cover head, and extend past waist
• Hand washing
• Physician should not have artificial/long nails
• Chlorhexidine instead of iodine – good scrub (friction for at least 30 seconds), at least 10cm in diameter spanning from ear to clavicle to trachea. Allow to dry completely.
• Chlorhexidine disc: Use of a chlorhexidine-impregnated disc (e.g. Biopatch) around the catheter insertion site has been shown to reduce the rate of catheter-related-BSI. When placing these discs, make sure that the catheter is fed through the hole in the disc and that the chlorhexidine side of the disc faces the skin (white side facing skin, light blue side facing up).
• Risk of infection increases with each needle stick. If you are having trouble, seek help!
• If your patient requires removal of hair prior to the procedure, remember that razors can cause significant skin abrasions – clipping is recommended.
• Appropriately anchor/sew catheter in place to prevent it from moving in and out of the skin.
• Minimal number of ports and minimal accessing is associated with decreased infection rate.
• Catheter related bacteremia rates:
•
o 8.6% with IJ vs. 3.9% for subclavian in study by Ruesche et al, 2002 but this was not statistically significant.
M. Injury to adjacent nerves
• Brachial plexus injury has been reported with IJ catheter insertions
• Femoral nerve injury has been reported with femoral catheter placements
N. Malposition of catheter tip:
• Reported in 1.8 – 14% of IJ placements (Ruesch et al 2002, Gladwin et al 1999, Iovino et al 2001)
• Reported in 1.8-9.3% of Subclavian placements (Ruesch, Mansfield, Iovino)
O. Pneumothorax:
• Increased rate of pneumothorax with multiple passes of needle. If having trouble, ask for help from experienced person.
• Patient may cough, develop pleuritic pain, develop cardiopulmonary compromise, or be asymptomatic
• Remember to check a chest x-ray whether or not a line was successfully placed after attempting IJ or subclavian line placement
• If air aspirated, make sure to check a delayed chest x-ray as sometimes pneumothoraces are not immediately visible
P. Subcutaneous fluid infiltration
• Important to confirm that all ports draw back blood and flush easily.
• Important to confirm location of line with post procedure chest x-ray.
Q. Tamponade (Cardiac)
• Ensure appropriate placement of catheter tip via chest x-ray following procedure.
R. Tracheal perforation/Endotracheal cuff perforation
S. Vein thrombosis
• Femoral veins: ~ 20% with thrombotic complications (Mian et al 1997 & Merrer et al 2001)
• Internal Jugular: wide range of published thrombosis rates (0-66%), but thought generally to be of lower risk for thrombosis than femoral lines.
• Subclavian: 1-2% risk of thrombosis; keep in mind that there is about a 50% risk of subclavian stenosis development in patients undergoing subclavian line placement for dialysis so don’t put dialysis catheters there.
• Thrombosis is most often due to poor tip placement. Ideally, the catheter tip should be in the lower 1/3 of the SVC or at the caval-atrial junction, at which time the tip is parallel to the vena cava walls. Tips that impinge against the vessel wall initiate venous thrombosis.
• Mural/catheter related thromboses are associated with increased risk of catheter-related infections.
KEY POINTS : Risks and Complications:
• Minimize the risk of ALL complications by having appropriate experience or supervision.
• Minimize the risk of infection by using wide sterile precautions, hand washing, and adequate cleansing of the site (Chlorhexidine with friction for 30 seconds is the preferred method).
• Minimize the risk of thrombotic complications by ensuring that the catheter tip is appropriately located centrally within the distal 1/3 of the SVC or at the cavo-atrial junction.
• Prevent guidewire embolization. Keep your hand on the wire when possible and never loose site of the guidewire during the insertion process.
• Minimize the risk of air embolism. Trendelenberg position is required. If patient can't tolerate this position, consider femoral placement of line, PICC, or peripheral IV.







IV. Using Ultrasound
Using ultrasound for CVC may be a new technique for many of you. It takes somepractice to become competent.
• Veins usually compress easily (unless they have clot)
• Arteries are much less compressible and have obvious pulsations, which can be enhanced by compression (unless the patient is in cardiac arrest or severely hypotensive).
• If the diameter of the vein is <>



V. Procedure of Ultrasound-Guided Central Venous Catheterization using the Internal Jugular Approach in the Adult
A. Obtain Informed Consent
Elective Insertion
• Identify appropriate indication for procedure – question if peripheral vascular access would suffice
• If procedure is elective, obtain consent from patient or family member:
o Inform patient of medical indication for procedure
o Discuss both the benefits and the risks.
o Discuss alternatives to central line placement.
o Discuss management of potential complications.
o Have patient or family member sign consent form and place form into medical record.
For further information on obtaining informed consent, go to the SHC Intrasite website, hover mouse over “Forms, Policies and References” and click on “Administrative Manual”. Type in “Informed Consent” in search window and the full policy will appear.
Emergency Insertion
• A specific consent form is not needed in an emergency. However, the physician must fully document the nature of the emergency in the progress notes and, if applicable, any attempts to notify the patient’s family to obtain consent.
B. Before Starting
• Identify appropriate indication for procedure – would peripheral access suffice?
• Identify potential contraindications to the procedure and correct those that are correctable.
• Is this an emergency or should you wait to obtain consent?
• Is the consent in the chart? Have you appropriately described the risks and benefits to patient and/or family members?
• Allergy assessment: latex? Chlorhexidine? Iodine? If antibiotic impregnated line – those antibiotics?
• Choose your site wisely
• Gather all necessary materials and equipment at bedside:
o Sterile gown – for all participants
o Appropriately sized sterile gloves – for all participants
o Cap – for all participants
o Mask with face shield – for all participants
o Ultrasound
o Needle guide/sterile sheath/sterile gel
o CVC kit
o Sterile saline to flush line
o Sterile transparent dressing (do not apply Biopatch antimicrobial disk at time of insertion; nurse will apply 24 hours after insertion)
o Extra chloraprep
o Bedside table
• Ensure that you have appropriate assistance/supervision
• Ensure appropriate monitoring of the patient. We suggest a non-invasive blood pressure cuff with either continuous ECG monitoring or pulse-oximetry set on audible so that any arrhythmia can be detected.
C. The Procedure
• Complete the Time Out section (final verification) on the SHC Boarding Pass Form (Universal Protocol) for a CVC that does not require moderate sedation (if a CVC requires moderate sedation, the entire Boarding Pass Form must be completed). The Time Out must be conducted immediately prior to the CVC. The team performing the procedure uses active communication to reconfirm the following elements:
o Correct patient identity
o Correct procedure verified with consent
o Correct site and side
o Correct patient position
o Availability of any special equipment or special requirements
• Patient adequately restrained/sedated/cooperative
• Position the patient
o Supine
o Trendelenberg – 15% - 30%
o Head turned slightly away from site (RIJ site preferred)
o Comfortable bed height
• Locate your landmarks – between the two heads of the sternocleidomastoid and lateral to the carotid pulse.
• Non-sterile ultrasound exam of the right neck to verify anatomy, including relative location of RIJ and carotid, patency of RIJ, depth of RIJ (usually about 1.5 cm).
• Prep the area with chlorhexidine – 10 cm radius from ear superiorly to clavicle inferiorly, across trachea medially. For maximal effectiveness, apply the chlorhexidine using friction in multiple directions (side to side, then up-down, then diagonally) for 30 seconds. NOT IN CIRCLES!
• Open tray with appropriate care that contents remain sterile
• Put on cap, mask
• PERFORM HAND HYGIENE (either wash hands for at least 10 seconds or apply alcohol-based gel to hands)
• Gown & glove with special attention paid so that sleeves, etc are not contaminated inadvertently
• Drape patient with wide sterile barrier – make sure you use the adhesive that is there to prevent the drape from moving and contaminating your site.
• Place sterile site rite cover on ultrasound probe
• Locate vein in cross section – is it collapsible?
• Pick a site where carotid is not directly overlying or underlying vein, if possible
• Use the appropriate needle guide based on depth seen on ultrasound
• Move the probe up and down the site to identify the direction in which the vein is running. Position the needle and the probe so that the bevel will enter the vein in the direction that the vein is running.
• If your patient is awake, please be kind and talk them through what you are doing – provide reassurance.
• Local anesthetic – make sure to put negative pressure on syringe so as not to provide an IV bolus of lidocaine. Adding a small amount of sterile sodium bicarbonate ( 1:10 ratio) to the lidocaine will take the “burn” out of the lidocaine.
• Placing a small nick in skin at site of planned needle insertion decreases the force needed to direct the large bore needle through the skin making inadvertently deep needle punctures less likely. Also ensures better probe contact with skin and visualization of needle passing into vasculature.
• BEFORE CANNULATING THE VEIN, MAKE SURE THAT ALL MATERIALS ARE WITHIN EASY REACH
o Gauze
o Guidewire
o Scalpel
o Dilator
o Catheter – with brown cap removed
o Flushes
o Suture material
• Puncture IJ under DIRECT ULTRASONOGRAPHIC GUIDANCE and remember that it is important to USE THE NEEDLE GUIDE.
• WATCH THE SCREEN! The needle appears as a hyperechoic line. Most often, the vein will compress as the needle approaches and then rebound once the needle enters the vein.
• Confirm blood return.
o Is the blood bright red?
o Is there pulsatile flow?
•
♣ If so, you should remove needle and place pressure for 5-10 minutes
♣ If not sure, there are a number of ways to check placement
• Transduce
• Confirm location via ultrasound
• Stabilize needle, remove from site rite probe by tipping the probe away from the needle (not by lifting the probe which may change the position of the needle).
• Drop the needle angle in the direction that the vein is running and ensure continued blood return.
• Thread the guidewire through the needle/syringe
♣ If taking syringe off the needle, make sure to minimize the risk of air embolus by quickly inserting the guidewire. Many place their thumb or finger over needle hub, but this may move the needle and result in failure to pass the wire.
♣ Keep an eye on monitor for any cardiac arrhythmias
• Never force the guidewire.
• You can confirm venous placement by visualizing guidewire in lumen of vein using ultrasound probe.
• Remove the needle from the wire
• Nick skin with scalpel
• Dilate skin and subcutaneous track with
• Remove dilator and pass central venous catheter over wire into the SVC (don’t let go of the wire). The wire should exit the brown port. Make sure that the guidewire is visibly exiting the brown(proximal) port of the catheter BEFORE threading the catheter tip through the skin.
• Remove guidewire
• Withdraw blood then flush with saline. Repeat for all ports.
♣ The pre-filled flush syringes are not sterile – though the saline is.
•
o Either ask the assistant to empty the saline into your tray and use one of the sterile syringes to flush the ports or allow your assistant to help flush the ports – maintaining your own sterility.
• Securely suture the catheter in place
• Apply sterile transparent dressing
• Confirm bilateral breath sounds
• Dispose of your sharps!
D. Troubleshooting during the Procedure
• If you are having trouble, the most important thing to remember is to ASK FOR HELP!
Can’t find the vein:
• Are you using the site rite?
• Any reasons that the anatomy might be distorted?
• Clots?
• Is your patient in Trendelenberg?
• Is your patient grossly hypovolemic?
• Is the head overextended/over rotated?
• Are you pressing down on the neck with too much force?
Can’t thread the wire:
• Place syringe back on needle hub and ensure that you are still in the vein – get good blood flow
• Rotate the needle/change the angle – is the bevel facing in the correct direction?
• Rotate the guidewire
• DO NOT FORCE THE WIRE THROUGH
Can’t withdraw the guidewire:
• Remove wire and needle as a whole unit to prevent shearing of the wire and possible wire embolism.
E. After the Line is In:
• Wash hands
• Order a chest x-ray
• Write procedure note
• LOOK at the chest x-ray
o Where is line tip?
o Make sure you don’t see the guidewire!
o Make sure you don’t see a hemothorax!
o Make sure you don’t see a pneumothorax!
• Please disinfect the ultrasound and return it to its original location so the next doctor can find it when they need it!


KEY POINTS: The Procedure:
• Always obtain INFORMED CONSENT for elective central line insertions.
• If you cannot obtain consent in the case of an emergency, document the need in the chart.
• Use wide sterile barriers - cap, mask, gown, gloves, wide drape - and wash hands first.
• Be prepared - have all that you will need within arm's reach before puncturing the skin.
• Always obtain a chest x-ray following the procedure (even if you did not successfully place the line)
• Always check the chest x-ray for line tip placement, pneumothorax, hemothorax.







VI.A Word About Confirmation of Placement
• There is no confirmation method that can be used with 100% certainty
• Check for Pulsatile Flow:
o May see pulsatile flow from venous system during CPR
o May not see frankly pulsatile flow from patients with low flow states
• Check for bright red blood:
o May not see bright red blood arterial blood in patients with low flow states
o May not see bright red blood arterial blood in patients with severe hypoxemia.
• Transduce:
o This option is only available in the ICU.
o The small catheter found in the CVC kit, if not held firmly in place, may slip out of the vessel, making the guidewire impossible to pass and necessitating a second puncture.
o The catheter may become kinked, making the guidewire difficult to re-pass.
• Hold up pressure tubing:
o This may be misleading in patients with very elevated CVPs
o This may increase the risk of air embolus
• ABG/VBG Comparison:
o This may be misleading in patients with low flow states or severe hypoxemia.
o The results take several minutes to come back.
• Ultrasound Confirmation of Guidewire Placement:
o If venous system was misidentified in the original ultrasound, it may once again be misidentified.
o In patients with markedly elevated CVPs, the venous system may not be as easily compressible.
VIII. Management of Complications
Air Embolus:
• Suspect this if a patient decompensates during your procedure.
• Occlude any open lumen.
• Place patient in left lateral decubitus position & Trendelenberg to position the RV outflow tract inferior to the RV, thus floating air away from the outflow tract (Duran’ts position).
• Provide high FiO2 to encourage nitrogen resorption
• Attempt to aspirate air through your catheter.
• CXR in left lat decubitus may show air in heart & heart exam may reveal mill wheel murmur
Arrhythmia:
• Usually results from deep placement of the guidewire or line and resolves upon repositioning.
• If unstable, initiate ACLS.
Arterial Puncture:
• With needle only: withdraw needle and apply 5-10 minutes of pressure. If patient develops bradycardia (carotid massage), release pressure.
o CXR to r/o hemothorax
o Frequent vitals
o Hematocrit checks
• With dilator/catheter: Surgical emergency. Leave line/dilator in place and call vascular surgery right away.
Catheter Infection
• If catheter is no longer needed, remove catheter
• If blood cultures are positive, remove catheter
• See separate Duke CVC Curriculum Website (DICON) for more detailed discussion
Catheter Knotting:
• Leave catheter in place and request help from IR or vascular service.
Dysrhythmias:
• Usually occurs secondary to stimulation of myocardium by catheter or guidewire
• Usually resolves after withdrawal of catheter or guidewire
• If necessary, initiate ACLS protocols.
• Try to estimate distance from insertion site to SVC prior to insertion.
Guidewire Embolization:
• Watch for arrhythmias and be prepared to manage them.
• Obtain a CXR to check the location.
• Consult IR emergently for immediate removal.
Neck Hematoma:
• Monitor patient for airway compromise/carotid occlusion
Pneumothorax:
• Monitor with serial chest x-rays if small and patient spontaneously breathing without respiratory distress.
• If hemodynamic instability, place 14-16 gauge angiocath in the 2nd intercostal space, midclavicular line. Remove needle, leave open to air, call for emergent chest tube placement.
• If hemodynamically stable, not on positive pressure ventilation, and <>

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