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In practice, I tend to estimate the length based on patient height and body habitus and the CVC insertion location. In practice, site sterility is often more difficult to achieve in the groin than at other sites.įormulas for Catheter Insertion Length Based on Patient Height and Approach Site * more recent studies have found infection rates comparable to the IJ route in optimal ICU settings. Risk of thoracic duct injury on left Poor landmarks in patients with obesity/ neck oedemaĬatheter malposition more common (especially right SCV)Ĭaution in patients with IVC filter Delayed circulation of drugs during CPR Uncomfortable and not suited for prolonged accessĭressings more difficult to maintain (especially if patient has a tracheostomy) Lowest rates of thrombosis Higher rate of stenosis (concern for long term dialysis) Potential to impede cerebral venous drainage and increase intracranial pressure Non compressible site (contraindicated if bleeding diathesis)Ĭompressible site Highest rate of unintended arterial cannulation Higher success rate with novice operator with ultrasound guidanceĬompressible site Risk of carotid artery puncture Side-of-bed access Trendelenburg position not required Does not interfere with airway management Most accessible site during CPR Side-of-bed access Trendelenberg position required Accessible during airway management Longer path from skin to vessel Head-of-bed access Tredelenberg position required Difficult access during airway management Collapsible vein if hypovolemia The following table compares the common CVC insertion sites, which each having pros and cons: There are exceptions, for instance the subclavian route is usually best avoided in patients at risk of longterm dialysis (due to risk of vessel stenosis) or severe lung pathology (where the slightly higher risk of pneumothorax may be catastrophic). In general, the order of preference is subclavian (or axillary), internal jugular, then femoral. infection (no difference in the rate of catheter-related bloodstream infections between the IJ, SC and Femoral sites -> 2.5 infections/ 1000 catheter days)Ĭhoice of insertion site should be tailored to the needs and status of the patient.Video demonstration of landmark approach to IJV CVC insertion approach: slight external rotation of hip, palpate pulse, medial to arterial pulsation.boundaries of the femoral triangle are adductor longus and sartorius.“NAVEL”: nerve – artery – vein – empty space – lymph node (lateral to medial).approaches: supraclaviclar, infraclavicular and lateral.posterior relations: subclavian artery, first rib, scalenus anterior, phrenic nerve and fascia over pleura.anterior relations: skin, external jugular vein, clavicle.superior relations: midpoint of clavicle.identify the carotid and mid point of medial SCM border, aim toward ipsilateral nipple.direct needle towards jugular notch (blood should be aspirated within 5cm).insert 2-3 finger breaths above clavicle along posterior border of SCM.advance 60 degrees to skin aiming towards ipsilateral nipple (blood should be obtained within 3cm).insert 1cm above the apex of head of sternocleidomastoid and clavicle.inferior petrosal sinus, facial, pharyngeal, lingual, superior thyroid, middle thyroid, occipital veins.posterior relations: transverse process of the cervical vertebrae, levator scapulae, scalenus medius and anterior, cervical plexus, phrenic nerve, thyrocervical trunk, vertebral vein, 1st part of subclavian artery.anterolateral relations: skin, superficial fascia, platysma, cervical fascia, sternomastoid, sternohyoid, omohyoid.medial relations: internal and common carotid arteries, 9th to 12th cranial nerves above common carotid artery and vagus.joins subclavian vein behind sternal extremity of clavicle.ensure control of the guidewire at all times.brown lumen is the distal lumen (used for CVP monitoring).raised intracranial pressure (ICP) (cannot tilt head down).overlying skin infection, burn or other disease processįemoral access can still be used in the following situations:.Large bore peripheral IV lines, RICC lines, Swan sheaths or IO access are preferred for rapid fluid resuscitation. Renal replacement therapy, plasmapheresis and apheresis (using a vascath).vasoactive agents, chemotherapy or parenteral nutrition administration) Infusions of irritant substances (e.g.Central venous oxygen saturation (ScvO2) monitoring/sampling.Central venous pressure (CVP) monitoring.Intravenous (IV) access (especially if difficult peripheral access).Central venous catheter (CVC) is a cannula placed in a central vein (e.g.
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