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Identifying a Vein for CVC Insertion

 
 
 
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Overview

    • Do

    • Think about the future plan for this patient, and whether this site will be needed for any other access
    • Don't

    • Don’t insert a needle through a burn, oedema or infected tissue
    • Don’t insert a CVC into an area with localised deformity, e.g. clavicular or femoral fracture
    • Don’t insert a subclavian CVC on the same side as a pacemaker
    • Don’t insert a subclavian CVC into a coagulopathic patient
    • Avoid a femoral CVC in a patient who is incontinent - especially of faeces

Internal Jugular Vein

    • Look

    • Between the two heads of the sternocleidomastoid muscle - ask the patient to turn their head.
  • To identify the vein using ultrasound, place the probe between the two heads of the sternocleidomastoid and look for a large-bore, non-pulsating, collapsible vessel lateral to the carotid artery.
    • Considerations

    • Use the right internal jugular vein where possible, due to its larger diameter and proximity to the superior vena cava.

Subclavian Vein

  • Identify the junction of the medial third and lateral two-thirds of the clavicle. The needle should be inserted 1cm inferior and lateral to this, pointing toward the sternal notch, upward and away from the underlying lung apex.
    • Considerations

    • Avoid in patients with clavicular fracture
    • Avoid in coagulopathic patients, as it is impossible to compress the artery if it is punctured
    • Avoid on the same side as a pacemaker

Femoral Vein

  • To identify the vein using ultrasound, place the probe in the groin over the femoral triangle, below the inguinal ligament. Look for a large-bore, non-pulsating, collapsible vessel medial to the femoral artery.
    • Considerations

    • Makes ambulation difficult
    • Preferred for coagulopathic patients, due to ability to compress the site
    • Higher risk of infection
    • Higher risk of thrombosis
 
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 Bannon MP, Heller SF, Rivera M. Anatomic considerations for central venous cannulation. Risk Manag Healthc Policy. 2011;4:27-39. Czepizak CA, O’Callaghan JM, Venus B. Evaluation of formulas for optimal positioning of central venous catheters. Chest. 1995 Jun 30;107(6):1662-4.
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 Vesely TM. Central venous catheter tip position: a continuing controversy. Journal of Vascular and Interventional Radiology. 2003 May 31;14(5):527-34.