Central Venous Line (CVL) – Comprehensive Lecture Map

Vital-Sign Snapshot (Clinical Context — Page 1)

Typical bedside monitor display prior to or during central–line insertion
- ECG II/ECG V: heart rate $68\ \text{bpm}$
- Arterial blood pressure (ABP): $102/53\ \text{mmHg}$ (mean $73\ \text{mmHg}$ )
- Pulmonary-artery pressure (PAP): $28/9\ \text{mmHg}$ (mean $16\ \text{mmHg}$ )
- Central venous pressure (CVP): $4\ \text{mmHg}$
- SpO $_2$ : $100\%$
- End-tidal CO $<em>2$ (EtCO $</em>2$ ): $26\ \text{mmHg}$
- Airway pressure (AWP): $19/5\ \text{cm H}_2\text{O}$
- Anesthetic settings: EtISO $0.9\%$ , FiO $_2$ $56\%$ , tidal volume $530\ \text{mL}$
Significance: underscores need for hemodynamic access/monitoring and reminds that CVL placement often occurs in high-acuity settings.

Objectives (Page 2)

Master indications & contraindications
Recognize complications and how to mitigate them
Learn step-by-step technique (general + site-specific)
Review tips, materials, and troubleshooting pearls

Core Anatomy Refresher (Page 3)

Entry point often just inferior to the clavicle (subclavian) or at base of neck (IJ)
Catheter tip ideally resides in lower superior vena cava (SVC) near right atrium
Multiple hubs allow simultaneous infusions/pressure monitoring

Indications (Page 4)

Hemodynamic monitoring
- Central venous pressure (CVP) & venous blood gases
Rapid or large-volume resuscitation / difficult peripheral access
Cardiac arrest drug delivery
Hyperalimentation (TPN) & vesicant / concentrated solutions
Transvenous pacemaker or pressure wires (Swan-Ganz, etc.)
Specialized procedures: cardiac cath, pulmonary angiography, hemodialysis

Absolute Contraindications

Patient refusal / inability to cooperate
Uncorrected coagulopathy or thrombocytopenia ("bleeding diathesis")
Local skin infection, burn, or distorted landmarks
Existing pneumothorax/hemothorax on the contralateral side (risking bilateral PTX)

Relative Contraindications

Positive-end-expiratory pressure (PEEP) ventilation (raises PTX risk)
Single-lung patients (loss of remaining lung would be catastrophic)

Complications (Page 5)

Vascular

Arterial puncture, hematoma, AV fistula, thrombosis/embolus, air embolus

Infectious

Cellulitis, sepsis, osteomyelitis, septic arthritis

Miscellaneous / Mechanical

Dysrhythmias (wire-induced), catheter knotting/malposition
Pleural/mediastinal injuries: pneumothorax, hemothorax, hydrothorax, hemomediastinum
Organ injury: bowel or bladder perforation (rare, usually femoral/abdominal misadventure)
Nerve damage

Six Generic Steps (Page 6)

Patient positioning & site prep (Trendelenburg, full sterile field)
Venipuncture (aspirate dark non-pulsatile blood)
Guide-wire insertion (Seldinger technique)
Tract dilation
Catheter advancement over wire
Wire removal, flushing, securement, dressing

Triple-Lumen Catheter Color Coding (Page 7)

Blue = Medial lumen (gauge $18$ )
White = Proximal lumen (gauge $16$ )
Brown = Distal lumen (gauge $16$ ; highest flow, ideal for CVP/vasopressors)

Major Categories of Central Venous Catheters (Page 8)

Nontunneled
Tunneled
Peripherally inserted (PICC)
Totally implantable ports

Huber Needle (Page 9)

Non-coring needle used to access implanted ports without damaging the septum

Equipment Snapshot (Page 10)

Commercial kits (e.g., Arrow®) typically include:
- Introducer needle, guide-wire, dilator, syringe, scalpel, catheter, caps, suture, chlorhexidine, dressing
Medication examples: heparin $10\ \text{mg/mL}$ for locking, local lidocaine

Radiographic Examples (Pages 11–13)

Dialysis two-lumen catheter via left internal jugular; neck scars mark previous insertions
CXR: catheter coursing from right subclavian into SVC; confirm tip just above right atrium
Comparison of triple-lumen CVC vs. totally implanted port

Non-Tunneled External Catheters (Pages 14–15)

Material: polyurethane; lengths $6$ – $8$ inches, $1$ – $4$ lumens
Pros: quick bedside insertion/removal, high flow, low cost
Cons: higher infection risk, require secure dressing & frequent exchange
Usual veins: subclavian, internal jugular, femoral
Common brand: Quinton (often dialysis-specific)

Tunneled Catheters (Pages 16–18)

Placed surgically; catheter enters vein then tunnels subcutaneously to exit distant site
Dacron cuff promotes tissue ingrowth (infection barrier); no dressing needed after healing
Ideal for long-term therapy (months–years): chemotherapy, TPN, frequent transfusions
Brands: Hickman®, Groshong® (valved tip)
External segment repairable; sutures removed after $7$ – $10$ days

Peripherally Inserted Central Catheters — PICC (Page 19)

Inserted in arm (basilic > cephalic); tip advanced to SVC
Single or double lumen; bedside or interventional radiology procedure
Duration: weeks to months; useful for home-based IV antibiotics/TPN
Lower PTX risk; must monitor for DVT of upper extremity

Basic Principles for Any CVL (Page 20)

Confirm line necessity (risk–benefit)
Master surface & ultrasound anatomy
Familiarize with kit contents before draping
Optimize patient: supine, Trendelenburg 10$°–15$°, right-side preference (shorter path to SVC)
Sterile, slow, deliberate technique; request assistance early
ALWAYS aspirate for venous blood return before infusion
Post-procedure CXR for IJ & subclavian lines to verify tip & rule out PTX

Site-Specific Pros/Cons (Page 21)

Site	Advantages	Disadvantages
Internal Jugular	Bleeding visible & compressible; low malposition; lower PTX risk	Carotid puncture risk; PTX still possible
Femoral	Fast; no PTX; best in CPR/emergencies; few thoracic complications	Highest infection & DVT rates; inconvenient for ambulation
Subclavian	Comfortable, fixed landmarks	Highest PTX risk; vein non-compressible; avoid in infants < 2 yrs & ventilated pts

Subclavian Approach (Page 22–23)

Position: supine, Trendelenburg, arm abducted, shoulders neutral; right side preferred
Landmarks: junction of medial & middle thirds of clavicle, deltopectoral groove tubercle
Needle: advance parallel to skin, aiming at suprasternal notch while hugging inferior clavicle border
Confirm venous flash (<25 gtt/min), thread wire without resistance

Internal Jugular – Central Approach (Pages 24–26)

Landmarks: triangle between sternal & clavicular SCM heads + clavicle
Non-dominant hand palpates carotid; needle 30$°–40$° lateral to artery aiming at ipsilateral nipple
Vein depth $1$ – $1.5\ \text{cm}$ ; avoid deep probing to protect pleura & nerves

Femoral Approach (Pages 27–28)

Supine; identify NAVEL (nerve-artery-vein-empty-lymph) order from lateral to medial
Insert $2\ \text{cm}$ below inguinal ligament, medial to femoral pulse, needle 45$° toward umbilicus

Post-Catheter Tasks (Page 29)

Aspirate & flush each lumen with $10\ \text{mL}$ saline; verify brisk blood return
Replace all caps after blood draws; use Biopatch/CHG disk at exit site
Secure with sutures + transparent dressing (e.g., Tegaderm®)
Mandatory CXR for IJ & SC lines; measure catheter length vs. carina (~T4–T5) for tip location

Ultrasound-Guided Access (Page 30)

Becoming standard of care: real-time visualization ↓ complications
Allows measurement of vein diameter & compressibility (rule-out thrombus)
Particularly useful in obesity, coagulopathy, or variant anatomy

Central-Line Blood Draw Protocol (Pages 31–32)

Gather supplies: alcohol swabs, gloves, $10\ \text{mL}$ pre-filled NS syringes, empty syringes, tubes, vacutainer, sterile caps
Hand hygiene, apply gloves, hold infusions if safe
Disconnect IV tubing with sterile technique; scrub hub for $15\ \text{s}$ ("juice the orange")
Attach saline syringe, flush, then withdraw waste volume equal to catheter dead space (per policy)
Collect ordered specimens, then flush again with saline and lock per protocol

Order of Draw Mnemonic

“Bunnies Love Roaming Gardens, Looking for Delicious Leafy Greens, Yum!”

Blood Culture (yellow/BC bottles)
Light Blue – sodium citrate
Red – no additive / clot activator
Gold – SST
Light Green – lithium heparin
Dark Green – sodium heparin
Lavender – EDTA
Gray – sodium fluoride
Yellow – ACD solution

Ethical & Practical Considerations

Informed consent detailing risks (PTX, bleeding, infection) and alternatives (IO, peripheral)
Strict asepsis mitigates catheter-related bloodstream infection (CRBSI); bundle compliance audited in many ICUs
Daily reassessment: "Does the patient still need a central line?" (reduces dwell time & infection)
Competency validation for operators; simulation & ultrasound training now mandated by many boards/provider credentialing bodies

High-Yield Numerical Facts & Formulas

Ideal catheter tip: $2\ \text{cm}$ above right atrial junction (CXR carina rule)
CVP normal range: $2$ – $6\ \text{mmHg}$
MAP computed: $MAP = \dfrac{SBP + 2(DBP)}{3}$ (e.g., $\dfrac{102 + 2\times53}{3} = 73\ \text{mmHg}$ )
Flow varies with radius $r$ (Poiseuille): $Q \propto r^{4}$ — largest lumen → fastest transfusion

Quick Tips & Pearls

Trendelenburg augments IJ diameter ≈ $30\%$ and decreases air-embolism risk
Always keep patient in slight Trendelenburg until catheter capped/connected
If arrhythmia occurs while advancing wire, withdraw slightly—wire likely irritating endocardium
For subclavian attempts, abandoning after $3$ failed passes reduces PTX risk
Ultrasound: target compressible, non-pulsatile, round (short axis) or ovoid (long axis) vessel
Document catheter details: site, side, lumens, length inserted, lot number, patient tolerance

Integration with Prior Learning

Builds on aseptic technique principles from earlier surgical-skills lecture
Reinforces cardiovascular anatomy & physiology (venous return, pressure monitoring)
Provides real-world application for fluid-resuscitation pharmacology and hemodynamic equations examined previously

Commonly Tested Exam Points

Identify indication vs. contraindication scenarios
Match complication with prevention strategy (e.g., air embolus → Trendelenburg & Valsalva on removal)
Calculate MAP/CVP interpretation
Recognize correct CXR tip placement vs. malposition (e.g., azygous or right atrium)
Memorize order of draw & triple-lumen color coding