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Central Venous Catheter Insertion Guide a Comprehensive Introduction to Central line Insertion

Video Guide

Setup

Ultrasound Technique

Internal Jugular Vein (Short Axis View)

Internal Jugular Vein (Long Axis View with Manometry)

Axillary & Subclavian Veins

Femoral Vein

Peripherally Inserted Central Catheter

Self Test Questions

1. In the absence of allergies, which of the following is suitable for proceduralist hand washing prior to CVC insertion?

Chlorhexidine and alcohol are great at killing gram positive bacteria!

2. Which of the following is the lest reliable in detecting an accidental arterial puncture?

  • Arterio-venous blood gas comparison
  • Ultrasound imaging
  • Electronic digital manometry
  • Fluid column analog manometry

All 4 options are useful. Ultrasound is prone to mistaken misidentification of an artery which may be why the artery was cannulated in the first place. My preferred method, for what it is worth is fluid column analog manometry.

3. Which of the following organisms is least likely to cause a catheter related blood stream infection?

  • Coagulase-negative staphylococci
  • Enterococcus
  • E-coli
  • Candida

Most central line infections are caused by gram positive bacteria and, to a lesser degree, fungi. Gram negative line infections are rare.

4. When inserting a CVC into the right internal jugular vein of a 150 cm tall woman, which of the following skin-to-tip depths is most likely to correctly place the tip?

  • 19 cm
  • 16 cm
  • 14 cm
  • 15 cm

Check the Peres equations (page 9 of the written guide).

In the case of a right internal jugular vein insertion, the equation is (height in cm / 10) - 1.

5. As compared with chlorhexidine based solutions, povidone-iodine solutions are associated with aproxomately:

  • half as many catheter-related bloodstream infections
  • the same rate of catheter-related bloodstream infections
  • twice as many catheter-related bloodstream infections
  • four times as many catheter-related bloodstream infections

This is a big deal. Use chlorhexidine unless you have a good reason not to.

6. Choose the least suitable site for a central line insertion in a patient with severe liver failure.

  • left internal jugular vein
  • left femoral vein
  • right subclavian vein
  • basilic (PICC)

The concern here is coagulopathy and, mainly, thrombocytopenia. If a patient has a significant bleeding tendency the subclavian should be the vein of last resort.

7. As compared with the unsheathed introducing needle, the catheter-on-needle supplied in the Arrow™ CVC kit is generally:

  • Better for finding the vein in obese patients
  • Better for inserting subclavian CVCs
  • Reduces the risk of fracturing the guid wire
  • Is more visible on ultrasound

Most prefer to use an unsheathed introducing needle to cannulate the vein and advance the needle through. It is stiffer and easier to manipulate, especially deeper in soft tissue. If it is your preference you should be aware of the risk of fracturing the guide wire if you retract it through the the unsheathed needle.

8. Of the following complications of a sub-clavian central line insertion, which is more common on left side?

  • pneumothorax
  • arterial puncture
  • thoracic duct injury
  • tracheal trauma

9. What is the most appropriate step in managing inadvertent catheterisation of of an artery?

  • immediate removal of the catheter and manual compression for 5 minutes
  • immediate removal of the catheter and manual compression for 20 minutes
  • in an emergency situation, it is acceptable to use the catheter for infusions
  • consult vascular surgery

Once an artery has been dilated the vessel is going to need a surgeon to fix the damage. External pressure is unlikely to be enough.

10. Which of the following is not an advantage of right over left sided internal jugular CVC insertion?

  • Lower risk of chylothorax
  • There is a lower risk of cardiac arrhythmia with insertions on the right
  • The right internal jugular vein tends to be bigger than the left
  • The right internal jugular vein tends to be more superficial than the left

Most factors favour a right sided approach, especially if the proceduralist is right hand dominant. One might expect the wire to advance into the heart more often on the right but this is not born out in clinical trials.

11. When positioning a patient for an internal jugular vein CVC insertion, what is the ideal amount of patient head rotation?

  • 30 degrees towards the side of insertion
  • 15 degrees away from the side of insertion
  • 45 degrees away from the side of insertion
  • 60 degrees away from the side of insertion

I commonly see trainees rotating the head too far away from the site of insertion. Ultrasound research shows that this reduces the diameter of the internal jugular vein.

12. What is the most effective skin disinfectant in preventing central line infections?

  • 2% clorhexedine
  • 2% chlorhexedine and 70% alcohol
  • 7.5% povidone-iodine
  • 1% cetrimide

See page 5 of the written guide.

Chaiyakunapruk N, Veenstra DL, Lipsky BA, Saint S. Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis. Ann. Intern. Med. 2002 Jun 4;136(11):792–801.

13. The axillary vein is a direct continuation of which vein?

  • Basilic
  • Cephalic
  • Venae comitantes
  • Brachial

14. Which is the correct formula for estimating the distance in centimetres from the right subclavian vein to the junction of the superior vena cava and right atrium?

  • Height / 10
  • Height / 10 - 2
  • Height / 10 + 4
  • Height / 10 + 2

15. Which of the following signs indicates a suitable clinical area to perform a CVC insertion?

You should be looking for the international sign for a "cardiac protected area."

16. Which of the following is the most reliable method to distinguish arterial from venous blood?

  • comparative blood gas analysis
  • ultrasound imaging of the catheter
  • aspirated blood colour
  • pressure contour

17. What is the typical rate of catheter-related bloodstream infections in a general ICU population?

  • 1–8 per 1000 catheter days
  • 10–18 per 1000 catheter days
  • 10–18 per 10 000 catheter days
  • < 1 per 100 000 catheter days

Most units used to achieve rates of CVC infection up around 8 per 1000 catheter-days. Now that we take the risk of line infection more seriously and are more careful about sterility most units achieve a rate closer to 2 per 1000 catheter-days.

18. Reserve your dominant hand for:

  • Controlling the needle and syringe
  • Manipulating the ultrasound probe
  • Anchoring the needle to the patient
  • Applying gauze with pressure

19. Which of the following should not be attempted via a peripherally inserted central catheter (PICC) in the basilic vein?

  • noradrenalin infusion
  • total parenteral nutrition (TPN)
  • central venous pressure (CVP) monitoring
  • calcium chloride infusion

CVP measurement via a PICC line is prone to error.

20. Which of the following statements with regards to ultrasound is false?

  • The guide wire does not cause ultrasound reverberation
  • Most ultrasound machines have an acoustic enhancement dial
  • Duplex ultrasound is helpful because it shows up arterial blood as red
  • The acoustic shadow created by the clavicle is not improved by adding more ultrasound jelly

Don't be fooled. BART — Blue, Away; Red, Towards so it depends on the orientation of your probe relative to the direction of flow of blood in the artery. Note also, even BART can be reversed in the preferences of some ultrasound machines.

21. Which of the following is the least appropriate for aggressive fluid resuscitation?

  • basilic (PICC)
  • right subclavian vein
  • left femoral vein
  • left internal jugular vein

PICCs have a long and narrow lumen and have very slow flow rates. PICCs are terrible for rapid fluid resuscitation. Multi-lumen CVCs are better but not ideal. Central vein sheath and rapid infusion catheters are ideal for rapid infusions.

22. In assessing a patient for CVC insertion, which of the following examination findings is least important?

  • An implanted pacemaker
  • Confusion
  • Arm cellulitis
  • Atrial fibrillation

Atrial fibrillation has no baring on the risks of CVC insertion and insertion site preference.

23. A suitable insertion point on the femoral vein is typically:

  • At the level of the ingunal ligament
  • Just superior to the junction with the superficial epigastric vein
  • Just superior to the junction with the great saphenous vein
  • Just medial to the point of maximal pulsation in the femoral triangle

The insertion point should definitely be inferior to the level of the inguinal ligament to avoid the potential of a bleed into a non tamponading space (the retroperitoneum). The junction with the superficial epigastric vein is usually at the level of the inguinal ligament. The position of maximal pulsation is a traditional landmark but it is inferior to ultrasound guidance. The junction with the great saphenous vein is safely inferior to the inguinal ligament.

24. As compared with a standard syringe, the hollow blue syringe (Raulerson syringe) that is supplied in the Arrow™ CVC kit makes it easier to:

  • Detect accidental arterial cannulation
  • Feel small variations in soft tissue as the needle and syringe are advanced
  • Feed the guide wire without disconnecting needle from syringe
  • Feel a loss of resistance to infiltration

The Raulerson syringe has many drawbacks but I do not use it mainly because I do not want to feed the guide wire without disconnecting needle from syringe. I want to see what colour the blood coming out of the patient is and how it is flowing. Without this advantage it holds no appeal.

25. When selecting the most appropriate CVC insertion site, of the following investigations, which is the least important?

  • Core temperature
  • Platelet count
  • Renal function studies
  • Blood group

Core temperature, platelet count and renal function can all affect haemostasis, which is a key factor in deciding the safest insertion site. As an aside, a low platelet count is more important than deranged clotting studies in predicting CVC insertion complications.

26. Which of the following is considered a microshock?

  • 75 microamps
  • 125 microamps
  • 10 milliamps
  • 1000 milliamps

See the written guide.

27. Which of the the following are least likely to indicate malplacement?

  • resistance to passage of wire
  • ectopic beats on ECG
  • chest pain
  • bright red blood

Ectopic beats on the ECG can be a sign that you are touching the myocardium and may be on the right track. Best retract the wire a bit though.

28. Which of the following insertion sites is generally the most suitable site for a CVC insertion during CPR?

  • Internal jugular vein
  • Axillary vein
  • Subclavian vein
  • Femoral vein

It is a matter of physical access. The top end of the patient tends to be crowded. There was even an RCT of IJ v Femoral insertion during CPR that found it took less time and was more successful to aim for the femoral vein.

29. The axillary vein becomes the subclavian vein:

  • As it passes over the lateral border of the first rib
  • At the junction with the cephalic vein
  • As it passes under the lateral border of the clavicle
  • At the point at which it crosses over the subclavian artery

30. What is the most effective way of preventing an accidental air embolus during and internal jugular vein CVC insertion?

  • Use of ultrasound guidance
  • The Trendelenburg position
  • Saline flushing the CVC lumens prior to insertion
  • Turning the patient’s head 30 degrees towards the contralatteral side

It is all about keeping the pressure gradients in favour of fluid coming out of the needle / CVC. Mainly a concern in the non-intubated patient.

31. As compared with CICCs, PICCs are associated with:

  • Lower rates of catheter-related bloodstream infections in critically ill patients
  • Lower rates of catheter-related DVTs
  • About the same rates of catheter-related bloodstream infections
  • Lower rates of thrombophlebitis

There is a common misconception that PICCs are safer than CVC. When studied with similar patient groups PICCs are associated with higher rates of thrombophlebitis and DVTs, and a similar rate of line infections.

32. What is a good anatomical reference point for checking CVC depth on chest X-ray?

  • SVC-atrial junction
  • Right pulmonary artery
  • Cardiac reflection
  • Carina

The carina is readily identifiable on the chest x-ray. This and its correlation with the midpoint of the superior vena cava (SVC) makes it an ideal landmark. The carina is about 6 cm long so provided the CVC tip is within 3 cm of the carina it probably lies safely in the SVC.