- What it is / Why you do it
- Large-bore venous access for:
- Vasoactive meds (pressors, inotropes) — avoid peripheral extravasation
- Hemodynamic monitoring (CVP, ScvO₂) (limited utility but testable)
- Rapid infusion (trauma/hemorrhage) if no good peripheral access
- High-osmolar/irritant infusions (TPN, chemo, hypertonic solutions)
- Frequent blood draws
- Hemodialysis/apheresis (needs dialysis catheter, not standard triple-lumen)
- Large-bore venous access for:
- Common sites (pros/cons)
- Internal jugular (IJ) (often US-guided)
- Pros: Compressible (better if bleeding), good US visualization
- Cons: Carotid puncture, pt discomfort/neck mobility issues
- Subclavian
- Pros: Lowest infection risk, comfortable for long-term
- Cons: Not compressible → bad choice in coagulopathy; ↑ pneumothorax risk
- Femoral
- Pros: Fast during codes/trauma, avoids pneumothorax, easiest in shock
- Cons: ↑ infection + thrombosis risk; limits ambulation
- Internal jugular (IJ) (often US-guided)
Exam move: If high bleeding risk/coagulopathy, prefer IJ or femoral (compressible), avoid subclavian.
- Contraindications (practical, testable)
- Absolute (rare)
- Overlying infection/burn at insertion site
- Venous thrombosis/occlusion of target vessel
- Relative
- Coagulopathy/therapeutic anticoagulation (esp subclavian)
- Distorted anatomy (tumor, prior surgery/radiation)
- Severe hypoxemia/PEEP dependence (pneumothorax could be catastrophic → avoid subclavian)
- Absolute (rare)
- Technique essentials (high yield)
- Ultrasound guidance: improves success, ↓ arterial puncture/pneumothorax (esp IJ/femoral)
- Sterile technique: hand hygiene, cap/mask, sterile gown/gloves, full-body drape, chlorhexidine prep
- Seldinger technique: needle → guidewire → dilator → catheter
- Air embolism prevention
- Pt supine/Trendelenburg (IJ/subclavian)
- Occlusive dressings; clamp lumens; instruct pt not to inspire deeply during line manipulation
- Confirming placement
- IJ/Subclavian CVC: portable chest x-ray to confirm tip position + rule out pneumothorax (classic Step 2) c
- US can confirm venous cannulation and detect immediate pneumothorax, but many exams still expect post-procedure CXR
- Femoral: CXR not needed for pneumothorax; confirm function/aspiration/flush
- Complications (recognize + next step)
- Mechanical
- Pneumothorax (subclavian > IJ)
- Sx: sudden dyspnea, pleuritic CP, ↓ breath sounds
- Tx: O₂; needle decompression if tension → chest tube
- Pneumothorax (subclavian > IJ)
- Arterial puncture (carotid/femoral)
- Small needle puncture: remove + direct pressure
- Large-bore/dilator in artery: leave in place + vascular surgery
- Hematoma (esp anticoagulated)
- Air embolism
- Sx: acute resp distress, “mill wheel” murmur (classically)
- Tx: Left lateral decubitus + Trendelenburg, 100% O₂
- Arrhythmia (wire irritates RV) → pull back wire
- Malposition (contralateral veins, azygos, RA) → reposition
- Thrombotic
- Upper extremity DVT/SVC syndrome (arm/neck swelling, collateral veins)
- Infectious
- CLABSI risk: femoral highest; subclavian lowest
- Mechanical
- Line infection approach (Step 2 algorithm)
- Suspected CLABSI (fever/chills, no other source):
- Draw blood cultures (often from line + peripheral) before abx
- Start empiric IV abx if unstable/high risk
- Remove catheter if:
- Severe sepsis/hemodynamic instability
- Purulence at site
- Persistent bacteremia
- S. aureus, Candida, Pseudomonas, or complicated infection
- Consider catheter salvage only in select stable pts w/ low-virulence orgs + no complications
- Suspected CLABSI (fever/chills, no other source):
- Which access is “best” in common scenarios
- Code/CPR, crashing pt: femoral (fast, no pneumothorax)
- Need lowest infection risk for longer use: subclavian (if no coagulopathy)
- Coagulopathy: IJ (US-guided) or femoral; avoid subclavian
- High ventilator settings/severe COPD: avoid subclavian if possible (pneumothorax risk)