Teaching topics from the New England Journal of Medicine - Vol. 357, No. 24, December 13, 2007
Procedure: Central Venous Catheterization
The placement of a central venous catheter is indicated for the continuous monitoring of central venous pressure and for the delivery of critical or caustic medications.
Complications of Central Line Placement
Specific complications associated temporarily with placement of a subclavian line include hemothorax and pneumothorax, air embolism, inadvertent arterial puncture, and aortic perforation. Obtain a chest radiograph after placement to assess for complications and to confirm correct placement of the catheter. Common malplacement locations include placement transverse to the contralateral subclavian vein, retrograde into the ipsilateral internal jugular vein, or potentially the contralateral internal jugular vein.
Guidelines to Decrease Risk of Infection
The Institute for Healthcare Improvement has developed specific guidelines to help decrease the risk of infection in patients with central venous catheters. The guidelines include the use of proper hand hygiene, the use of maximal barrier precautions during placement, the use of chlorhexidine skin antisepsis, and daily review of the need for the catheter.
Morning Report Questions
Q: In what position should a patient be placed in for insertion of a central line in the subclavian vein? Does the use of a rolled towel under the spine increase or decrease the size of the subclavian vein?
A: A patient who is undergoing placement of a central line in the subclavian vein should be placed in a 15-degree Trendelenburg position. If you place a rolled towel or similar object under the spine to help identify the patient's external landmarks, be aware that propping the shoulder or turning the head has been shown to decrease the size of the vein on ultrasonography.
Q: What are general contraindications for placement of a central venous catheter?
A: General contraindications for placement of a central venous catheter include infection of the area overlying the target vein and thrombosis of the target vein. Specific contraindications to the subclavian approach include fracture of the ipsilateral clavicle or anterior proximal ribs, which can distort the anatomy and make placement difficult. Greater caution should be used when placing a central venous catheter in coagulopathic patients. The location of the artery (beneath the clavicle) makes application of direct pressure nearly impossible in attempts to control bleeding.
這裡有 teaching video 可以下載：
http://content.nejm.org/cgi/video_dl/357/24/e26/
Procedure: Central Venous Catheterization
The placement of a central venous catheter is indicated for the continuous monitoring of central venous pressure and for the delivery of critical or caustic medications.
Complications of Central Line Placement
Specific complications associated temporarily with placement of a subclavian line include hemothorax and pneumothorax, air embolism, inadvertent arterial puncture, and aortic perforation. Obtain a chest radiograph after placement to assess for complications and to confirm correct placement of the catheter. Common malplacement locations include placement transverse to the contralateral subclavian vein, retrograde into the ipsilateral internal jugular vein, or potentially the contralateral internal jugular vein.
Guidelines to Decrease Risk of Infection
The Institute for Healthcare Improvement has developed specific guidelines to help decrease the risk of infection in patients with central venous catheters. The guidelines include the use of proper hand hygiene, the use of maximal barrier precautions during placement, the use of chlorhexidine skin antisepsis, and daily review of the need for the catheter.
Morning Report Questions
Q: In what position should a patient be placed in for insertion of a central line in the subclavian vein? Does the use of a rolled towel under the spine increase or decrease the size of the subclavian vein?
A: A patient who is undergoing placement of a central line in the subclavian vein should be placed in a 15-degree Trendelenburg position. If you place a rolled towel or similar object under the spine to help identify the patient's external landmarks, be aware that propping the shoulder or turning the head has been shown to decrease the size of the vein on ultrasonography.
Q: What are general contraindications for placement of a central venous catheter?
A: General contraindications for placement of a central venous catheter include infection of the area overlying the target vein and thrombosis of the target vein. Specific contraindications to the subclavian approach include fracture of the ipsilateral clavicle or anterior proximal ribs, which can distort the anatomy and make placement difficult. Greater caution should be used when placing a central venous catheter in coagulopathic patients. The location of the artery (beneath the clavicle) makes application of direct pressure nearly impossible in attempts to control bleeding.
這裡有 teaching video 可以下載：
http://content.nejm.org/cgi/video_dl/357/24/e26/
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