Choice of Route

The Internal Jugular route represents less risk than Subclavian in unpractised hands.  Subclavian catheterization is the route of choice from an infective risk perspective, followed by internal jugular and then femoral.  Each site has characteristics which make it preferable under certain circumstances, and where the operator is in any doubt, this should be discussed with senior staff members.

Subclavian

Avoid situations where pneumothorax would be fatal, (ie. Severe respiratory failure, lung hyperinflation).

Avoid patients therapeutically anticoagulated or coagulopathic

  • INR > 2.0
  • APTT >50 sec
  • Platelet count <50 000

It may be appropriate to attempt to reverse abnormal clotting prior to insertion of a CV catheter, however this should be discussed with the duty Intensive Care Specialist.

Always choose side of the chest that is least effective for ventilation, or in which there is already an intercostal catheter.

Internal Jugular

This route is associated with a higher risk of infection than subclavian access.  However there is a lower risk of pleural puncture (for high jugular approach) and better control of haemorrhage than the subclavian approach.

Internal Jugular approach is the route of choice for dialysis catheter insertion for awake patients.

Femoral

Femoral catheterization has been thought to confer a high risk of infection relative to subclavian access, but this is not correct.  The incidence of thrombosis is probably similar to other sites.

Good flow characteristics for dialysis catheters, using a 20cm or longer catheter, (co-operative or sedated patients).

Relatively low risk route for inexperienced operators in high risk patients (ie; uncorrected coagulopathy, severe respiratory failure).

Reference

Merrer J et al.  Complications of femoral and subclavian venous catheterization in critically ill patients.  JAMA 2001.  Aug 286 (6): 700-707.

Line Management

Routine line replacement is not required.

Consider removing lines if:

  • They are not required any longer

  • The patient has evidence of unexplained systemic infection

  • Insertion site infection or positive blood culture with likely organism (S epidermidis)

 
Guide wire exchanges should not be performed unless discussed with the duty intensive care specialist.

Complications

At insertion:

  • Arterial puncture

  • Pneumothorax

  • Neural injury (phrenic nerve, brachial plexus, femoral nerve, cervical plexus)

  • Atrial ectopy, arrhythmia

 

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Page last reviewed: 13 May 2014
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