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Guide for Central Venous Catheterization

CentralVenousCathete

rs


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The handbook series cvc-partner deals with the use and application ofcentral venous catheters. Arterial or pulmonary catheters, hemodialysiscatheters, tunneled or implanted catheters are not included in the

category of central venous catheters in this series.

All information corresponds to the current standard of knowledge inthe field.

The absence of trademarks does not indicate that product names arenot protected.

This series has been prepared in consultation with many users towhom we wish to express our heartfelt gratitude for their variouscontributions. It is the intention of this series to assist the varioususers which needs a continuos dialogue with our readers. Any comment

or tip is welcome and should be sent to [email protected] orplaced at the homepage www.cvc-partner.com.


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Guide for Central Venous Catheterization


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Preface

The present handbook is part of a new, unique concept wheremedical specialists demonstrate the technique of centralvenipuncture for other medical staff.The manual contains a concise summary of the skills necessaryfor central venipuncture, and in combination with the corre-sponding video tape Introduction of Central Venous Cathetersby the Seldinger Technique all practical aspects of this interven-tion are described and shown in detail.Central venous catheterisation allows for an adequate therapy ofcritically ill patients during complex therapeutic interventions,especially in anaesthesia, intensive care and emergency medi-cine. A successful venipuncture requires profound knowledge ofthe indication and anatomic conditions, comprehensive experi-ences, a precise technique as well as high quality instruments(puncture set and catheter). Continuous technical developmentsand the resulting improvements led to a significant increase inpatient safety. Todays medical professionals can choose from avariety of catheters and puncture techniques to match the indi-vidual requirements of each patient. In case of elective insertionof a central venous catheter the method of choice should be theSeldinger technique due to a reduced trauma and a larger vari-ety of catheters available. After exact catheter positioning and

verification of the correct catheter tip position in the vena cava(right in front of the atrium) by ECG-control via the Seldingerwire, an additional x-ray control is usually no more necessary.This significantly reduces the costs as well as the exposure tox-rays for both, patients and medical staff.

The techniques of central venous catheterisation and catheterplacement via Seldinger wire can be learned easily by eachmedical specialist who is interested to do so. The presenthandbook on central venipuncture is a concise summary of theessential practical skills necessary for this intervention. Themedical who is willing to learn these techniques can profit wellfrom this practice-oriented manual. Tips from daily experienceswill help to build on his own experiences and to quickly gainpractical competence in this technique. To the experienced, thishandbook gives a survey on the current technical improvementsin catheter materials and puncture techniques. He will findinformation on how to further improve his technique as well assuggestions how to pass his knowledge and practical experienceson to medical assistants. I do hope that this excellent andpractice-oriented manual will find many readers, eager toimprove their knowledge.

Heidelberg, in March 2002

Prof. Dr. Johann MotschMedical DirectorDepartment of AnaesthesiologyUniversity Hospital Heidelberg


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1 When Is Central Venous Catheterization Indicated 7

2 Criteria for the Selecting of a Puncture Site 10

3 From venesection to the Seldinger technique 14

4 Selecting the proper catheter 18

5 Preperation for Catheterization 23

6 Catheter Placement with the Seldinger Method 26

7 Catheter Management 32

8 What To Do When Complications Occur 34

9 Glossary 38

Contents


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7

The increased rate of morbidityamong patients in critical caremedicine often necessitates complexanesthesiological interventions wherea central venous catheter can beessential. For each patient the

reasons for catheterization must begiven careful consideration.

When Is Central Venous Catheterization Indicated


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8

When Is Central Venous Catheterization Indicated

The history of central venous cannulation starts in 1929 whenForssmann described the advance of a plastic tube to the heartby puncturing his own arm vein (1). At the beginning of the1950s Aubaniac reported about the puncture of the subclavianvein. This puncture technique helped to broaden the use of thistechnically demanding procedure (2). Since this time centralvenous catheterization has developed to a standard procedure inroutine clinical practice. In critical care and emergency medicineas well as for long-term therapies such as chemotherapy or dial-ysis, the use of central venous catheters or central lines hasdeveloped into an essential element of medical practice. Theongoing technical development of these medical products hasresulted in a continual improvement of the therapeutic optionsfor patients.

A central venous catheter is selected (3), when an i.v. catheteris not sufficient for the intended clinical therapy and it isnecessary to have access to a large volume blood vessel for:

Quick administration of large volume substitution and/ordrugsAdministration of i.v. solutions or drugs in the event of thecollapse of peripheral vessels (shock)Administration of irritating or toxic drugs(e.g. catecholamines, chemotherapeutic agents)Administration of high-osmolarity solutions (> 800 mosm/l),e.g. for parenteral nutritionTherapies lasting several days or weeks which require

a venous accessVein-venous hemofiltration (dialysis)Measurement of central venous pressure during or afteran operation


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9

Central Venous Catheters

The catheter tip of the central line is always in the superioror inferior vena cava thus guaranteeing the rapid distribution ofinfused solutions in the vascular system. So-called midlinecatheters are not advanced to the vena cava but are positionedin one of the large veins in the vicinity of the heart (e.g. sub-clavian vein).

For patients with clotting disturbances, particular attention mustbe given to using a gentle puncture technique (e.g. the Seldingermethod, Section 3 From Venesection to the SeldingerTechnique). The puncture location must be carefullyselected when the patient has skin abnormalities such as scarsor burns or unusual anatomical features, e.g. a large goiter inthe puncture area. This is also the case when the operation fieldis in close vicinity to the puncture site.

The decision to make use of a central venous catheter mustalways be made on the basis of a strict risk-benefit analysis.The key point in making this decision is the following: A centralvenous catheter should only be used when other access routes orprocedures are not appropriate. The catheter should beremoved promptly as soon as it is no longer required.

(1) Forssmann, W.:Die Sondierung des rechten Herzens.Klin. Wschr. 1929, 8: 2080

(2) Aubaniac, R.:Linjection intraveineuse sosclaviculaire,advantages et technique.

Presse Mdicale 1952, 60: 1456(3) Kirby, R. R.:Clinical Anesthesia Practice.W.B. Saunders Philadelphia 2002,2nd edition: 531541

Literature


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Criteria for the Selection of a Puncture Site

A correct assessment of ones ownexperience, the patients condition andthe purpose for which the central venouscatheter will be used are the main factorsdetermining the selection of a puncturesite. Six different access sites havebecome widely used in clinical practiceowing to their favorable risk-benefitprofile.


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11

The six most frequently used access routes for central venouscatheters are:

the internal jugular veinthe subclavian veinthe basilic veinthe external jugular veinthe brachiocephalic veinthe femoral vein.

A range of other puncture sites including locations such as thecephalic vein or the brachial vein in the upper arm are used lessfrequently because of their anatomical variability (1).For most of the access routes there are at least two differentpuncture directions which may be employed. For the subclavianvein, for example, there is an infraclavicular and also a sub-clavicular puncture approach. A detailed description of thevarious puncture approaches is to be found in Latto et al. (1).The most important factors determining the selection of thepuncture site are:

the experience of the userthe condition of the patient, particularly the pressureconditions in the venous systemthe eventual use to which the central line will be put and

the situation in which the catheter is inserted (e.g. theavailability of sterile material for draping the patient andinserting the catheter).

Physicians with less extensive experience should choose anaccess route where a puncture mistake cannot result in life-threatening complications. A puncture location that fits this cri-terion is the basilic vein. This venous access is also used forlong-term therapies or for inserting catheters which are notadvanced all the way to the heart, e.g. midline catheters orperipherally inserted central venous catheters (PICC).If the circulatory condition of the patient is severely disturbed,then peripheral puncture locations are not suitable since theveins will be collapsed. In such cases, the subclavian vein or thebrachiocephalic vein are possible choices because the lumens ofthese veins always remain open as a result of their placement inconnective tissue. Risks associated with the puncture of theseveins can be found in the table presented below (2).If infusions are to be administered to a conscious patient via acentral venous catheter over a period of several weeks, then anaccess point should be selected that can be well tolerated by thepatient and easily maintained. The basilic vein or the subclavianvein is generally preferred in such cases.The femoral vein is only used when other access routes havebeen rejected. Typical indications for the puncture of thefemoral vein are burn injuries on the upper body or patients who

are undergoing long-term therapy that requires a rotation ofpuncture locations .

Basilic veinNo

The decision tree presented below provides assistance in selecting a puncture location depending on the specific situation.

Internal and external jugular veinSubclavian vein

Basilic veinBrachiocephalic vein

Femoral vein

Subclavian veinFemoral vein

Some experiencewith central venous cannulation

Almost normal blood pressure

Head injuries or Neck/Spine syndrome

Subclavian veinBrachiocephalic veinFemoral vein

No

Reanimation/State of shock

Internal jugular veinExternal jugular vein

Subclavian veinBrachiocephalic veinBasilic veinFemoral vein

No


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Criteria for the Selection of a Puncture Site

Knowledge

Beginner,experienced

Success rate

Almost 95%

Location

Hospital

Remark regarding puncture

Preferred: Internaljugular vein dextra (straightvein course)

Internal jugular vein

Experienced Almost 95 % Hospital,Particularly well-suitedfor emergency medicine

Lumen is always open evenfor shock patients, becausevein is fixed in mediastinalconnective tissue

Subclavian vein


About 80 % Hospital,Particularly well suited fornon-sterile surroundings

Easy to puncture, comparablewith i.v. cannula

Basilic vein


60 %90 % Hospital,particularly well suited foremergency medicine

Thrusting puncture of thevessel

External jugular vein

Experienced About 85 % Hospital,particularly well suited foremergency medicine

Lumen is always open evenfor shock patients, becausevein is fixed in mediastinalconnective tissue

Brachiocephalic vein(= Innominate vein)

Experienced Almost 95 % Hospital,Selected patients(burn cases, cardiology)

The puncture is done approx.1 cm medial of the artery in aslightly diagonal directiontowards proximal, in a depthof 24 cm

Femoral vein


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Special Features

Trendelenburg position,head turned away frompuncture site

Complications

Complication rate: 02 %;Puncture of the carotidartery; Pneumothorax,Hemothorax, Air embolism

Trendelenburg position, headturned slightly to the side;As catheter is advanced,head must be turned backtowards puncture site;

Valsalva maneuver canimprove the filling of the vein

Complication rate: 25 %;Pneumothorax, Hemothorax,Infusion thorax; Injury of thecranially positioned veinsand arteries;Damage of the brachial

Complication rate up to 17%Incorrect catheter placement

Difficulties in advancing thecatheter can be avoided byoverstretching the patientsarm

Trendelenburg position, headturned away from puncturesite; for better filling of thevein, apply pressure a fingerswidth above the clavicle

Complication rate: 211%;Unsuccessful puncture of thevein; Difficulty in advancingcatheter; Incorrect catheterplacement

Trendelenburg position, headturned away from puncturesite; not suitable for cervicalspine patients

Complication rate: not avail-able; Pneumothorax, Infusionthorax; Injury of the craniallypositioned subclavian artery

Place a cushion under thepatients buttock whenpuncturing the vena femoralis

Complication rate: 515 %;Thrombosis, lung embolism,ascending infections

(1) Latto, I. P. et al. (2000):Percutaneous central venous and arterial catheterization. W.

B. Saunders London 3rd edition(2) Malatinsky, J. et al.:

Misplacement and Loopformation of central venouscatheters. Acta Anaesth. Scan b. 1976, 20:237247

Literature

1

2

3

4

5

6

41

5

2

3

6


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From venesection to the Seldinger technique

Over the last 60 odd years, physicianshave gradually been improving thetechnique for inserting central venouscatheters beginning first with self-constructed devices and later usingindustrially produced items so that therisks for patients have steadily declined.

Today, the Seldinger technique is themethod of choice in many countries forplacing central venous catheters.


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(A)

(B)

(C)

Surgical venous incision (venesection)Prior to the invention of percutaneous kits to place a centralvenous catheter it was always necessary to surgically expose thevessel in order to introduce a venous catheter. Today this tech-nique is only rarely used, for example when implanting a long-term catheter or as last resort when other puncture techniquescannot be employed.To place the central venous catheter using this technique, thevessel is surgically exposed, clamped at two points and then

opened with a small incision. The proximal vein clamp is openedand the catheter is then introduced into the vessel lumenthrough the opening. Following this, the vessel and surroundingtissue are surgically closed. This placement technique can onlybe used for large-bore veins. Careful maintenance of asepticconditions is essential. The catheter placement requires a largeamount of time and is therefore only suitable for special indica-tions such as long-term catheterization.The technique should only be performed by experiencedspecialists and should not be employed on a routine basis.

Catheter-through-needle techniqueA significant improvement to the venesection was the firstpercutaneous method using a metal needle. After successfulpuncture of the vessel (A) the catheter is advanced through theneedle to the vena cava (B). As soon as the intended position hasbeen reached, the placement is checked by means of a chestradiograph. Then the steel needle is withdrawn and fixed at thedistal hub of the catheter (C). To avoid injuring the patient, thesharp bevel of the needle must be secured, for example with a

needle guard that is placed over the distal end of the catheterand the needle (1). This procedure represents a significantimprovement over venesection. However, the juncture betweenthe catheter and the puncture hole in the vessel wall is too loosewhich often results in hematoma formation. Another serious dis-advantage is the fact that the plastic catheter is inside a metalneedle. Withdrawal of the catheter through the needle must beavoided in all situations because this can result in the shearingoff of the plastic catheter tubing. In the worst case, the sharpneedle bevel cuts through the catheter. The resultant fragmentscan then enter the venous blood system and cause seriouscatheter embolisms (see chapter 8 What To Do When

Complications Occur).This puncture technique puts the patient at unnecessary risk, asthere are other procedures that allow a safe placement of a cen-tral venous catheter. The through-the-needle technique is not tobe performed on a routine basis.


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From venesection to the Seldinger technique

(A)

(B)

(C)

(A)

(B)

(C)

Catheter-over-needle techniqueCatheter-over needle kits quickly replaced the former puncturetechnique due to distinct technical improvements. For thismethod, a needle surrounded by a plastic cannula until close tothe needle tip is used to perform the puncture (A). Distal to thepatient, the plastic cannula gives way to a catheter, which issurrounded by a protective sheath. After puncture of the vein,the needle is withdrawn out of the catheter and the sheath via afine wire (B). The catheter is then advanced into the blood vessel(C) (1). In contrast to the catheter-through-needle technique,there is almost no hematoma formation since the catheter overthe needle completely fills the puncture hole created by theneedle. A negative aspect of this method is the fact that alarge-diameter puncture needle must be used, which makes thepuncture of the vessel sometimes difficult. In addition, there isno interior guidewire along which the catheter can be advancedin the vein. This makes it difficult to successfully place thecatheter along a venous course that is not straight, for examplewhen puncturing the subclavian vein. This puncture technique isprincipally suited for routine applications and in emergencysituations. However, it requires high manual dexterity and muchexperience.

Catheter-through-cannula techniqueThe introduction of the catheter-through cannula techniquein the Sixties greatly improved the placement security and thepatient safety. With this technique, the blood vessel is pre-punctured with an i.v. catheter. The i.v. catheter consists of aneedle surrounded by a plastic cannula. After puncture of thevessel, the needle is withdrawn (A) and the cannula remains inthe blood stream. The central venous catheter, which usually iscontained in a protective sheath, is connected to the cannula byan airtight coupling (B). The catheter is then advanced throughthe cannula into the blood vessel. Positioning is facilitated bymeans of a mandrin inside the catheter. The cannula isremoved distally after the correct catheter position has beenreached (C) (1).As the catheter is advanced it slides over the smooth plasticwalls of the cannula and not over a sharp needle edge. Theshearing off or separation of fragments from the central venouscatheter is clearly avoided. The through-cannula techniquepresents fewer risks for the patient and provides significantlybetter handling for the user, who is able to change the position

of the central venous catheter at any time during the placementprocedure.The catheter-through cannula technique is part of a physiciansstandard repertoire to be used in the hospital or in emergencysituations for central venous puncture.


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Guidewire technique = Seldinger techniqueThe Seldinger technique was first described in 1953 for anarterial approach (2). In the field of anesthesiology and criticalcare, the puncture technique quickly acquired a leading role.When puncturing the blood vessel, the user may choose betweena steel needle or an i.v. catheter. For safety reasons, the i.v.catheter is preferred. When using the i.v. catheter, the steelneedle is removed so that the plastic cannula remains in thevein. Through this cannula or alternatively a steel needle, aflexible guidewire is advanced into the vein (A). Then the needleor cannula is removed (B). The diameter of the puncture needleis always smaller than the central venous catheter. To facilitatethe entry of the catheter through the tissue, a dilator made ofplastic is put over the guidewire and advanced into the tissue.Then the central venous catheter is threaded over the wire andadvanced into the vein (C). The guidewire stabilizes the plasticcatheter and facilitates its positioning. After the placement ofthe catheter has been checked, the wire is removed (D).The puncture hole in the blood vessel can be kept very smallusing the Seldinger technique. This is a significant advantagewith patients suffering from clotting disorders. The centralvenous catheter, which always has a larger diameter than the

puncture needle, completely fills the original puncture hole.Hematoma formation is therefore almost entirely ruled out.Positioning of the central venous catheter is made much easierby the presence of the guidewire. The central venous catheter ismuch more readily advanced and directed through the veinthanks to the metal guidewire.Despite the exacting requirements for maintaining sterility andthe complexity of the puncture procedure, the Seldinger tech-nique has come to be very widely used. It is suitable for hospitaluse for all indications.

(1) Latto, I. P. et al.:Percutaneous central venous and arterial catheterisation.

W. B. Saunders London 2000, 3rd

edition: 1331(2) Seldinger, S. I.:Catheter replacement of needle in percutaneousarteriography: new technique.Acta Radiologica 1953, 39: 368

Literature

(A)

(B)

(C)

(D)


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Selecting the proper catheter

Technical advances have made centralvenous catheterization safe and easy, greatlyexpanding the application ofcentral venous catheters. The wide range ofcatheters offered by different

companies makes it possible to select anoptimal product for the particular therapyrequirements.


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Material choiceCentral venous catheters intended for short-term use up to30 days are usually made of polyurethane. Due to its low throm-bosis rate this plastic material is clearly superior to polyvinylchloride or polyethylene, which were commonly used in formertimes (1). At room temperature a catheter made of polyurethaneis sufficiently stiff to easily push it forward into the vein. After ashort time exposed to the 37 C temperature of the bloodstream,the polyurethane becomes softer and more flexible, thus reduc-ing the risk of irritating the venous wall. Polyvinyl chloride andpolyethylene catheters do not possess this softening character-istic and therefore should no longer be used (2).

Therefore central venous catheters are used for the short-termapplication espescially because of there mechanical charac-teristics (4).

For the long-term application a lot of special catheters areavailable.They are made of silicon (3) witch is known for its high biocom-patibilty and well proven mechanical characteristics.


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Soft tipThe quality of the catheter tipis of particular importance forcatheter placement. If the tiphas sharp edges or unevenpolymer outcroppings, theseproduct faults can injure thesensitive venous wall duringadvancing of the catheter.Injuries of the venous wallmight lead to thrombosis for-mation. A faulty catheter tip ofthis sort also creates risks afterplacement because thecatheter moves in the bloodvessel in conjunction with theheartbeat and might erode thevenous wall. A rounded andreadily malleable soft tip pro-vides safety during placementand also while the catheter isin use.

Surface qualityThe surface and workmanship of the plastic catheter representsan important quality criterion that affects the rate of complica-tions (5). Depending on the roughness of the catheter, bloodcells and plasma components such as fibrinogen are depositedon the catheter surface. The deposited blood platelets andplasma proteins act as an initiator and center of thrombusformation. A smooth catheter surface, in particular at thelumen apertures, is therefore a crucial factor in determiningwhether there will be rapid thrombus formation. Specialized

cardiological catheters (e.g. angiography catheters) oftendisplay special surface modifications such as hydrophilic

polymers or heparin coatings that should reducethrombus formation. In the anesthesiology field the

importance of such modifications is a matter ofdispute.

Placement control

A modern central venous catheter should be visible along its fulllength in a radiograph. To make the catheter visible in mostcases heavy metals are mixed into the plastic material. Shouldsome portion of the catheter tubing be cut off inside the patientor should the catheter form a loop, the radiographic contrastallows easy recovery of the catheter.In many cases, a radiograph procedure is used to check thecorrect placement of the catheter. In recent years, however, theuse of an ECG lead to check the position of the catheter tip hasbecome increasingly widespread. This technique provides areliable indication of catheter position even during catheterplacement (see Handbook 2). Various manufacturers offer sets

that allow the ECG signal to be conducted via a saline solution.A simpler and more elegant method is to conduct the ECGsignal via a conductive wire like the Seldinger guidewire. Inselecting a catheter set, this aspect of checking catheter positionwithout additional x-ray exposure should be taken into account.


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GuidewireAnother important component of Seldinger systems in additionto the catheter is the metallic guidewire. Following puncture,this wire is advanced into the blood vessel and then serves as aguide for the placement of the catheter (see Section 6). Theguidewire must be at once sturdy (so as to withstand hightensile force when being pulled) and highly flexible to facilitatethe advance of the catheter. These characteristics are obtainedwhen special hardened steel thread is closely wrappedaround a core. In addition, many manufacturersoffer guidewires either with straight or so-called J-tips. The J-tip gives way as soon as it encounters anobstacle and is therefore preferred so as to protectthe venous wall. Due to this high pliability, however, itis in rare instances difficult to find the access route tothe vena cava. In such cases, a second attempt should bemade using a straight tip. Both types of tip should, of course,have a rounded end and not have any outcroppings.

NeedlesOther components of the catheter set differ depending on themanufacturer, the intended use and the preferences of the

user. General recommendations are therefore difficult to make.B. Braun offers three different introduction needles for thepuncture of the vein: a Seldinger needle, an i.v. catheter or avalve needle. When using the i.v. catheter, the catheter isadvanced through the plastic cannula that remains in the blood-stream, making it highly unlikely that the catheter could besheared off by mistake. The Seldinger needle and valve needleeach consist of a steel needle; the valve needle, however,provides a second access port in a Y-fixture. Both needles areused for the Seldinger method. The guidewire is advancedthrough the steel needle. This must be performed with great carebecause the sharp bevel of the needle can damage the guidewire

(see Section 6). Both of these needle types should therefore onlybe used by experienced physicians. The second port of the valveneedle allows to advance the Seldinger wire into the bloodvessel while a syringe is attached to the needle.

(1) Curelaru, I. et al.:Thrombogenicity in Central Venous Catheterization III.A Comparison Between Soft Polyvinylchloride and SoftPolyurethane Elastomer, Long, Antebrachial Catheters.Acta Anaesth. Scan. 1984, 28: 204208Pottecher et al.:Thrombogenicity of central venous catheters.Europ J Anaesth 1984, 1: 361365

(2) Pearson, M. L. and the Hospital Infection Control PracticesAdvisory Committee (HICPAC): Guidelines for prevention ofintravascular-device-related infections. Infect Control HospEpidemiol 1996, 17: 438473.

(3) Moss, A. H. et al.:Use of a silicone catheter with a Dacron cuff for dialysisshort-term vascular access.Am J Kidney Dis 1988, 12: 492498.

(4) Lind, T.: Stability of intravenous catheter in long term use.

Lancet 1981: 673(5) Hecker, J. F., Scandrett, L. A.:

Roughness and thrombogenicity of the outer surfacesof intravascular catheters.J Biomed Mat Res 1985, 19: 381395

Literature


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Adults Children Adults

Diameter: 4F (18G)5F (16G)6F (14G)

Length: 15 cm, 20 cm, 30 cm

Diameter: 7F: 16G/16G14G/18G

9F: 13G/13G12F: 11G/11G

Length: 15 cm, 20 cm, 25 cm, 30 cm

Diameter: 7F: 16G/18G/18G12F: 16G/12G/12G

Length: 15 cm, 20 cm, 25 cm, 30 cm

Diameter: 9F: 16G/18G/18G/14G


Diameter: 12F:16G/18G/18G/18G/12G


Diameter: 3F (22G)4F (18G)


Diameter: 4F: 22G/22G5F: 18G/20G


Diameter: 5,5F: 20G/22G/22G


Diameter: 3F (22G)4F (18G)5F (16G)6F (14G)


Diameter: 4F: 18G/20G6F: 16G/18G

Length: 20 cm, 32 cm, 45 cm, 60 cm, 70 cm

CertofixSeldinger guidewire with J-tipCatheter with soft tip, transparent extension tubing and Safsitevalves, available with various puncture sets

Leading manufacturer offer a broad range of catheters suited to the age of the patient, the puncture site and the puncturetechnique. The following table show the product range of B. Braun Melsungen indicative of the wide variety of catheters availableon the market. A summary of catheters available from B. Braun Melsungen is attached to this handbook at the end.

CavafixCatheter with transparent protective sheathCatheter with plastic mandrin or ECG J-wire asmandrin, available with various puncture sets


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Preparation for Catheterization

Like all anesthesiological procedures,central venous catheterization demandsgood knowledge of the patient. Preventivemeasures such as positioning of the heador aseptic technique during inserting of thecatheter as well as follow-up

activities such as checking the catheterlumens for obstruction help to avoidcomplications.


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Preparation for Catheterization

Anamnesis / Reviewing medical recordsThe following subjects should be addressed with particularattention: Medication intake, in particular anti-coagulant therapy Previous infectious, pulmonary or cardiac illnesses Known allergic reactions

Visual inspection of the intended puncture site and theausculation of the lungs and heart are essential elements of thepatient examination. If the intended puncture site is not usableowing to a skin ailment or if it is located in the operating area,then a more suitable point of access should beselected. An ongoing anti-coagulation therapy necessitates acareful risk/benefit analysis and the selection of a puncturesite where a bleeding incident could be kept under control(e.g. jugular vein, basilic vein).

Clotting statusPrior to the insertion of a central venous catheter, the clottingstatus of the patient must be known. The following clinicalparameters are taken into consideration (1):

Thrombocyte count: Normal range 150400 x 109/l.

Thrombocytes are essential for blood clotting.Thrombopathy begins at 30 x109 thrombocytes/l.With an elevated thrombocyte count, the patient must beclosely monitored following the procedure so as to quicklyrecognize any developing infection.

Fibrinogen concentration: Normal range 24 g/l.Fibrinogen is essential for hemostasis. At 1,20 g/l thefibrinogen concentration is no longer sufficient forhemostasis during an operation.

Partial thromboplastin time (PTT): Normal range:

2640 seconds, longer with anti-coagulation therapy.Measure for the speed of blood clotting.Prolonged PTT times and a reduced thromboplastin time(see below) are indicative of serious disorders in the clotting sys-tem (e.g. consumptive coagulopathy, liver damage,anti-coagulation therapy).

Thromboplastin time or INR: Normal range: 0.71 (70100%).Anti-coagulation therapy reduces the value to 0.15.Measure for the speed of blood clotting. INR value of of 0.5(delayed blood clotting) requires a drug therapy to increase thevalue before a central venous catheter may be inserted.

Thrombin time (TT): Normal range 1822 seconds.This time becomes longer when the patient undergoes heparintherapy or when there is a high concentration of fibrinogenbreakdown products. Measure for the speed of blood clotting.

Length measurementAfter selection of the puncture location, the necessary catheterlength is determined by use of a measurement tape. When punc-turing the right subclavian or jugular vein the correctcatheter position immediately before the right atrium isreached in 1316 cm. The approach from the left side of thebody requires 1520 cm. If the anatomical landmarks areunclear, it is advisable to conduct an ultrasound examination ofthe course of the vein so as to make an accurate estimateof the required catheter length (2).

Ultrasound examination of the veinIt may be advisable to conduct an ultrasound examinationof the course of the vein depending on the experience of theuser or the anatomical situation of the patient (3). If it is notpossible to get a clear imaging of the course of the vein atthe planned puncture location, then it is better to select adifferent puncture site.


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Positioning of the patientIn the neck and shoulder region, the liquid pressure in the largeveins is lower than the atmospheric pressure. Unimpeded airentry through an 18G puncture needle could therefore allow asmuch as 100 ml of air to enter the venous system in a singlesecond. This can result in an air embolism and the death of thepatient.When puncturing the internal or external jugular veins as well asthe subclavian or brachiocephalic veins, it is advisable to put thepatients head in the Trendelenburg position. This entails lower-ing the head by 1530 with the patient in a supine position soas to increase the venous pressure (caution: cranio-cerebralinjuries with increased cranial pressure).No special positioning of the patient is necessary for puncture inthe region of the arm. For the most frequently used puncturetechniques the patient is placed in a dorsal position (4).

Sterile catheter placement techniqueThe central venous catheter forms a sort of bridge betweenthe outer world and the venous blood system, creating apossible pathway for the infiltration of germs.To avoid infection, strict aseptic practices should be observedwhen placing the catheter. Skin disinfection of the patient andof the physician inserting the catheter is essential (5). If acentral line must be inserted outside of the hospital, for examplein an emergency situation, then it is necessary to use a puncturetechnique that rules out the possibility of a contamination ofthe catheter. Commercially available catheter-through-cannulasystems provide safety sheaths that prevent direct contactbetween the catheter and the person inserting it. Care should betaken that all other components of the system are also handledunder aseptic conditions.In the hospital, there are no restrictions as to the employedpuncture technique arising from the surrounding sterileconditions. Central venous puncture is performed using amaximum sterile barrier practice. The physician performing thepuncture wears a mask, cap, gloves and gown. In the puncturearea, the patient is covered with a large, sterile drape.

(1) Hope, R. A. et al.:Oxford Handbook of clinical medicine. Bern 19903rd edition: 700701

(2) Kirby, R. R. et al.:Clinical Anesthesia Practice.W. B. Saunders Philadelphia 2002, 2nd edition: 531540

(3) Fry, W. R. et al.:Ultrasound guided central venous access. Arch Surg. 1999,134: 738741

(4) Latto, I. P. et al.:Percutaneous central venous and arterial catheterization.W. B. Saunders London 2000, 3rd edition

(5) Pearson, M. L. and the Hospital Infection Control PracticesAdvisory Committee (HICPAC):Guidelines for prevention of intravascular-device-relatedinfections.Infect Control Hosp Epidemiol 1996, 17: 438473.

Literature


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26

Catheter Placement with the Seldinger Method

The placement of a central venouscatheter using the Seldinger method iseasy to learn but requires some manualdexterity. Thanks to modern cathetertechnology, it is possible to preventsome complications such as incorrect

positioning of the catheter alreadyduring the placement procedure.


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21

Central venous puncture usually occurs in the context of acomprehensive anesthesiological intervention with the accompa-nying preparation of the patient (e.g. Trendelenburg position,sedation, intubation, etc.). Because of the better accessibility itaffords, the right internal jugular vein is recommended forright-handed physicians.

1The patient is disinfected in the puncturearea and amply covered with sterile drapes.

The head is turned to the opposite side andslightly extended dorsally. The puncture siteis located lateral to the easily felt carotidartery and between the two heads of thesternocleidomastoid muscle.

25 ml of a local anesthetic is injected into thepuncture area. With an attached syringe thepuncture needle is inserted in a caudal directionat an angle of 30 to the skin between the twobellies of the sternocleidomastoid muscle towardthe ipsilateral nipple. The vein is reached at adepth of 2.54.5 cm.


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28


543

3If the blood flowing backinto the syringe is mostlydark red and not flowingwith a pulsing rhythm(indicative of arterial blood),then the guidewire can be

advanced via the punctureneedle. Be sure that there isa secure connection between

the needle and the dispenserunit of the guidewire.

4The guidewire is at first inserted only 56 cm. The puncture needleis removed; the venous position of the guidewire must not be altered

during this procedure. The skin directly at the puncture site can bewidened with a scalpel (caution: do not damage the guidewire).A dilator that can be threaded over the guidewire and advanceddownward to the vein is a safer way of facilitating the subsequentintroduction of the catheter. The dilator is then removed.

5The central venous catheter is advancedinto the vein over the guidewire. A lengthmarking on the guidewire indicate whenthe catheter tip has almost reached the

tip of the wire but the flexible J-tipremains outside of the catheter. Whenthis point has been reached, the catheterand the guidewire are then advancedtogether further into the vein.


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29


876

6A universal adapter for conducting anelectrical signal from the guidewire isattached to the distal end of the guidewire.The ECG signal is switched over to theguidewire lead. The advancement of thecatheter (with the guidewire inside) iscontinually monitored on the ECG screen.

8All catheter lumens arechecked for possibleobstructions using physio-logical saline solution.

7When the catheter is advanced

into the right atrium, a pro-

nounced elevation of the

P-wave occurs in the electro-

cardiogram. It must be re-

tracted approximately 2 cm

and is now positioned correctly

in the superior vena cava.


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109

Checking the position of the central venous catheterThe correct position of the catheter is in the vena cava directlybefore the right atrium. If the catheter is too deeply inserted thecardiac muscle can be damaged, which in the worst case canresult in the death of the patient (cardiac tamponade).Commonly a chest radiograph is made directly after placementof the catheter. Modern catheter sets, however, make itpossible to spare the patient this x-ray exposure by conductingan ECG during the placement procedure. The catheter isinitially advanced to the point where an elevated P-wave isvisible in the electrocardiogram; then it is retracted 2 cm.The ECG reading returns to normal. The elimination of an

elevated P-wave is a clear signal of the catheters positionbefore the right atrium. In some circumstances, a chestradiograph may still be necessary to rule out the occurrenceof puncturing errors (e.g. a puncture of the pleural cavity).

10Blood on the skin at the puncture site is cleanedaway and the site is covered with a transparentdressing. The type of catheter and any compli-cations that may have occurred are noted in thepatients file.

9The sliding fixation wing is brought intoposition and the clip for catheter fixation

is attached. Unintended slippage of thecatheter out of the vena cava is ruled outas far as possible by this arrangement.The fixation wing is attached to the skinwith purse-string suture.


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Testing catheter functionDespite having checked the catheter position using the ECG lead,it is still essential to test that all the catheter lumens are free ofobstructions. A syringe filled with physiological saline solution is

connected to each of the lumens and blood is briefly aspirated.The aspirated solution is reinjected. If the aspiration or injectionis obstructed, then the position of the catheter must be verifiedwith a chest radiograph and corrected if necessary. If a Seldingersystem has been used, the repositioning can be done easily.Catheters of the over-the-needle and through-the-cannula typescan only be manipulated to a limited degree. If it is not possibleto free the catheter lumens, then the catheter must be removed.

Idle catheter lumenDepending on the policy of the particular hospital, unusedlumens may be filled with a so-called lock solution. The locksolution is composed of saline solution together with a heparinand/or an antibiotic. The solution in the catheter lumen preventsblood flowing back into the lumen. The heparin additive shouldhelp to prevent the deposit of blood platelets and resultant clotformation.

Asepsis during catheter careThe puncture site must be examined daily for signs of infection(redness), effluence and pain when pressed, so that any localinfection will be quickly recognized. A transparent dressing overthe puncture site facilitates this inspection. The dressing shouldbe changed in accordance with the hospital policy for cathetercare and if there is any indication of a local infection or conta-mination of the site. A local infection which is not recognized intime facilitates entry of bacteria and might damage the skinaround the puncture site. Depending on the degree of infection,it may be necessary to remove and replace the entire catheter.

Kirby, R. R. et al.:

Clinical Anesthesia Practice.W. B. Saunders Philadelphia 2002, 2nd edition: 531534Latto, I. P. et al.:Percutaneous central venous and arterial catheterization.W. B. Saunders London 2000, 3rd edition

Literature


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Catheter Management

32

Meticulous aseptic technique duringcatheter placement and catheter careis a prerequisite to avoid catheter-associated infections. The infusionsystem must be checked in the samecareful way as the catheter because of

the numerous possibilities for pathogengerms to enter the catheter via theluminal pathway.


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Depending on the indication central venous catheter can be usedshort-term, e.g. for 12 days or up to several weeks. A longerindwelling time increases the risk for the patient to acquire acatheter-associated infection which is one of the most seriouscomplications related to central venous catheterization (1).If clinical signs of a local infection at the puncture site (redness,tenderness, pain, heat) or of a systemic infection (fever, chilling,low blood pressure) occur and blood culture from two differentsites show bacteria whereas no second source for a bacteremiais obvious then a catheter-associated infection is proposed (2).

Top priority for the catheter management is to reduce thenumber of bacteria settling on the catheter's outer surface orinvading the bloodstream via the infusion lines.Bacteria can attach to the catheter surface during placement ifaseptic technique has not been properly adhered to e.g. duringemergency placement. Improper disinfection of the patients skinopens the possibility for bacteria to enter the bloodstream bymigrating along the catheter. Clinical studies indicate thatmeticulous aseptic technique during catheter placement lowersthe infection risk. This means mask, cap, glove and gown for the

physician and a large sterile dressing around the puncture site(3).

After catheter placement the puncture site is covered by awound dressing. In principle bacteria can quickly proliferatebeneath this dressing and migrate along the catheter into thebloodstream if the catheter surface does not prevent thisinvasion pathway. Careful, daily control of the puncture site andthe wound dressing is necessary to prevent bacterial invasion.Clotted blood or wound secretion at the puncture site must beremoved using sterile saline solution. If clinical signs of a local

infection are obvious the puncture site must be disinfected.Experts do not recommend the use of topical antibiotics (4).

Depending on the recommendations of the hospital the centralvenous catheter is immediately removed if a catheter-associatedinfection has been recognized. The central venous catheter caneasily be exchanged if a Seldinger guidewire is used.Replacing an infected catheter with a new one at the samesite has provoked some discussion because of the risk tocontaminate the new catheter (5).

Instead of an immediate replacement one could try to sanitizethe infected catheter. A highly concentrated antibiotic locksolution is filled into the lumen for several hours. The antibioticshould kill the bacteria on the catheter surface. The successrate for this method greatly differs leaving a high risk for the

patient to become septic if the antibiotic lock method has notworked.

Careful catheter care includes all measures related to theinfusion line. Any position in the infusion line that can beopened to the exterior, e.g. a stopcock or any change of theinfusion line opens the possibility for bacterial colonization ifaseptic techniques are not adhered to. Bacteria, which once haveentered the lumen of an infusion line, will migrate into thecatheter lumen and proliferate on it.A scheduled change of infusion line has shown some promise toavoid catheter-associated infections. Infusion lines which areused for infusing lipid containing solutions a change after 24 his recommended. Infusion lines for application of medicines orother infusion solutions can be exchanged after 48 h (3).

The importance of using a good aseptic technique will help toreduce the incidence of catheter-associated infections.

(1) Raad, I. I. :Intravascular-catheter related infections.Lancet 1998, 351: 893898

(2) Garner, J. S.:CDC definitions for nosocomial infections.Am J Infect Control 1988, 16: 128140

(3) Pearson, M. L. and the Hospital Infection Control PracticesAdvisory Committee (HICPAC):Guidelines for prevention of intravascular-device-relatedinfections.Infect Control Hosp Epidemiol 1996, 17: 438473

(4) Raad, I. I. et al.:Prevention of central venous catheter-related infections

by using maximal sterile barrier precautions during insertion.Infect Control Hosp Epidemiol 1994, 15: 231238

(5) Bach, A. et al.:Infections risk of replacing venous catheters by theguidewire technique. Zbl Hyg 1992, 193: 150159

Literature


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34

What To Do When Complications Occur

Central venous catheterization requiresrepeated practice to minimize the riskof complications. A correct estimationof ones own skills and the selection ofan appropriate puncture technique forthat skill level help to avoid unwanted

difficulties for the patient.


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Each puncture technique has its own risk profile independentof the users experience. The most important complications ofeach access method are described in section 2: Criteria for theSelecting of a Puncture Site.

The table on the following pages lists the complications thatoccur most frequently or that may be life threatening (seeLiterature 17). The second column shows when the first signs ofthe complication normally become evident (Onset Time).A strict division between early, late and long-term complicationsis not possible and therefore has not been made.If there are no symptoms of a complication in the first 15minutes following the puncture, it cannot be assumed thatthe catheterization is necessarily complication-free. Manyinjuries that are caused directly during the placement of thecentral venous catheter (e.g. damage to the inner wall of thevein) first become clinically recognizable some days later.The third column lists the clinical observations that will bemade in the event of the respective complications. The fourthcolumn indicates counter-measures that may be taken to limitthe effects of the complication.Complications which can be fatal when diagnosed too late are

highlighted in red in the table.

(1) Dailey, R. H.:Late vascular perforations by cvp catheter tips.J Emergency Med 1988, 6: 137140

(2) Gravenstein, N.:In vitro evaluation of relative perforating potential of centralvenous catheters: Comparison of materials, selected models,number of lumens, and angles of incidence to simulatedmembrane. J Clin Mat. 1991, 7: 16

(3) Fletcher, S. J. et al.:Safe placement of central venous catheters: where shouldthe tip of the catheter lie?Br. J Anaesth. 2000, 85: 188191

(4) Timsit, J.-F.:Central vein catheter-related thrombosis in intensivecare patients.Chest 1998, 114: 207213

(5) Malatinsky, J. et al.:Misplacement and Loopformation of central venouscatheters. Acta Anaesth. Scand 1976, 20: 237247

(6) Hennessey, B.:

Venous Air Embolism: Keep Your Patient out of Danger.Americ. J Nurs. 1993, 93: 5456

(7) Thomas, C. J., Butler, C. S.:Delayed pneumothorax and hydrothorax with central venouscatheter migration. Anaesthesia 1999, 54: 987998

Literature


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36

What To Do When Complications Occur

Complication

- Into tissue

- With perforation of the vessel

- With arterial damage

- With puncture of pleural cavity

- With nerve damage

- in another vein

- single lumen openings outside

the vein

- too deeply inserted in the rightatrium

- with puncture of the cardiacmuscle

- Catheter embolism

- Guidewire embolism- Air embolism

- Dysrhythmia

- Thrombosis

- Local infection

- Catheter associated infection tothe point of sepsis

Onset time

Immediately

Immediately

Immediately

In the first 15 minutes, on the same day

Immediately, in the first 15 minutes, on the same day

On the same day

Immediately, in the first 15 minutes, on the same day

Immediately

On the same day, within one week

Immediately

ImmediatelyImmediately, in the first 15 minutes

Immediately, on the same day, within one week

On the same day, within one week

Within one week

Within one week

Incorrect Puncture

Embolism

Incorrect catheter position

Other Disorders

Infection


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Observation

No reflux of blood, No other observable damage

Initially no reflux of blood; when needle is withdrawn reflux ofblood. Swift hematoma formation

Blood reflux in synch with pulse, brightly colored blood

No reflux of blood through lumen after infusionBreathing problems, PneumothoraxAbsent or delayed effect of administered drugs

Paresis

Usually coincidental chest radiograph finding

No reflux of blood through lumen, lumen obstructed for infusion

After infusion: tissue tender to touch (Hydrothorax)Absent or delayed effect of administered drugs

Arrhythmia, extrasystole

Pericardium tamponade, falling blood pressure, asystole,cardiac arrest

Portions of the puncture needle are missingPortions of the catheter are missing when retracted

Portions of the guidewire are missing when retractedOxygen deficiency, gasping breathingStop of circulation

Arrhythmia, extrasystoleVentricular fillibration from disturbance of cardiac impulsepropogation

Vein sensitive to pressure

Redness, effluence, puncture site sensitive to pressure

Fever or shivering, blood culture with detection of bacteria, lowblood pressure, oliguria

Counter-Measures

New puncture attempt at the same location (up to 3 times)or at a new location

Compression bandage, Change of puncture location

Compression bandage, surgical closure of vessel

Removal of catheter, Pleura drainage if pneumothoraxoccures

wait and see

Check with chest radiograph, with ECG

If possible, repositioning of catheter; if not, removal ofcatheter, new puncture

If possible, repositioning of catheter; if not, removal of

catheter, new puncture

Repositioning if possible

Pericardiocentesis, Resuscitation

Radiographic inspection, surgical removal or wait and see

Radiographic inspection, surgical removal or wait and seeCheck of all medical items in the infusion system for airtightness, respiration

ECG examination, Drug therapy, Defibrillation

Sonography, Application of anticoagulant drugs, Removalof catheter

Inspection and disinfection of puncture site

Broad-spectrum antibiotic therapy, Removal of catheter



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Glossar

Antibiotic lock technique

Catheter

Catheter-through-needle

Catheter-over-needle

Catheter-through-cannula

Cannula

Central venous catheter

Hemothorax

Hydrothorax

Intravenous catheter

Lock solution

Midline

Needle

Pneumothorax

PICC

Seldinger technique

Trendelenburg position

Tunneled catheter

Valsalva maneuver

Instillation of an highly concentrated antibiotic solution in the catheter lumen to eradicatebacteria on the catheter surface

Semi-rigid or soft plastic tubing of longer length used for central venous catheterization

Technique for cvc placement: catheter is pushed through a needle

Technique for cvc placement: needle is surrounded by catheter. After puncture needle isretracted and catheter remains in place

Technique for cvc placement: needle is surrounded by cannula and retracted after puncture.Catheter is pushed through the cannula

Short and rigid plastic tube, mainly used as intravenous catheter for short-term use

Venous catheter which has been placed either via peripheral veins or via large bore veins closeto the heart; its tip lies in the vena cava or close to the heart

Accumulation of blood beneath the pleura due to simultaneous puncturing of a large bloodvessel and the pleura

Accumulation of infusion solution beneath the pleura due to malposition of a catheter tip

Short venous catheter which is always placed via a peripheral vein

Physiological saline solution with or without heparin which is instilled in an idle catheter lumento prevent clot formation

Peripherally inserted venous catheter whose tip doesnt lie in the vena cava superior but moreperipherally

Metal tube with bevel to puncture tissue and blood vessels

Collapse of one or both lungs due to puncturing of the pleura and loss of pressure

Peripherally inserted central venous catheter whose tip lies in the superior vena cava

Technique for cvc placement: a metal guidewire is advanced through the puncture needleor i.v. catheter into the vein; the central venous catheter is threaded over the wire and aftercorrect placement of the catheter just before the atrium the wire is retracted

About 15 inclined position of head and chest to increase blood volume in abdominal veins

Exit site of central venous catheter is remote to the venipuncture site in order to prevent fastmigration of skin bacteria through the puncture site into the blood vessel

Expiration of patient through nose with closed lips, increases blood volume in subclavian vein


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