The tale of central venous line: Seldinger’s technique, indications, contraindications and complications

The tale of central venous line

• On December 29, 1831, William Brooke O’Shaughnessy who was a young medical graduate wrote to The Lancet one of the shortest and yet most significant letter ever sent to the journal. He presented the results of his own blood analyses and showed that the “copious diarrhoea of cholera leads to dehydration, electrolyte depletion, acidosis and N2 retention”, and that “treatment must depend on intravenous replacement of deficient salt and water. Doctors began testing his suggestions, leading to successfully saving lives of nearly half of their patients
• Thomas Latta, also known as the father of intravenous fluid therapy, was a GP from Leith who, in 1832, treated patients with his own fluid formula ( Na⁺ 134 , K⁺ 0, Ca⁺⁺ 0,Cl^_ 118 and HCO₃^– 16 mmol/L) and saved the lives of many patients. There were no needles at that time, so he cannulated the vein with a quill and used the veins from a pig as a conduit for infusion. He infused 6 pints of Latta’s solution and the patient showed signs of improvement and survived. Dr Latta did all this in Edinburgh Cholera Hospital.
• In1844, Frances Rynd introduced metallic needles.
• In 1852, Charles Pravas introduced his syringe which was made of silver.
• In 1929, Werner Forssmann was the first physician to use a trocar to cannulate the central veins. The applications and techniques have been progressively improved since then.
• In 1945, David Masa, an anaesthetist at the Mayo clinic, introduced a plastic needle, this in combination with the introduction of the aseptic technique by Walters in the same years and the autoclave in the 1950s, resulted in an explosion in the use of intravenous fluids.
• In 1953, Sven Ivar Seldinger, a Swedish Radiologist introduced his Seldinger technique for vascular access and this has become the dominant method in use. For this achievement he was awarded with the Noble prize in 1956.
• For the last two decades, central venous catheterisation has been made easier and safer by the availability of ultrasound.
• Central venous catheterisation is a form of invasive monitoring widely used in critical care, anaesthesia, emergency medicine, cardiology and other specialties. The most commonly used vessels are internal jugular vein and subclavian or femoral veins.

 

The following description is mainly for trainees, but may be of use to anyone involved in placing these devices. The acronyms are created in such a way that they could be remembered easily. For the sake of completion, Peripherally inserted central catheter lines are briefly mentioned also.

 

Practical steps while doing Seldinger’s technique, just remember”CVP”

(please see the diagram)

C Confirm patient’s ID

Consent checked

Contraindications looked for!

Competent ODA present

Check equipment eg Ultrasound and monitors

Convenient in supine/head down

Cervical area selected (usually)

Chlorhexidine 2% used to clean

Clean drapes

Cutaneous LA injected if awake

V Visualise (US Guidance) IJV

Vein cannulated

Venous blood aspirated

P  Push J wire into the cannula

Pull the needle out

Puncture site dilated

Plastic multilumen line railroaded

Prove that line is in the vein(USG)

Plaster dressing/stitching done

Pressure transducer attached

Post-procedure X-ray chest

Pneumothorax looked for

Procedure documented

 

Indications for Central venous catheterisation

To mention the indications for CVP line insertion, refer to” CENTRALINE”

C    CVP monitoring in critically ill patient

Continuous Renal replacement therapy

E     Exsanguinating patient

N    Nutritional support (Parenteral nutrition)

T     Transvenous pacing

R    Resuscitation (post-cardiac arrest)

A    Administration of inotropes

L     Long term tunnelled CVP for chemo

I      Introducer for pulmonary artery catheter

N    None/absent peripheral veins

E     Extraction of air embolus (rare indication)

    

 

Surgical indications (remember SELDINGER)

S  Stenting of IJV/subclavian vein

E   Endocrine surgery eg.phaeochromcytoma

L  Liver transplant

D  Dissecting Aortic aneurysm

I   IVC filter

N  Neurosurgery eg.acoustic neuroma

G  Gut/intestinal transplant

E  Extracorporeal circulation eg.ECMO CPR

R  Radiological eg.TIPs

 

 

 

Contraindications to CVP line insertion

Remember “10Cs”

C Consent?

C Confidence/competence of clinician?

C Combatant patient if awake

C Coagulation problems

C Congenital anomaly of the neck

C Cervical trauma

C Contaminated site

C Constricted/stenotic vein

C Clot in the vein

C Calcified tricuspid valve?

 

Complications of CVP line insertion

Remember ”VAS-CATHETER”

V    Vascular injury (carotid puncture, less when USG used)

A    Arrhythmias

S     Sepsis and infections

 

C    Cardiac tamponade

A    Air embolism

T     Thoracic duct injury (chylothrax)

H    Haemothorax, pneumothorax

E     Erosion (late complication)

T     Thrombosis

E     Embolization of guidewire

R    Reaction to plastic material and/or antibiotic coating

 

Indications for PICC line

PICC line means a peripherally inserted central catheter. It is an alternative approach to CVP line insertion (internal jugular or subclavian venous approach).In some situations where that approach is contraindicated ie trauma to C-spine.PICC lines can be inserted into a peripheral vein into antecubital fossa. To remember the indications, remember peripherally inserted central venous catheter (PICVC).

P Parenteral nutrition

I Inotropes infusion

C Chemotherapy

V Vesicant drugs being used

C Contraindications to IJV

 

 

 

References:

1.Seldinger SI(1953)” Catheter replacement of the needle in percutaneous angiography” Acta   Radiology 39(5):368-76

2.Higgs ZC,Mcafee DA,Braithwaite BD, Maxwell-Armstrong CA(2005) lancet 366(9494):1407-9

 

Authors:

Dr Sher Mohammad¹ and Dr Martin Rowland², Dr Naveena Sukumaram³ ,Dr Diaeddin Sagar⁴ and Dr Amjad Hussain⁵

             Consultant anaesthetist^1,2, SAS anaesthetics³ ,Trainee ACCS⁴, ST1 Radiology⁵

             Royal Hallamshire Hospital, Sheffield

             Email: sher.mohammed@nhs.net