CVP MONITORING,

SUBCLAVIAN VEIN
CATHETERIZATION, INTERNAL
JUGULAR VEIN CATHETERIZATION

GROUP 13
GROUP MEMBERS
● Badgaiyan, Ashutosh
● Khan, Shakil Ahmed
● Ruivanao, Wonyo
● Thengal, Mayushree
● Tou Pinto, Jessy Reinha
● Vuyyuru, Gyaneshwari Saibabu
 01
Central Venous
Pressure:
INTRO
 Definition
● Venous pressure

Venous pressure is a term that represents the average blood pressure within the
venous compartment

● Central venous pressure

CVP is also referred to as “filling pressure”, is the pressure of blood returning to,
or filling, the right atrium via inferior and superior vena cava
Pressure in the vena cava (CVP) is equal to the right atrial pressure (RAP)
It reflects the amount of blood returning to the heart and the ability of the heart to
pump the blood back into the arterial system.
Central Venous Catheter(CVC) :

● It is a catheter placed into a large vein.

● known as a central line(c-line), central venous line, or central venous access
catheter.
● It is a form of venous access.
● Catheters used are generally 15-30 cm in length made of silicone or polyurethane.
● These catheters are commonly placed in veins in the neck (internal jugular vein),
chest (subclavian vein or axillary vein), groin (femoral vein), or through veins in the
arms (also known as a PICC line, or peripherally inserted central catheters).
● Central lines are used to administer medication or fluids that are unable to be
taken by mouth
● To obtain blood tests (specifically the "central venous oxygen saturation")
● To administer fluid or blood products for large volume resuscitation, and to
measure central venous pressure.
Central venous catheters/Central lines

● It is a long, soft, thin, hollow tube that is placed

into a large vein emptying out in or near the
heart(SVC and IVC).
● A patient can get medicine, fluids, blood, or
nutrition through a central line. It also can be used
to draw blood.
● This type of catheter has special benefits in that it
can deliver fluids into a larger vein, and that it can
stay in the body for a longer period of time than a
usual, shorter IV.
● A central venous catheter differs from an
intravenous (IV) catheter placed in the hand or
arm (also called a “peripheral IV”).
● How is Central Venous Pressure taken?
video demonstration
Sites for Central
Venous
Catheters
Internal Jugular (IJV)
Most common
Quick & easy access (fewest risk)
Terminates in SVC (near R atrium)
Inserted to L – longer Catheter
Triangle's apex formed by the sternocleidomastoid
muscles’ two heads above the medial clavicle and is
usually 5 cm superior to the clavicle

Subclavian (SC)
More difficult to place Close to parallel to the skin as possible
until making contact with the clavicle
Terminates in SVC Under and along the inferior aspect of the
Inserted to L – longer Catheter clavicle towards the suprasternal notch
until venous blood is aspirated
.
Femoral
Least preferred
- Highest infection risk
Emergency (Δ 24 hrs.)
Terminates in IVC

1 to 2 cm inferior to the inguinal

ligament
CVC significance
Medications Nutrition
Some meds are irritants/vesicants ❏ No enteral nutrition
❏ Infused in small veins = issues ❏ Give via IV
❏ Large vein more dilution ❏ TPN (try to avoid)
Certain meds need central line
Other Indications
❏ vasopressors, chemotherapeutic agents
Multiple infusions (for really sick patients) Hemodialysis
❏ PIV prone to going bad/infiltrate ❏ Temporary access
❏ Secure access ❏ Faster flow rate
❏
Other Access
Fluids
❏ Transvenous Pacer
❏ Large volume fluid/blood ❏ Cardiac device
❏ Large catheters – ↑ flow ❏ SWAN - monitor the heart's function

Poor vascular access PIV almost

impossible
Risks involved
with CVC
 02
Internal jugular
vein
catheterization
 INTERNAL JUGULAR VEIN
CATHETERIZATION

Internal jugular vein catheterization, also known as

central venous catheterization, is a medical procedure
that involves the placement of a catheter into the internal
jugular vein. The internal jugular vein is a major vein
located in the neck that provides direct access to the
central venous system.
 INDICATIONS
● Secure or long-term venous access that is not available using other sites
● Inability to obtain peripheral venous access or intraosseous infusion
● IV infusion of concentrated or irritating fluids
● IV infusion of high flows or large fluid volumes beyond what is possible
using peripheral venous catheters
● Access to a large vein for administration of hypertonic solutions (eg, for
total parenteral nutrition [TPN])
● Monitoring of central venous pressure (CVP)
● Hemodialysis or plasmapheresis
● Transvenous cardiac pacing or pulmonary arterial monitoring
(Swan-Ganz catheter)
● Placement of inferior vena cava filter.
 CONTRAINDICATIONS
RELATIVE ABSOLUTE
● Coagulopathy, including therapeutic ● Internal jugular vein thrombosis
anticoagulation ● Local infection at the insertion site
● Local anatomic distortion, traumatic or ● Antibiotic-impregnated catheter in
congenital, or gross obesity allergic patient
● Superior vena cava syndrome
● Severe cardiorespiratory insufficiency
or increased intracranial or intraocular
pressure History of prior
catheterization of the intended central
vein
● Uncooperative patient Left bundle
branch block
EQUIPMENT (STERILE PROCEDURE):

● Antiseptic solution (eg, chlorhexidine-alcohol,

chlorhexidine, povidone iodine, alcohol)
● Large sterile drapes, towels
● Sterile head caps, masks, gowns, gloves
● Face shields
 EQUIPMENT (SELDINGER PROCEDURE):
● Cardiac monitor
● Local anesthetic (eg, 1% lidocaine without epinephrine, about 5 mL)
● Small anesthetic needle (eg, 25 to 27 gauge, about 1 inch [3 cm] long)
● Large anesthetic/finder* needle (22 gauge, about 1.5 inches [4 cm] long)
● Introducer needle (eg, thin-walled, 18 or 16 gauge, with internally beveled
hub, about 2.5 inches [6 cm] long)
● 3- and 5-mL syringes (use slip-tip syringes for the finder and introducer
needles)
● Guidewire, J-tipped
● Scalpel (#11 blade)
● Dilator
 EQUIPMENT (SELDINGER PROCEDURE):
● Central venous catheter (adult: 8
French or larger, minimum length for
internal jugular catheter is 15 cm for
right side, 20 cm for left side)
● Sterile gauze (eg, 4 × 4 inch [10 × 10
cm] squares)
● Sterile saline for flushing catheter port
or ports
● Nonabsorbable nylon or silk suture
(eg, 3-0 or 4-0)
● Chlorhexidine patch, transparent
occlusive dressing
* A finder needle is a thinner needle used for
locating the vein before inserting the introducer
needle. It is generally recommended for non
ultrasound–guided internal jugular vein
cannulation.
 Preparation
● Electrolytes and clotting time should be checked before the procedure.
● Ask for the past history of previous central catheters.
● Explain risks and benefits:
○ Risks include infection, pain, local bleeding or hematoma, or
pneumothorax/hemothorax.
● The patient should be placed on a cardiac monitor to detect any
dysrhythmias triggered while advancing with wire.
● Sterilize the neck and clavicle area with chlorhexidine.
● The patient should be placed in a supine position, fluoroscopy should be
available with arms tucked at each side.
● Provide adequate local anesthesia. (For the uncooperative patient,
consider sedation.)
Techniques
Techniques
Techniques
 Procedure
● STEP 1 : Place the patient supine and in Trendelenburg position
STEP 1
STEP 2

● STEP 2 : Locate the triangle of formed by

the clavicle and two heads of
sternocleidomastoid muscle.
 ● STEP 3 : Use a 25-gauge needle to
infiltrate the apex of the triangle to raise
a small skin wheal with local anesthetic.

● STEP 4 : Attach a large-bore, deep-line needle to a 10mL syringe

and introduce into the site of the skin wheal caudally directed to the
ipsilateral nipple and at 30-degree angle to the frontal plane.
● STEP 5 : Apply intermittent backpressure.
● STEP 6 : Remove the syringe ● STEP 7 : Nick skin with a
& insert a guidewire through no. 11 blade and advance a
the large-bore needle. dilator 5 cm through the
Remove the needle, leaving guidewire
guidewire in place.
 ● STEP 9 : Remove the guidewire
and attach the IV tubing
● STEP 8 : Remove the dilator with the appropriate IV solution,
and advance the catheter in and insert
over the guidewire triple lumen catheter.
 ● STEP 10 : Securely suture
the assembly in place with
2-0 or 3-0 silk

● STEP 11 : Apply an occlusive

dressing.
● STEP 12 : Obtain a chest radiograph
immediately to verify placement of the
catheter tip and to rule out
pneumothorax
 03
Subclavian Vein
Catheterization
Subclavian line can be placed quickly using anatomic
landmarks and are often performed in trauma settings
when cervical collars obliterate the access to the internal
jugular (IJ) vein.

This approach was first put into clinical practice in 1965

(Yoffa) and is an underused method for gaining central
access.
Objective: To puncture the subclavian vein in its superior
aspect just as it joins the internal jugular vein.

Advantages:

●Consistent landmarks
●Increased patient comfort
●Lower potential for infection or arterial injury compared
with other sites of access.
 Indications
●Secure or long-term venous access that is not available using other sites
●Inability to obtain peripheral venous access or intraosseous infusion
●IV infusion of concentrated or irritating fluids
●IV infusion of high flows or large fluid volumes beyond what is possible using
peripheral venous catheters
●Nutrition support (TPN)
●Monitoring of central venous pressure (CVP)
●Hemodialysis or plasmapheresis

★The subclavian vein may be less preferred for stiff catheters or large-bore
hemodialysis catheters.
★A subclavian CVC is preferred for long-term venous access in nonbedridden
patients.
Contradiction
Relative Absolute

1. Presence of anticoagulation or 1. Distorted local anatomy (eg. from

bleeding disorder. vascular injury)

2. Patient who is excessively underweight 2. Local infection at insertion site.

or overweight.

3. Uncooperative patient 3. Trauma or ipsilateral clavicle, anterior

proximal rib or subclavian vessels

4. Current or possible thrombolysis 4. Coagulopathy (direct pressure to stop

bleeding cannot be applied to the
subclavian vein or artery because of their
location beneath the clavicle.

5. Chest - wall deformity

 Personnel, Equipment & Preparation:
Personnel:
● Surgeon/vascular surgeon/anaesthesiologist/ ICU
doctor
● Nurse

Equipment: (Sterile procedure, barrier protection)

● Antiseptic solution (eg,

chlorhexidine-alcohol,chlorhexidine, povidone
iodine, alcohol)
● Large sterile drapes, towels.
● Sterile head caps, masks, gowns, gloves
● Face shields
 Equipment : Seldinger technique : Catheter -over-guidewire

● Local anaesthetic
● Small anaesthetic needle & Large
anaesthetic needle
● Introducer needle
● Syringe (3-5mL)
● Guide wire (I- trip)
● Scalpel (#11 blade)
● Dilator
● Central venous catheter
● Sterile gauze
● Sterile saline
● Non- absorbabale nylon/silk suture
● Chlorhexidine patch, transparent occlusive
dressing
Prepare the equipment
● Place sterile equipment on
sterilely covered equipment
trays.
● Dress in sterile garb and use
barrier protection.
● Draw the local anesthetic into
a syringe.
● Optional: Attach a finder
needle to a 5-mL syringe
with 1 to 2 mL of sterile saline
in it.
● Attach the introducer
needle to a 5-mL syringe
with 1 to 2 mL of sterile
saline in it. Align the bevel
of the needle with the
volume markings on the
syringe.

● Pre-flush all lines of the

CVC with 3 to 5 mL of
sterile saline and then close
the ports with caps or
syringes.
 Prepare for sterile field

● Swab a broad area of skin with

antiseptic solution, encompassing the
entire clavicular area, as well as the side
of the neck and anterior chest to below
the ipsilateral nipple.
● Allow the antiseptic solution to dry
● Place sterile drapes around the site.
● Place large sterile drapes (eg, a
full-body drape) to establish a large
sterile field.
 Procedure
Step 1
● Scan above the clavicle for subclavian
vein.
● Administer Lidocaine approximately 1-2
cm lateral to the midpoint of the clavicle.

Step 2
● Insert needle level up (with syringe
attached) 1 cm inferior to the clavicle
while aiming toward the sternal notch
using a very low 5-10 degree angle of
insertion.
● During insertion, continuously aspirate to
confirm entry into subclavian vein.
Step 3

● Once aspiration of blood is

confirmed, hold needle steady.
● Turn needle half turn.
● Disconnect syringe and immediately
place finger over hub of needle to
prevent entrance of air.
Step 4

● If using a Raulerson syringe, insert wire

through the opening in the distal part of
plunger.
● Gently insert wire into vein approximately
10 to 20 centimeters or half the length of
the wire feeling for wire advancement
through vein.
● Do not pull back against level of needle at
any time.
● While stabilizing the wire in the vessel
Step 5
● Maintain wire stabilization, remove the needle.
Step 6
● Perform a skin nick if
necessary.
● Maintain the angle of the wire.
● Dilate the skin and venous
tissue to make room for the
catheter by fitting dilator over
the wire.
● Advance the dilator by pushing
and rotating it into the tissue
until it enters the vein.
Step 7
● Remove dilator and stabilize the wire.
● Slowly thread the catheter over the wire. The wire will exit the distal lumen.
Grasp wire, maintaining control
Step 8
● Place needleless connector on catheter lumens.
● Clean the insertion site to prepare for dressing and securement.
● Suture catheter through catheter wings using curved needle or apply
sutureless securement device.
● Apply sterile dressing in keeping with facility policy.

Step 9
● Confirm catheter terminal tip placement in the
distal superior vena cava (SVC), ideally at the
cavoatrial junction, using x-ray, fluoroscopy or
electrocardiogram (EKG) per facility policy.
 04
Methods of CVP
monitoring
 Methods
2 methods of CVP monitoring:

1. Direct method (invasive)

2. Indirect method (non-invasive)

Direct method:-
a. Manual (via manometer)
b. Automated (transducer)

Indirect:-
Inspection of jugular vein pulsations in the
neck
 Direct (invasive ) method

Via Transducer

●500ml NS
●Pressure bag
●Transducer kit
●Transducer holder
●Transducer cable
●IV pole
Set up the equipment
●Maintain aseptic technique
●Open the transducer kit and tighten all the
connections
●Insert the 500 ml saline in the pressure bag, and
spike it with pressure tubing.
●Turn the bag upside down. Squeeze the bag gently.
●Hang it on IV pole.
●Squeeze the drip chamber until it is
half-filled with saline.
●Inflate the pressure bag to 300 mmHg and turn
stopcock to upwards
●Clamp IV tubing
●Place the transducer holder on IV pole
●Place transducer in transducer holder
●Attach the IV tubing and the PM line in the
transducer kit
●Unclamp the tubing and remove air from the
tubing by activating the flush device.
Phlebostatic axis: Level stop-cock on the
transducer to the Phlebostatic axis of the
patient
Attach the transducer cable to the
monitor
●Attach the transducer cable to the
monitor
●Turn the stopcock at the transducer
UPWARDS
●Remove the cap at the transducer,
now tubing is open to air.
●Hit “ZERO” on monitor
●Replace the cap
●Turn stopcock at transducer
horizontal (off to atmospheric air)
●CHECK THE WAVE FORM
 Check the wave form
❖The a wave reflects right atrial contraction.
a wave : This wave is due to the increased atrial pressure during right atrial contraction.
It correlates with the P wave on an EKG.
❖The c wave reflects closure of the tricuspid valve.

c wave : This wave is caused by a slight elevation of the tricuspid valve into the right
atrium during early ventricular contraction. It correlates with the end of the QRS
segment on an EKG.

❖The v wave reflects the right atrial filling during ventricular systole.
v wave : This wave arises from the pressure produced when the blood filling the right
atrium comes up against a closed tricuspid valve. It occurs as the T wave is ending on
an EKG.

❖The CVP measurement is the mean of the a wave.

❖x descent : This wave is probably caused by the downward movement of the ventricle during
systolic contraction. It occurs before the T wave on an EKG.
❖ y descent : This wave is produced by the tricuspid valve opening in diastole with blood flowing
into the right ventricle. It occurs before the P wave on an EKG.
 Direct (invasive ) method

Via Manometer
- Line up the manometer arm with the
phlebostatic axis ensuring that the
bubble is between the two lines of the
spirit level
- Move the manometer scale up and
down to allow the bubble to be aligned
with zero on the scale. This is referred
to as 'zeroing the manometer'.
- Turn the three-way tap off to the
patient and open to the
manometer
- Open the IV fluid bag and slowly
fill the manometer to a level
higher than the expected CVP
- Turn off the flow from the fluid
bag and open the threeway tap
from the manometer to the
patient
- When the fluid stops falling the
CVP measurement can be read.
If the fluid moves with the
patient's breathing, read the
measurement from the lower
number
- Turn the tap off to the
manometer
- Document the
measurement and report
any changes or
abnormalities

video demonstration
 Indirect method
video demo
THANK YOU !!
U