COVID-19 / Coronavirus Outbreak: How To Establish A Central Venous Access By Placing A Central Venous Catheter

Coronavirus / COVID-19 Procedures
JoVE Journal
Coronavirus / COVID-19 Procedures
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Wunderlich, R., Nikomanis, P. S., Häberle, H., Münch, A. COVID-19 / Coronavirus Outbreak: How To Establish A Central Venous Access By Placing A Central Venous Catheter. J. Vis. Exp. (159), e6432, (2020).

Abstract

In pandemic times, medical staff is becoming a key resource in fighting the infection. To achieve the best medical care, relevant techniques and procedures have to be taught to medical staff while reducing the risk of infection. Intensive care medical treatment can necessitate central venous catheters due to different indications like vasopressor therapy or treatment of the patient with vein irrigating substances. This video shows the placement of central venous catheters for intensive care patients. 

Protocol

Indications for a central venous catheter include the need to apply vein irrigating substances, administration of short acting drugs like vasopressors or cytostatic drugs, measurement of central venous pressure and central venous blood oxygenation, or a poor peripheral vein status. A Shaldon-catheter can be placed if the patient needs hemodialysis in renal failure or a high flow volume access.

  1. Necessary materials should be prepared outside the patient room and placed on a sterile shelf.
  2. Don personal protective gear (gown, cap, goggles, gloves), as well as a FFP3 / N-95 mask, visor, and a second pair of gloves.
  3. Position the bed, set up the materials, and place the patient in supine position with their head rotated to the opposite side. Check the vital parameter monitoring and activate the QRS sound. If there are no contradictions for it, bring the patient into Trendelenburg position for better vein filling.
  4. Put additional towels under the neck and shoulder to absorb excess disinfection liquids.
  5. Perform a sonography of the puncture area to identify relevant anatomical structures and exclude intravascular clots. In this case, the internal jugular vein is used, but alternative puncture sites can be the femoral or subclavian veins. For a quick sonographic identification of anatomical structures, pressure can be applied to differentiate between the artery and the vein. 
  6. Perform a local anesthesia or deepen the sedation after disinfection of the puncture site.
  7. Don sterile gown and gloves.
  8. Perform a generous disinfection of the puncture area and place sterile covers around the disinfected area. Cover the sonic head with a sterile coat.
  9. The catheter should be prepared and all lumen filled with 0.9% NaCl to avoid air embolism during the procedure.
  10. Identify the vein you want to puncture using sonography (shown is the access to the internal jugular vein) and advance the cannula towards the vein under sonographic control with continuous aspiration.
  11. When blood is aspirable, advance the guidewire through the cannula to approximately 20cm. While advancing the wire, observe the ECG for extrasystoles, which indicate that the wire is near the right of the heart.
  12. Remove the cannula and perform a sonographic position control of the guidewire in the vein.
  13. If a Shaldon-catheter is needed, the placement of the guidewire must be repeated with another wire.
  14. Dilate the tissue with the dilatator. A small incision may be necessary in patients with rigid skin.
  15. Remove the dilatator and insert the central venous catheter. The catheter insertion depth depends on the patient's body height. It is important to hold the guidewire to avoid accidentally losing it in the patient. 
  16. Aspirate all lumen and flush with 0.9% NaCl.
  17. Secure the catheter with sutures and cover it with sterile bandages.
  18. If a Shaldon-catheter is needed, repeat the procedure in the same way as for the central venous catheter.
  19. If needed, blood cultures can be obtained under sterile conditions
  20. Remove the sterile covers.
  21. A chest X-ray may be performed for position control and to exclude complications like pneumothoraxes.

Disclosures

No conflicts of interest declared.