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Extra info for Critical Care: A Volume in the Requisites in Anesthesiology Series
Cardiac output was at one time determined using indicator dye methods (Fick principle) or manual thermodilution measurements using iced saline. Most catheters currently in use have instead a heater-coil which allows continuous automated cardiac output determination without the variability introduced by manual injections. The principle of thermodilution remains founded on a temperature gradient between the heater-coil and a more distally placed temperature sensor. The greater the cardiac output, the faster the blood flow around the catheter, and the less and more transient the change in blood temperature (Figure 3-12).
On the other hand, the catheter will bend and kink under the clavicle and therefore only the steel needle should be used for the subclavian approach. Following insertion of the guide wire, with the J-tip leading, the introducer needle or catheter is withdrawn and a dilator is inserted. A scalpel is used to cut the skin at the insertion site and facilitate passage of the dilator and, ultimately, the catheter. The smaller the cut, the smaller the chance of lacerating the EJ vein, or cutting into the IJ vein.
Medial (sternal) head of sternocleidomastoid muscle Carotid artery Trachea Figure 3-5 Clavicle Superior vena cava Cephalic vein Basilic vein Approaches to central venous access: (1) the anterior approach Sternum to the IJ vein in the high to mid-anterior triangle of the neck; (2) the supraclavicular approach; (3) the common entry point into the subclavian vein; (4) the posterior approach to the IJ vein. See text for details. Note that the carotid artery runs medial to the IJ vein. 5 cm above the clavicle into the neck.