Central Line Placement


 INDICATIONS 
  • Need for CVP monitoring
  • Need for rapid volume resuscitation
  • Need for emergent venous access
  • Need for non-emergent venous access in patients with poor or no peripheral access
  • Need to infuse hyperalimentation or other concentrated solutions
  • Need for emergent hemodyalisis

  CONTRAINDICATIONS
  • Relative:
    • Distorted local anatomy or landmarks or previous radiation therapy
    • Cellulitis, burns, abrasions over insertion site
    • Suspected proximal vascular injury
    • Bleeding disorders or patient on anticoagulants

 
EQUIPTMENT
  • 1% lidocaine
  • 26-gauge needle
  • 2-mL Luer-Lok syringe (for anesthetic)
  • 10-mL non–Luer-Lok syringe (for catheter placement)
  • Swabs
  • Preparation solution
  • Gloves
  • Drapes
  • Catheter device
  • Intravenous tubing
  • Intravenous solution
  • Needle holder
  • 4-0 silk (or nylon) sutures
  • Suture scissors
  • Antibiotic ointment
  • Gauze pads
  • Tincture of benzoin
  • Cloth tape


 

Seldinger (guidewire) technique:

Thin-walled needle is used to introduce a guidewire into the vessel lumen. A catheter is placed over the guidewire and once it is in place, the guidewire is removed.

Steps Comments
1. Gown in standard sterile fashion. Use sterile gloves and gown. Wear mask and hair covering.
2. Identify vessel using either US guidance or landmarks. --
3. Prep and drape patient using standard sterile procedure. Prep a wide area so an alternate site can be used if initial attempts fail.
Prep the entire ipsilateral neck and upper chest when preparing to insert an internal jugular or subclavian catheter.
4. Open the central catheter kit. --
A. Inspect for content in a sterile fashion.
B. Place kit close to bedside and operator.
C. Maintain sterile conditions.
5. Anesthetize area in all conscious patients. Inject area with 1%–2% lidocaine.
Anesthetize the periosteum of the clavicle if using the subclavian approach.
Reorient to landmarks after injection.
6. Hold the 18-gauge introducer needle on a 10-mL syringe in the dominant hand and align the needle to the target. --
7. Advance the needle slowly though the skin and subcutaneous tissue until a flash of dark venous blood appears. Maintain steady constant aspiration of syringe.
8. Stabilize the needle with the nondominant hand. --
9. Check for continued free venous flow with aspiration. If no flow is noted, withdraw the needle slightly, as the needle may have breached the posterior vessel wall.
10. Remove the syringe attached to the needle and immediately occlude the catheter with a finger. This maneuver helps to prevent introducing air in the catheter and subsequent central system air embolism.
11. Insert the guidewire gently through the needle. Always maintain a firm grip on the wire -- do not let go of the wire for any reason. The wire should advance with minimal resistance.
Do not force the wire for any reason.
If the wire does not pass easily, reattach the syringe and aspirate to confirm continued venous flow.
Reposition the needle as needed.
Premature ventricular contractions or dysrhythmias during wire advancement may indicate that the wire is in the right atrium or beyond.
12. Remove the needle over the wire when the guidewire is inserted at least 10 cm into the vessel. --
13. Incise the skin with a #11 blade scalpel at the entry site to accommodate the venodilator or catheter. Do not cut the guidewire.
14. Advance the dilator or catheter over the guidewire into the vessel lumen with a gentle twisting motion. --
15. Remove the dilator (if used), and advance the catheter over the wire until the wire is advanced through the distal port. Maintain a grip on the guidewire during this procedure.
16. Grab the end of the guidewire. --
17. Advance the catheter to the appropriate depth. --
18. Remove the guidewire. --
19. Aspirate and flush all ports to confirm catheter function. --
20. Secure catheter with suture and apply a sterile transparent dressing. --
21. Confirm catheter placement in the superior vena cava with chest x-ray. A catheter tip in the right atrium can perforate the right atrium and cause hemothorax or hemomediastinum with pericardial tamponade.
Examine the chest x-ray for signs of complications.


A. Needle is inserted through skin and vessel until venous blood aspirated.
B.
Guidewire is inserted gently through the needle and advanced.
C.
Needle is removed over guidewire.
D.
The skin is incised.
E.
Dilator or catheter is inserted over the guidewire.
F.
The guidewire is removed

 

Subclavian technique

Overview: Patient is placed in Trendelenberg position. Vein lies posterior to the medial third of the clavicle. Aim needle toward suprasternal notch. Vein is entered at a depth of 3-4 cm .

Equipment:

  • Central venous catheter tray (line kit)
  • Sterile gloves
  • Antiseptic solution with skin swab
  • Sterile drapes or towels
  • Sterile gown
  • Sterile saline flush, approximately 30 mL
  • Lidocaine 1% (obtain additional vial of lidocaine 1% if needed)
  • Gauze
  • Dressing
  • Scalpel, No. 11

Positioning:

  • Place the patient in the supine position.
  • If possible, the bed should be raised to a comfortable height for the operator so bending over is unnecessary.
  • Do not place towels between the shoulder blades or turn the head, as this has been shown to decrease the size of the subclavian vein.
  • Place the patient in 15 º of Trendelenburg position to reduce the risk of air embolism. Increasing this angle does not improve vessel distention as the subclavian vein is fixed within surrounding tissue.
  • Needle insertion site options include the following:
    • 1 cm inferior to the junctions of the middle and medial third of the clavicle
    • Inferior to the clavicle at the deltopectoral groove
    • Just lateral to the midclavicular line, with the needle perpendicular along the inferior lateral clavicle
    • One fingerbreadth lateral to the angle of the clavicle
  • Sternal notch: Direct the insertion needle toward this target in the coronal plane.

Technique:

  1. Explain the procedure, benefits, risks, and complications and obtain a signed informed consent.
  2. Position the patient.
  3. Identify landmarks.
  4. Open the line kit, and position the equipment so it is easy to reach. One may want to retract the curved J-tip wire into the plastic loop sheath for easy directing into the introducer needle. Also, uncap the distal lumen, which is commonly the brown lumen.
  5. Prepare the insertion site with the iodine or alcohol solution provided in the kit. This amount of preparation is often inadequate, and a wide area around the insertion site should be liberally prepared with 4 x 4 cm gauze soaked in a povidone iodine solution (e.g., Betadine). Prepare the neck as well, in case the subclavian approach fails and another approach must be attempted.
  6. Put on sterile mask, gown, and gloves.
  7. Drape the patient in a sterile fashion, with the insertion site exposed.
  8. Using a generous amount of lidocaine 1%, infiltrate the skin, subcutaneous tissue, and, possibly, the clavicular periosteum.
  9. Position the bevel of the introducer needle in line with the numbers on the syringe. Upon insertion, orient the bevel to open caudally, which facilitates smooth caudal progression of the guide wire down the vein toward the right atrium.
  10. Insert the introducer needle at the desired landmark while gently withdrawing the plunger of the syringe. Advance the needle under and along the inferior border of the clavicle, making sure the needle is virtually horizontal to the chest wall. Once under the clavicle, the needle should be advanced toward the suprasternal notch until the vein is entered. If the vein is difficult to locate, remove the introducer needle, flush it clean of clots, and try again. Change insertion sites after 3 unsuccessful passes with the introducer needle.
  11. When venous blood is freely aspirated, disconnect the syringe from the needle, immediately occlude the lumen to prevent air embolism, and reach for the guide wire.
  12. Insert the guide wire through the needle into the vein with the J-tip directed caudally to improve successful placement into the subclavian vein. If using a kit that allows for the wire to be placed directly through a port on the syringe, then it is not necessary to disconnect the syringe. Beware that disconnecting the syringe gives the added benefit of allowing verification of nonpulsatile flow of venous blood.
  13. Advance the wire until it is mostly in the vein or until ectopy is seen on the cardiac monitor. Then, retract the wire 3-4 centimeters.
  14. Holding the wire in place, withdraw the introducer needle and set aside.
  15. Use the tip of the scalpel to make a small stab just against the wire to enlarge the catheter entry site.
  16. Thread the dilator over the wire and into the vein with a firm and gentle twisting motion while maintaining constant control of the wire. After the introducer is inserted, hold the wire in place and remove the dilator.
  17. Thread the catheter over the wire until it exits the distal (brown) lumen and grasp the wire as it exist the catheter. Continue to thread the catheter into the vein to the desired length.
  18. Hold the catheter in place and remove the wire. After the wire is removed, occlude the open lumen.
  19. Attach a syringe with some saline in it to the hub and aspirate blood. Take needed samples and then flush the line with saline and recap. Repeat this step with all lumens.
  20. Verify line placement with chest radiograph. The tip of the line should end in the vena cava at the manubriosternal angle, not in the right atrium.
  21. Suture the catheter in place. For patient comfort, the clinician may need to infiltrate this area prior to suturing.
  22. Apply a clean dressing.


 

 

 

Internal Jugular technique

Internal jugular: Patient is placed in Trendelenberg position and head is turned slightly away from puncture site. The vein usually lies anterior and lateral of the carotid artery just deep to the SCM muscle at the level of the thyroid cartilage. Vein can be accessed medial to the SCM aiming toward ipsilateral nipple (anterior approach), lateral to the SCM aiming towards sternoclavicular notch (posterior approach), and between the sternal and clavicular heads of the SCM (central approach) (see Figure 19.5).

NOTE:
 - Use 16 on Right (push in till 15 unless Tall pt, then push all the way to 16)
 - 20 on Left (push all the way to 20 unless short pt; then push till 18 or 19)



Anatomy of thoracic veins.

 

Femoral technique

Contraindications:

  • uncooperative patient
  • Presence of infection, Trauma, Distorted anatomy
  • Obesity
  • Coagulopathy
  • Operator inexperience
  • Lack of supervision

Complications:

  • Femoral Catheter, if left in place for more than a few days is associated with increased risk of infection and thrombosis, compared to IJ or Subclavian.

Procedure:

  • Patient is supine.
  • Vein lies medial to femoral artery below the inguinal ligament.
  • Palpate femoral pulse and place needle just medial to it below inguinal ligament.







 

  COMPLICATIONS
■ Pneumothorax, hydrothorax (higher with SC access)
■ Vein or artery laceration, bleeding/hematomas that can compress airway (IJ)
■ Arterial puncture (higher with IJ access)
■ Air embolism
■ Infections (higher with femoral vein access)
■ Dysrhythmias

 INTERPRETATION OF RESULTS 
■ The return of pulsatile flow signifies arterial puncture.
■ Dysrhythmias signal irritation of atria or ventricles. Guidewires and catheters should be pulled back until dysrhythmias stop.
■ Vein has been entered successfully when a flashback of dark venous blood that flows freely into the syringe is obtained.
■ CXR will show appropriate placement of subclavian and internal jugular catheterization.


NOTE
- During IJ central line insertion, ultrasound helps you find the internal jugular vein and avoid the common carotid artery.
- For IJ and subclavian lines, use Trendelenburg to increase intrathoracic pressure and decrease the risk of an air embolism.