Central Line

Indications

  • Inadequate peripheral venous access

  • Vasopressors

  • High-volume flow

    • Note: Large bore peripheral IV or IO access preferred for rapid fluid resuscitation

Choice of site

  • Usually central access not required if peripheral IV access can be obtained

  • Internal jugular access (especially right-sided) carries lowest rate of catheter malposition

    • Entry point usually between the anterior and posterior head of SCM

    • Internal jugular (IJ) vein usually lateral and superficial to carotid

      • Vein more compressible

      • Consider doppler to confirm

  • Femoral venous access may be preferred during CPR

    • External rotate hip, midinguinal point between ASIS and pubic tubercle

    • NAVEL (lateral to medial); vein medial to artery

Sterile vs. Non-Sterile

  • Be CLEAR if non-sterile will need to be changed in 24h

Preparation

  • Hair should be clipped (rather than shaved)

  • Generally supine preferred

    • Trendelenburg facilitates venous filling for jugular/subclavian access and may reduce risk of venous air embolism

    • Abdominal compression or valsalva can increase IJ vein diameter

  • Consider ECG monitoring to detect dysrhythmia from guidewire irritation of myocardium

  • Position ultrasound machine properly

    • Identify vein with ultrasound

    • Adjust ultrasound settings, including gain/depth, for optimal viewing

    • Evaluate vein for patency

    • Short-axis vs. long-axis view

Procedure

  • Prep wide to bilateral sites

    • Allow prep to dry

  • PPE: Gown, glove, mask, faceshield, hairnet

  • Drape and sterile field

  • Open central line kit

    • Take off brown cap on port

    • Take off needle cap from angiocath or needle and check if syringe works

    • Take out wire, take off cover, regress J-tip

    • If needed, draw up local anesthesia

  • Transducer cover

    • Use cover to grab probe, and rubber band

    • Sterile ultrasound gel inside and outside probe sheath

  • Cannulate the vein under ultrasound guidance

    • Can use angiocatheter over needle rather than simple needle

      • Can confirm in vein vs. artery with extension tubing (seeing blood level decrease as you raise tubing)

    • Insert guidewire into vein through access needle (or catheter)

      • Confirm guidewire position in vein via ultrasound

      • Ensure at least 20cm of wire inserted in vessel

    • Remove needle while controlling guidewire

    • Small stab incision in skin at puncture site adjacent to guidewire

    • Advance dilator over guidewire then remove

    • Thread catheter over guidewire

      • Insertion length depends on height and approach

        • Generally deeper preferred as line can be withdrawn

        • Right internal jugular vein catheter length = height in cm / 10 (or measure to sternal notch)

        • Femoral vein catheter length = consider 15-30cm

      • Confirm catheter position in vein via ultrasound

    • Remove guidewire through the brown port

    • Aspirate blood from each access hub and flush with saline

  • Suture in place

    • Large bites with air knots to prevent skin necrosis

  • Place biopatch

  • Apply tegaderm/dressing

Complications

  • Pneumothorax

  • Arterial puncture

  • Hematoma

  • Thrombosis or Embolus (air/guide wire)

  • Infection