The LSUHSC New Orleans
Emergency Medicine Interest Group
The Student Procedure Manual
Central Venous Line
by Mark Wegmann, Aruna Akundi,
and Scott Branting with
Indications for Central Venous Access
Anatomy and Approaches
-Middle or Central Jugular Approach (IJ)
-Posterior Jugular Approach (IJ)
-Infraclavicular Subclavian (SC) Approach
Procedure For All Central Venous Access
Indications for Central Venous Access
- Rapid fluid replacement especially during external cardiac compressions. The
femoral and internal jugular sites can be accessed without discontinuing CPR
- Central Venous Pressure (CVP) monitoring
- Passage of transvenous pacemakers.
- Pressure measurement via a pulmonary artery (Swan-Ganz) catheter in critically
- Clinical contraindications for use of upper extremities or lack of peripheral
- When intravenous access can not be obtained elsewhere.
- Emergency cardiopulmonary bypass for resuscitation.
- Charcoal hemoperfusion for severe drug overdose
- Parenteral nutrition
- Drug Administration - irritant medications, vasoactive agents, concentrated
- Aspiration for venous air embolism
- Emergency dialysis - acute hemodialysis, plasmapheresis
- Pulmonary artery catheterization
- Distortion of the local anatomy or the skin at the site.
- Extremes of weight that interfere with access to the site.
- Evidence of vasculitis; this is a relative contraindication.
- Evidence of cellulitis or infection of desired area
- Prior long-term cannulation of the site.
- Previous injection of sclerosing agents at the site.
- Suspected great vessel injury.
- Previous radiation therapy administered to the area.
- Ambulatory patients requiring central lines should not have femoral lines; these
patients are more likely to kink the catheter and ultimately dislodge the device
- Significant trauma to the site.
- Patients with coagulopathies; this is a relative contraindication to all central
- Patients who are uncooperative and/or combative.
- Infants and small children
Equipment (Usually all found in the central line
- Size and length of catheter are determined by the application. Measure the
depth of catheter placement from the insertion site to the sternal notch plus
approximately 5 centimeters.
- Catheter device
- Single lumen- standard adult size: 5F (F=French);
- Double lumen- standard adult size: 7F; length: 20cm
- Triple lumen- standard adult size: 7F; length: 30cm
- Double lumen dialysis: standard adult size: I IF;
- Introducers: standard adult size: IOF/7F; length 10/20cm
- "J" wire(guidewire that is flexible at one end)
- Iodine solution and sterile cleaning
- Lidocaine, 1% or 2%, solution and small syringe for topical anesthesia.
- 22 or 25 gauge finder needle and 10 or 15 cc syringe.
- 16 or 18 gauge introducer needle and a 10 or 15 cc syringe. #1 I Scalpel.
- Dilator: some kits may come with more than one size.
- Luer lock caps for the distal catheter ports.
- Heparin or saline flush.
- Extra 4x4 gauze sponges.
- Swabs, prep solution, sterile gloves, drapes
- IV tubing and solution
- Needle holder
- 4-0 silk sutures, suture scissors
- Antibiotic ointment, gauze pads, tincture of benzoin
- Cloth tape
Anatomy and Approaches
Procedure For All Central Venous Access
- Place the patient in a supine position, and tilt the patient cephalad at approximately
a 10 to 15 degree angle. This Trendelenburg position will distend the jugular
and subclavian vein making access easier. This also reduces the chance of air
embolism. For the femoral approach leave the patient flat.
- The right side is preferred in subclavian and jugular access because the dome
of the pleura is lower on that side thus reducing the chance of pneumothorax.
Turn the patients head in the direction opposite to that of the approach.
- It is best to mark the site that is to be used using the end of a pen, but not
with the pen's ink. Use the tip of the pen to make a small indentation at the
site if time is available.
- Using the sponges and iodine solution, start at the marked spot and circle outward
without crossing over previous circles, prepping an area large enough to include
IJ and Clavicular approaches. Repeat this three times to sterilize the area.
- Note: It may be a good idea to repeat this sterilization process for the opposite
side in case it becomes necessary to go to the other site.
- Apply the sterile drape with the center opening over the marked area.
- Using the lidocaine solution and the small syringe, make a skin wheal ove'r
the marked area to anesthetize the site. Then proceed downward at a 45 degree
angle, as directed above, toward the head approximately I to 1.5 cm deep to
the mark, aspirating as you go. While withdrawing the needle inject more lidocaine
to anesthetize the deeper structure. If you accidentally hit the vein at this
point, do not inject lidocaine until you have pulled back and aspirated to make
sure you have left the vessel.
- Next, use the 25 gauge or 22 gauge finder needle attached to the 10 or 15 cc
syringe. Insert the syringe through the skin wheal and through the tract you
anesthetized downward aspirating all the way down until the needle enters the
vein and venous blood is returned into the syringe. When you have entered the
vein, stop and hold the needle very steady.
- Note: some personnel will skip using the finder needle altogether and will use
the introducer needle attached to the syringe for this step, thus saving a stick.
Insert introducer needle at the same angle and beside the finder needle,, aspirating
while inserting, until the needle is in the vein and there is good venous return.
- Remove the finder needle but maintain control of the introducer needle. If you
only used the introducer needle, then maintain control of the introducer needle.
Also, remove the syringe from the introducer needle.
*Remainder of procedure describes the Seldinger Technique
- Take the guidewire holder into your free hand and retract the wire until only
0.5 cm of the tip is visible. You will notice that the tip of the guide wire
is curved; this is to help the guide wire pass once it has entered the vein.
It is also very flexible which is why it will straighten when pulled back into
the guidewire holder. Do not attempt to insert the guidewire if the curved end
is sticking out.
- Insert the guidewire through the introducer needle until you have approximately
20 cm remaining and it has cleared the guidewire holder. Now keep one hand on
the introducer needle and the other on the guidewire.
- FROM THIS POINT FORWARD, YOU MUST HAVE AT LEAST
ONE HAND ON THE GUIDEWIRE AT ALLTIMES.
- Hold the guidewire and remove the introducer needle.
- With the scalpel positioned so that cutting edge is away from guidewire and
the back of the blade is running along the guidewire, enlarge the cutaneous
puncture site to approximately I cm.
- Take the small dilator, or the only dilator, depending on your kit, and slip
it over the guidewire, at no time taking a hand off the guidewire. In other
words, hold the wire near the skin site while using your other hand to place
the dilator over the wire. Once the dilator is on the wire, then you may place
your other hand on the wire at the distal end and use the first hand to guide
the dilator. Push the dilator along the wire into the skin site and down to
the vein. You will feel some resistance at the venous site as the dilator hits
the curve in the guide wire as it enters the vein. Push the dilator only slightly
further than this so as not to shear the other side of the vein. Remove the
small, or only, dilator and, if necessary, repeat the process with the larger
- Before threading the catheter over the guidewire, make sure the most distal
port on the catheter is open with its cap off. Hold one hand on the guide wire
at the skin site and thread the catheter onto the wire from the opposite end
until the wire sticks out of the distal port. If necessary, you may remove a
small portion of the guidewire from the site. Once the wire is sticking out of the other side, take control
of the guidewire from this end and thread the catheter over the wire advancing
the catheter into the vessel so that catheter tip lies parallel to vessel. Make
sure to insert the catheter to the appropriate length that will be marked on
the catheter itself.
- Remove guide wire making sure to control the catheter with the other hand.
- Check to see if the catheter is in the vessel by using a syringe to aspirate.
Make sure the free flow of venous blood is present (if you are not sure that
it is venous blood, you can get a blood gas to determine if it is venous or
arterial). Once you are certain the catheter is properly placed, flush each
port with several milliliters of the heparin/sodium flush.
Secure the catheter using the suture material provided to the skin. 'rhe catheter
has a flange that contains two small holes through which you should thread your
suture needle prior to placing it in the skin. It is usually helpful to anesthetize
the sites of the suture skin penetration. Apply antibiotic ointment around the
site and dress appropriately.
- Order a chest x-ray immediately to confirm catheter placement and to rule out
pneumothorax, or a flat plate abdominal film for femoral access confirmation.
- At this point, you may attach your intravenous fluids or give medications.
- Accidental arterial perforation; if the artery is punctured on the attempt,
remove the syringe and apply pressure to the site with sterile dressings for
- Pneumothorax/Hematoma/ Hemothorax formation (IJ/SC) Air embolus
- Infection and or thrombophlebitis
- Injury to the vagus nerve (IJ/SC)
- Perforation of endotracheal tube cuffs (IJ/SC)
- Catheter or wire embolus
- Loss of guide wire into vein
- Tracheal perforation
- Pericardial tamponade
- SVC obstruction
- Thoracic duct laceration
- Great vessel laceration
- Mural thrombus formation (IJ/SC)
- Nerve injury/ cerebral infarct
- Dysrhythmias (IJ/SC)
- Catheter knotting
*Remainder applies only to femoral access
- Perforation of peritoneum
- Perforation of bowel (likely if patient has femoral hemia)
- Psoas abscess from penetration of psoas fascia
- Puncturing of a distended bladder
- Septic arthritis of the hip by puncture of the joint capsule Leg swelling secondary
to impeded venous flow or hematoma formation
- Retroperitoneal bleeding after external iliac artery puncture
- Cummins RO, Bill JE, eds. Advanced Cardiac Life Support. Nashville,
TN: American Heart Association;
- Dronen SC. Central venous catheterization: subclavian vein approach. In:
Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine.
2n' ed. Philadelphia, Pa: WB Saunders Co; 1991: 325-340.
- Mihm FG, Rosenthal MH.Central venous catheterization: subclavian vein access.
In: Benumof JL, ed.Clinical Procedures in Anesthesia and Intensive Care.
Philadelphia, Pa: JB Lipincott Co; 1992: 339-370.
- Deneff MG. Central venous catheterization. In: Rippe JM, et al. eds. Procedures
and Techniques in Intensive Care Medicine. Philadelphia, Pa:Little, Brown
and Co; 1995: 15-30.
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