The LSUHSC New Orleans
Emergency Medicine Interest Group

Presents

The Student Procedure Manual


Central Venous Line

by Mark Wegmann, Aruna Akundi,
and Scott Branting with
Wayne Berkowitz

Indications for Central Venous Access
Contraindications
Equipment
Anatomy and Approaches
-Middle or Central Jugular Approach (IJ)
-Posterior Jugular Approach (IJ)
-Infraclavicular Subclavian (SC) Approach
-Supraclavicular(SC) Approach
-Femoral Approach
Procedure For All Central Venous Access
Seldinger Technique
Complications
References

Indications for Central Venous Access

Contraindications

Equipment (Usually all found in the central line kit).

Anatomy and Approaches

Procedure For All Central Venous Access

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. Apply the sterile drape with the center opening over the marked area.
  7. 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.
  8. 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.
  9. 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.
  10. 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

  1. 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.
  2. 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.
  3. FROM THIS POINT FORWARD, YOU MUST HAVE AT LEAST
    ONE HAND ON THE GUIDEWIRE AT ALLTIMES.

  4. Hold the guidewire and remove the introducer needle.
  5. 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.
  6. 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 size dilator.
  7. 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.
  8. Remove guide wire making sure to control the catheter with the other hand.
  9. 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.
  10. 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.
  11. At this point, you may attach your intravenous fluids or give medications.

Complications

*Remainder applies only to femoral access

REFERENCES

  1. Cummins RO, Bill JE, eds. Advanced Cardiac Life Support. Nashville, TN: American Heart Association;
    1994: 6.3-6.11.
  2. 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.
  3. 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.
  4. 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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