Central Line Placement

Central lines indications include failure to obtain peripheral access in an ICU level patient, patient resuscitation, central venous pressure /advanced cardiac monitoring, transvenous pacemaker placement, emergent dialysis, and medication infusions in which central lines are recommended. 

If the placement of the line is non-emergent, informed consent must be obtained from either the patient or the patient's designated power of attorney. Complications from placement include bleeding, infection, collapsed lung, thrombus, air embolism, irregular heart beat, or nerve/vein/arterial injury. . 

Once consent is obtained, choose a site appropriate for your line placement. A Time Out should be performed once site confirmation is confirmed. 

Clean the insertion site thoroughly with chlorhexidine or betadine and allow to dry. For all central access excluding femoral lines, the patient should lay flat with the head of bed dropped into Trendelenburg position. At this time, the provider should open the central line kit, apply sterile gown, gloves, hair net, and place a sterile covering over the patient with the access site exposed. 

Prepare all of your supplies. Clean the exposed area once more, flush the lines of your catheter with saline, apply a sterile sleeve to the ultrasound probe and draw up you lidocaine. 

Identify the desired access site using the ultrasound. Then use the lidocaine and create a 1-2 ml wheel just under the skin. Use the remaining lidocaine to inject downwards at a roughly 45 degree angle while watching with ultrasound to ensure the vessel is not injected. 

Remove the lidocaine needle. Now use the access needle to enter the vein. Drawing back constantly on the syringe will allow instant recognition of vein access, or if able, constant US visualization is adequate. 

Once there is blood return, leave the needle in place and remove the syringe. Insert the guidewire 20-25 cm into the needle. This should insert smoothly and if there is resistance, placement is likely not correct or not possible. Leaving the wire in place, remove the needle. 

Using the scalpel along the wire, make a small 1/2 cm incision where the wire enters the skin. Then take the dilator and advance about 1 cm over the wire. Remove the dilator and hold pressure at the access site with 2x2 gauze. 

Gently slide the catheter over the wire. The end of the wire will come out of the brown port. Do not insert the catheter into the access site until the wire is exposed via the brown port to avoid the wire migrating into the patient. When the catheter is in, remove the wire completely and cap the ports. Using a 5-10 ml syringe, draw back on all ports to unsure blood return. 

Suture the catheter in place and apply a sterile covering to the access site. Dispose all sharps in appropriate containers, and obtain a chest x-ray to confirm appropriate placement. Femoral lines are not able to be confirmed by x-ray and generally require no method of confirmation.