Central Line Placement
Please see the Annals of B Pod article on central line placement in order to review indications for this procedure and how to select an appropriate catheter.
Selecting an Insertion Site
Subclavian Surface Anatomy
- Assess the anatomy of the selected insertion site and evaluate it using ultrasound prior to starting procedure.
- Identify necessary PPE- wash hands, wear cap, mask, sterile gown, and sterile gloves. Use sterile probe cover for the ultrasound.
- Clean the insertion site with chlorhexidine.
- Place a full drape on the patient.
- Maintain sterile field throughout the procedure.
- Prepare equipment including flushing lines and placing caps on the ports.
- Identify the needle insertion site that will allow cannulation of the desired vein.
- Anesthetize the area over the insertion site.
- Insert and advance the needle while continuously aspirating.
- Follow the needle tip into the vessel using ultrasound guidance. Needle visualization is a critical micro skill in the performance of any ultrasound-guided procedure. Please watch this video from Dr. Stolz on how to improve your needle visualization.
- Successfully cannulate the vessel and ensure free return of dark red, non-pulsatile blood.
- Stabilize the needle while disconnecting the syringe.
Threading The Wire
- Insert guidewire through the needle to a depth of 20 cm.
- Remove needle while maintaining control of the guidewire.
- Confirm guidewire is in the vessel using ultrasound.
Dilating the Vessel and Subcutaneous Tissues
- Make small skin incision adjacent to the guidewire.
- Advance dilator over the guidewire and into skin with a twisting motion while maintaining control of the guidewire.
- Ensure the guidewire moves freely within the dilator, then remove dilator.
Advance the Catheter over the Guidewire
- Advance catheter over the guidewire and into the vessel to the appropriate depth for the selected insertion site.
- Remove guidewire and keep the brown port covered to prevent air entry until a cap can be placed on the brown port.
- Aspirate and flush each lumen.
Securing the Line
- Suture the line in place at the blue/white clips and the triangular holder.
- Add biopatch and place a sterile dressing.
- Obtain CXR following the procedure.
Other Links from Around the web
- NEJM Videos in Clinical Medicine Series
- EMCrit on Central Lines - https://emcrit.org/central-lines/
- Brown EM Blog - Central Line Basics Part 2
- 5 Tips for Central Lines - Haney Mallemat
- Kim, Won Young et al. (2012) Optimal insertion depth of central venous catheters—Is a formula required? A prospective cohort study. Injury , Vol. 43(1), 38-41.
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