1. Central Line placement
By Clare Di Bona
November 2015

2. Indications IV Access CVP monitoring Dialysis Transvenous pacing
Difficult peripheral access
Irritant drugs
Chemo
TPN
Vasoactive drugs ie noradrenaline
Calcium chloride
KCL
CVP monitoring
Dialysis
Transvenous pacing

3. Contraindications/precautions
Coagulopathy
Benefit versus risk
Femoral and IJV less risky than subclavian (can’t apply direct pressure over puncture site)
Respiratory failure
Difficult to lie flat therefore probably better to use the femoral approach
Raised ICP
Cannot tilt head down better to use the femoral approach
Other
Obstructed vein (thrombus, tumour)
Overlying skin infection, burn
Uncooperative patient…seriously reconsider or sedatives or after intubation if required

4. Complications/consent
Sometimes the patient is not fit to consent ie altered GCS, hypoxic, low BP….in this case act in the best interests of the patient
Otherwise it helps to keep the patient calm if you describe the procedure simply and talk frankly about risk versus benefits

5. Complications/consent
Pneumothorax (highest subclavian)
Infection
Thrombosis including DVT
Hemorrhage including haemothorax and haematoma formation
Arrhythmia on insertion guide wire
Guide wire embolus
Other: Air embolus, discomfort, unsuccessful procedure

6. Procedure Preparation Patient:
Is the patient stable ie can you lie them flat for a long period
Space at the head of the bed, exposure of the area
Staff: Need a dedicated nurse to help you draw up
Equipment
US machine positioned, turned on and set correctly
CVC line, cleaning equipment, local anaesthetic, suturing material, dressings, sterile gowns, drape, US probe cover, syringes for local and NS, drawing up needles

7. procedure
-Prepare yourself: wash hands-surgical wash, place on gown and gloves using aseptic technique
-Prepare the Equipment:
Line it up in order, draw up local and Normal saline in separate syringes (different sizes and different colours!!), Prime the line, leave the brown portal open, remember all bungs need to be primed too
-Trendelenburg position patient, head to the left (get nurse to help)
-Prepare the patient: clean (circle from middle out-repeat three times), drape
-Prepare the US probe (cover)
-Use landmarks (triangle formed by clavicle, lateral and medial head of sternocleidomastoid muscle target is the apex)
-Give local anaesthetic to the skin

8. Procedure
-At the apex of the triangle insert needle from the CVC kit (wide bore) to locate the IJV under US guidance by advancing and aspirating (head towards the ipsilateral nipple)
-Once blood is aspirating unscrew the syringe and hold needle in place, use thumb to cap it to prevent air embolism
-Thread through the guidewire to 20cm (2 black lines go through)
-Take out the needle
-Use scalpel to open the skin around the insertion of the wire (don’t cut wire!)
-Thread over the dilator then take it out
-Thread over the line….length=height/10 around 15-17cm for an adult.
NEVER LOSE SITE OF THE WIRE MAY HAVE TO PULL WIRE OUT A LITTLE IF IT GETS LOST IN THE CVC LINE

9. Procedure -Take the wire out
-Cap the brown port initially with thumb to prevent air embolus, then with bung
-Check all ports by aspirating and flushing with normal saline
-Suture in central line and place dressing over the top
-Check positioning
Use US to visualise the wire in the vein
CXR to check at junction of SVC and heart and to make sure no PTX
Blood gas if still unsure
-Document in notes: consent, procedure, depth of CVC

10. VIDEO https://www.youtube.com/watch?v=Lb1Z3bndmA8