Central Line Placement


Article Author:
Audrey Tse


Article Editor:
Michael Schick


Editors In Chief:
Michael Firstenberg
Lawrence Greiten


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
2/23/2019 11:58:52 AM

Introduction

A central venous line (CVL) is a large-bore central venous catheter that is placed using a sterile technique (unless an urgent clinical scenario prevents sterile technique placement) in certain clinical scenarios.[1][2][3][4]

Anatomy

In emergency medical practice, there are three possible sites for CVL placement in the adult patient. Each has advantages and disadvantages. The placement sites include the internal jugular vein, femoral vein, and subclavian vein. The right internal jugular vein and left subclavian vein are the most direct paths to the right atrium via the superior vena cava. The femoral veins are compressible sites and as such may be more appropriate for coagulopathic patients. The subclavian vein approach is at higher risk for pneumothorax than the internal jugular vein approach. Ultrasound guidance can be very helpful in all approaches and is the recommended approach. However, when ultrasound guidance is not feasible for various reasons, such as the emergency nature of a procedure, lack of equipment, or a patient's anatomy in a situation where there is limited room for the ultrasound transducer in the subclavian approach while manipulating the needle, CVLs may be placed using anatomical landmarks without ultrasound.

Indications

There are many different indications for placing a CVL, but in emergency medicine, the most common indications include:

  • Fluid resuscitation (including blood products)
  • Drug infusions that could otherwise cause phlebitis or sclerosis (e.g., vasopressors and hyperosmolar solutions)
  • Central venous pressure monitoring, pulmonary artery catheter introduction
  • Emergency venous access (due to difficult peripheral intravenous access)
  • Transvenous pacing wire placement

Contraindications

Contraindications include distorted local anatomy (such as for trauma), infection overlying the insertion site, or thrombus within the intended vein. Relative contraindications include coagulopathy, hemorrhage from target vessel, suspected proximal vascular injury, or combative patients.

Equipment

Most central line kits include:

  • Syringe and needle for local anesthetic
  • Small vial of 1% lidocaine
  • Syringe and introducer needle
  • Scalpel
  • Guidewire
  • Tissue dilator
  • Sterile dressing
  • Suture and needle
  • Central line catheter (of which there are several types, including triple-lumen, dual-lumen, and large bore single-lumen)

In addition, the operator will require a sterile gown, cap, sterile gloves, sterile gauze, sterile saline, face mask, and a sterile cleansing solution such as chlorhexidine. The operator should ensure that ultrasound, sterile ultrasound gel, and a sterile ultrasound probe are part of the setup as well.

Preparation

Place the patient in the appropriate position for the site selected, then prepare the site in a sterile fashion using the sterile solution, sterile gauze, and sterile drapes. For the internal jugular and subclavian approach, place the patient in reverse Trendelenburg with the head turned to the opposite side of the site. For the femoral vein, place the patient in the supine position with the inguinal area exposed; this usually means the target leg should be bent at the knee with the lateral aspect resting on the stretcher or bed. It is recommended to place the patient on cardiopulmonary monitoring for the duration of the procedure.

Technique

The steps are as follows:

  1. Infiltrate the skin with 1% lidocaine for local anesthesia around the site of the needle insertion.
  2. Use the bedside ultrasound to identify the target vein.
  3. If using landmarks for the subclavian vein CVL, the needle should be inserted approximately 1 cm inferior to the junction of the middle and medial third of the clavicle. If using landmarks for the femoral line CVL, the needle insertion site should be located approximately 1 cm to 3 cm below the inguinal ligament and 0.5 cm to 1 cm medial to where the femoral artery is pulsated.  
  4. Insert the introducer needle with negative pressure until venous blood is aspirated. For the subclavian CVL, insert the needle at an angle as close to parallel to the skin as possible until contact is made with the clavicle, then advanced the needle under and along the inferior aspect of the clavicle. Next, direct the tip of the needle towards the suprasternal notch until venous blood is aspirated.  Whenever possible, the introducer needle should be advanced under ultrasound guidance to ensure the tip does not enter the incorrect vessel or puncture through the distal edge of the vein.
  5. Once venous blood is aspirated, stop advancing the needle.  Carefully remove the syringe and thread the guidewire through the introducer needle hub.
  6. While still holding the guidewire in place, remove the introducer needle hub.
  7. If possible, use the ultrasound to confirm the guidewire is in the target vessel in two different views.
  8. Next, use the scalpel tip to make a small stab in the skin against the wire just large enough to accommodate the dilator (and eventually, the central venous catheter). Insert the dilator with a twisting motion.
  9. Advance the CVL over the guidewire. Make sure the distal lumen of the central line is uncapped to facilitate passage of the guidewire.
  10. Once the CVL is in place, remove the guidewire. Next, flush and aspirate all ports with the sterile saline.
  11. Secure the CVL in place with the suture and place a sterile dressing over the site.

Complications

Potential complications should be explained to the patient if possible while obtaining informed consent. Complications include pain at cannulation site, local hematoma, infection (both at the site as well as bacteremia), misplacement into another vessel (possibly causing arterial puncture or cannulation), vessel laceration or dissection, air embolism, thrombosis, and pneumothorax requiring a possible chest tube.[5][6][7]

Clinical Significance

Clinical pearls for consideration:

  • A chest X-ray should be performed immediately for the internal jugular and subclavian lines to ensure proper placement and absence of an iatrogenic pneumothorax. 
  • Be sure you are withdrawing venous blood before dilation and cannulation of the vessel.  
  • If internal jugular CVL attempt is unsuccessful, move to the ipsilateral subclavian vein. Never attempt the opposite side without a chest X-ray or ultrasound first to avoid bilateral pneumothoraces. 
  • Never let go of the guidewire as it may migrate distally into the vessel. Never force the wire on insertion because it may cause damage to the vessel or surrounding structures. Forcing the wire could also cause it to kink making removal difficult or impossible.
  • Always place your finger over the open hub of the needle to prevent an air embolism.
  • Always confirm placement with ultrasound, looking for reverberation artifact of the needle and/or tenting of the vessel wall. Needles cannot be visualized on ultrasound. Wires can be visualized so the operator can confirm at that step as well.
  • A venous blood gas can be aspirated off a femoral line to ensure it is not arterial.

Enhancing Healthcare Team Outcomes

Central lines are inserted by many healthcare professionals. However, the monitoring of these lines is usually done by the nurses. The site of entry has to be kept clean and the nurse has to monitor it for signs of infection. Depending on which location the line was inserted, complications also have to be monitored like a pneumothorax, hematoma, bleeding or extravasation. In general, healthcare workers should avoid lines in the groin for more than 24-48 hours as they are prone to infections and also make it difficult for the patient to ambulate or get out of bed. To ensure good practice and limit complications, most hospitals now have a team of healthcare professionals who are in charge of central line insertion and monitoring. Such universal practice has been shown to limit infections. [8][9](Level V)


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Central Line Placement - Questions

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A patient with a severe multiorgan trauma requires a central line. His blood work reveals coagulopathy. Which of the following venous sites is contraindicated in such a scenario?



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The right neck vein is preferred for internal jugular central line placement over the left because of what structure?



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Devices can assist with navigation and visualization of central catheters. Which of the following can assist with placement but is not adequate for confirming tip placement?



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A hemodynamically unstable patient has a right subclavian central line inserted and develops hypotension and shortness of breath ten minutes later. What is the next most appropriate step in management?



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A 17 year old male is brought into the emergency department with gunshot wounds to his right flank, left shoulder, and left mid-abdominal quadrant. He is hypotensive and tachycardic with altered mental status. Massive transfusion protocol is initiated. Where should the central line be placed?



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Which of the following is a contraindication to placing a central line in a patient?



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A nurse is assisting a critical care intensivist with a procedure to insert the device shown in the image below. Where is this device usually placed? Select all that apply.

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  • Image 6524 Not availableImage 6524 Not available
    Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD



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A patient who has sustained significant trauma during a motor vehicle accident presents to the emergency department and is hypotensive. The primary healthcare provider decides to insert a central venous line in the groin. Which of the following is a relative contraindication for femoral vein cannulation? Select all that apply.



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Central Line Placement - References

References

Mitsuda S,Tokumine J,Matsuda R,Yorozu T,Asao T, PICC insertion in the sitting position for a patient with congestive heart failure: A case report. Medicine. 2019 Feb;     [PubMed]
Derderian SC,Good R,Vuille-Dit-Bille RN,Carpenter T,Bensard DD, Central venous lines in critically ill children: Thrombosis but not infection is site dependent. Journal of pediatric surgery. 2018 Dec 27;     [PubMed]
El Ters N,Claassen C,Lancaster T,Barnette A,Eldridge W,Yazigi F,Brar K,Herco M,Rogowski L,Strand M,Vachharajani A, Central versus Low-Lying Umbilical Venous Catheters: A Multicenter Study of Practices and Complications. American journal of perinatology. 2018 Dec 19;     [PubMed]
Kim IJ,Shim DJ,Lee JH,Kim ET,Byeon JH,Lee HJ,Cho SG, Impact of subcutaneous tunnels on peripherally inserted catheter placement: a multicenter retrospective study. European radiology. 2018 Dec 17;     [PubMed]
Hicks BL,Brittan MS,Knapp-Clevenger R, Group Style Central Venous Catheter Education Using the GLAD Model. Journal of pediatric nursing. 2018 Nov 29;     [PubMed]
Pare JR,Pollock SE,Liu JH,Leo MM,Nelson KP, Central venous catheter placement after ultrasound guided peripheral IV placement for difficult vascular access patients. The American journal of emergency medicine. 2019 Feb;     [PubMed]
Presley B,Isenberg JD, Ultrasound Guided Intravenous Access 2018 Jan;     [PubMed]
Levit O,Shabanova V,Bizzarro M, Impact of a dedicated nursing team on central line-related complications in neonatal intensive care unit. The journal of maternal-fetal     [PubMed]
Chick JF,Reddy SN,Yam BL,Kobrin S,Trerotola SO, Institution of a Hospital-Based Central Venous Access Policy for Peripheral Vein Preservation in Patients with Chronic Kidney Disease: A 12-Year Experience. Journal of vascular and interventional radiology : JVIR. 2017 Mar;     [PubMed]

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