Central line insertion should be real-time ultrasound guided. The internal jugular is usually preferred to subclavian approach where possible as it is less likely to lead to pneumothorax
Indications for central line (central venous catheter) insertion
Administration of medications that require central access e.g. amiodarone, inotropes, high concentration electrolytes
Fluid balance monitoring with CVP
Intravenous access (long term or difficult peripherally)
Complications of central line (central venous catheter) insertion
Haemothorax
Pneumothorax
Haematoma
Inadvertent arterial puncture
Equipment required for central line (central venous catheter) insertion
Ultrasound and sterile ultrasound sheath
Sterile trolley
Sterile field, gloves, gown and mask
Seldinger central line kit
Saline flush
Chlorhexidine
Lignocaine (4ml (2 vials) of 2% is reasonable)
Suture
Scalpel
Sterile dressing
Pressure bag to attach to monitoring
Contraindications to central line (central venous catheter) insertion
Coagulopathy
Local infection
Avoid in raised intracranial pressure- aim for a femoral approach if required
Patient non-compliance
Pre-procedure
Consent patient if conscious otherwise document why the procedure is in the patients best interests
Position patient with head down if they can tolerate it, with head facing away from side of insertion
This ensures maximum venous filling
Ultrasound area to define anatomy
Having a nurse or assistant is helpful
Procedure for central line (central venous catheter) insertion
Wash hands and don sterile gown and gloves
Clean the area and apply sterile field. Make sure to have some spare gauze swabs ready.
Apply sterile sheath to the ultrasound probe
Confirm anatomy
Under ultrasound guidance insert lignocaine cutaneously, subcutaneously and around internal jugular.
Whilst lignocaine has time to work flush all lumens of the line and then clamp all lumens except the Seldinger port
Ensure caps are available for the lumens
Under ultrasound guidance take Seldinger needle attached to syringe and insert into the internal jugular vein
When blood is freely aspirated remove syringe and immediately inset Seldinger wire. This should pass easily
Keeping hold of the inserted wire, remove the needle. Ensure the wire stays in the vein as you do this
Use scalpel to make an small incision in the skin (approx 3mm). This should be done cutting away from the wire so as not to damage it
Pass the dilator over the wire and gently but firmly dilate a tract through to the internal jugular.
At this stage there may be some bleeding so ensure to have some swabs ready
Remove the dilator and pass the central line over the Seldinger wire. Do not advance the line until you have hold of the end of the wire
Once the central line is in place, remove the wire
Aspirate and flush all lumens and re clamp and apply lumen caps
Suture the line to allow 4 points of fixation
Dress with a clear dressing so the insertion point can be clearly seen
Post-procedure
Attach central line to pressure bag to allow CVP monitoring
Nursing staff can show you how to do this or will do it for you
Run a blood gas to ensure a venous sample
Chest x-ray to confirm placement and to check for pneumothorax
Clear documentation of date of insertion and monitor for infection
In the event of failure
Stop procedure
Seek senior help
Top Tips for central line (central venous catheter) insertion
Central lines can have multiple lumens. Most commonly 3,4 and 5 lumen lines are inserted. Confirm what the line will be used for and how many infusions a patient has to aid your selection of the line with the correct amount of lumens
Always ensure you are happy with your anatomy before commencing the procedure
Ensure your sterile trolley is well set up with the kit lined up in the order you will use things and a clear area for sharps. This will make your life easier.
