Central line

Video guide: https://www.youtube.com/watch?v=qeVdRCqy_mo

 

Indications

  • Extracorporeal therapies: HD, CRRT, Plasma (PLEX) or RBC exchange transfusion
  • Venous access for: Vasopressors, Chemotherapy, Parenteral nutrition, Hemodynamic monitoring (CVP, ScvO2), and cardiac parameters (via pulmonary artery catheter)

 

Contraindications: No true absolute contraindications

 

Pre-procedural considerations

  • All patients need to have telemetry & pulse oximetry monitoring
  • With every pt, consider LENGTH, LOCATION, LUMENS, and LINE TYPE!

 

Central Line

Short Stature (<5’5”)

Right IJ, Subclavian

<15 cm

Left IJ, Subcalvian

<20 cm

Femoral

<25 cm

Confirm length of catheter in your kit before you open/place the line!

 

Site

Advantages

Disadvantages

Internal Jugular Vein

Minimal risk of PTX; improve target with positioning and use of US; easily compressible if bleeding occurs

Risk of carotid puncture; difficult in obese pt; vein collapsibility with hypovolemia

Subclavian

More comfortable for pts; landmark driven approach; lowest risk of infection

Increased risk of PTX, harder to control bleeding with pressure; technically more difficult

Femoral

Easiest to access; no risk of PTX; can be placed during CPR and intubation

High risk of infection and difficult to sterilize; patient unable to move; higher thrombotic risk

 

Type of Line

Uses

Special Consideration

Triple Lumen
(7Fr)

Most common line placed; used for central access for vasopressors, caustic infusions (chemo)

Consider lumens needs; triple lumen is most versatile but can warrant dual lumen

MAC or Cordis*

‘Short and fat’ allowing rapid transfusion; MAC has two ports

MAC is placed with dilator still in introducer

Dialysis Catheter

(Trialysis, 12 Fr)

Dialysis line with two 12 Ga. Lumens for dialysis with a third 17 Ga. lumen for added access

Two serial dilations

*Can place triple lumen in MAC for additional ports; lose ability to rapidly transfuse 

 

 

Procedural considerations

  • Numb pt right after draping, then set up everything to allow time for lidocaine to work
  • Set supplies up in exactly the order of use to ensure all are present and functioning
  • Cap side ports with blue claves (not included in Trialysis kit) prior to flushing
  • For IJ access, place patient in slight Trendelenburg position to engorge vein
  • While advancing needle, ensure constant negative pressure with aspiration of plunger and visualization of needle tip with US
  • Always ensure guidewire is secured while it is inside a vein
  • Always ensure target for venous cannulation is visualized and guidewire is placed correctly prior to dilation: 1) Compression of target vessel 2) Non-pulsatile dark blood return (unless on 100%FiO2, may be brighter red) 3) US visualization or needle and wire 4) can use pressure tubing and angiocath to confirm CVP or obtain venous O2 sat

 

Post-procedural considerations

  • Every IJ or subclavian central line needs a confirmation CXR to confirm no PTX
  • Ideal placement of distal tip: in SVC just outside the right atrium. Approximately near/superior to carina and right tracheobronchial angle
  • Troubleshooting Complications:
    • Arterial Access or puncture: immediately remove needle and place non-occlusive pressure for 15 mins to prevent hematoma formation; if uncontrolled bleeding or artery was dilated, STAT vascular surgery consult
    • Bleeding: place direct pressure; subclavian access precludes ability to compress and confers highest bleeding risk; if uncontrolled, STAT vascular surgery consult
    • Pulmonary Complications: if free air aspirated into syringe, consider PTX vs poor seal of syringe & needle. Close attention to pulmonary complication & STAT CXR to assess PTX. If rapid deterioration, needle decompression and chest tube placement required
    • Venous Air Embolism: can occur if air introduced to system during placement, flushing, or if left open to the atmosphere. Effects are variable, but if suspected, place pt in left lateral decubitus position to trap air in right apex and place pt on 100% O2 to speed resorption
    • Arrhythmia: rationale for telemetry monitoring as guidewire often leads to atrial or ventricular arrhythmias; Immediately withdraw wire to lesser depth. If arrythmia persists, abort procedure and treat patient and determine cause