Central Line

Consent: Prior to performing the procedure, consent must be obtained from either the patient or a surrogate decision maker, and the proper consent form must be signed. Review the procedure, potential benefits, potential risks, and complications.

Ultrasound Survey: Utilizing the landmarks detailed below and the linear probe, you will use the ultrasound to find an appropriate site of venous cannulation. The probe marker should be facing YOUR left hand side. The vein will be compressible without any pulsation, and the artery will be pulsatile, thick walled, and non compressible. Track the vessels up and down, compressing at 3 different locations to ensure the site is without a thrombus. Find an appropriate site where the artery is not directly under or over the vein to avoid potential arterial puncture during the procedure.

1. Internal jugular (IJ) vein landmarks - the IJ lies within the triangle formed by the 2 heads of the sternocleidomastoid and the clavicle. You will cannulate the IJ at the apex where the 2 heads of sternocleidomastoid muscles meet, just lateral to the carotid artery (can palpate the carotid artery pulse if needed)

2. Subclavian vein landmarks - you will cannulate the subclavian vein inferior to the clavicle, around 1 cm caudal to the clavicle at the junction of the medial and middle third of the clavicle

3. Femoral vein landmarks - you will cannulate the femoral vein just inferior to the inguinal ligament just medial to the femoral artery (can palpate the femoral artery pulse if needed)

Prep Patient: Raise the patient’s bed to an appropriate height to avoid hunching over during the procedure.

1. Internal jugular and Subclavian: You will be performing the procedure at the head of the bed. Move the bed away from the wall to create space. Remove the headboard. Prior to starting the procedure, place the patient in a trendelenburg position (avoid doing this significantly ahead of time to avoid patient discomfort). The trendelenburg position reduces the risk of air embolism.

2. Femoral: You will be performing the procedure at the side of the bed. Remove the side rail. If the patient has a large pannus, tape the pannus upward and away by using the side rail on the opposite side of the bed to secure the tape. Avoid shaving the patient, as this increases the risk of site infection.

Sterilize: Place your bouffant cap on. Put on sterile gloves (see sterile approach tab for more detailed information). Ask an assistant to open the large chloraprep antiseptic swabsticks in a sterile fashion. Sterilize the cannulation site you located previously with at least 2 swabsticks, starting at the cannulation site and moving outwards in a circular manner for at least 2 min. Allow it to completely dry before starting the procedure. Discard your sterile gloves.

Gown Up: Wash your hands. Put your sterile gown on (see sterile approach tab for more detailed information). Then, put a new pair of sterile gloves on.

Prep Table and Kit: Using your assistant to open the packages, open up the half drape onto a table to create a sterile field. When prepping your table, align the items needed in order of how they are needed in the procedure to ensure the procedure goes smoothly (aka “mise en place”). You will first need your lidocaine, lidocaine syringe with blunt needle and anesthetizing needle, introducer needle with syringe attached, guidewire, scalpel, dilator, catheter, flushes, biopatch, 2 clips, suture material, and dressing. The guidewire’s tip is in a J position which makes it difficult to thread over the needle, thus, you will need to pull the tip slightly in to straighten the tip. Remove the blue disposable caps off the lumens of the catheter, and replace them with the heplocks. Leave the brown lumen open as the guidewire will pass through this lumen. Using the flushes, flush each lumen to remove air from the catheter to prevent air embolism.

Drape: Open the central line drape. The drape has arrows along with a body symbol to help you align the drape in the correct position. Remove the sticker lining. Align the opening of the drape at the cannulation site and stick the drape onto the site. Pull the top of the drape away from you, pull the next tab towards you, and the next two tabs towards the head and feet of the patient.

Probe Cover: The probe cover can be found in the Universal dressing & PPE kit or can be found individually. When you open the kit, you will find the probe cover, 2 rubber bands, and sterile ultrasound gel. Ask your assistant to place non-sterile gel on the top of the linear probe, and hand you the probe. Place your hand in the inside of the probe cover, grab the linear probe from the assistant, and then slide the cover off of your hand and over the probe down the cord. Ask the assistant to grab the end of the probe cover to slide it all the way down towards the floor. Secure one rubber band on the probe and another one around the cord. Open the sterile gel and squeeze it onto the central line drape near the procedure site so it is available nearby.

Time Out: Physician and RN will perform time out together in front of the patient. You will confirm the 3 P’s - proper patient, procedure, and location. Review allergies and confirm that informed consent was obtained.

Anesthetize: Patient’s may need IV sedation in addition to local anesthetics prior to the procedure if the patient is altered and agitated, as it is dangerous for the patient to move during the procedure. You will also locally anesthetize the site using lidocaine. Open the lidocaine, and attach the blunt needle to the syringe. The blunt needle allows you to draw the lidocaine into the syringe as it has a bigger diameter, however, you cannot inject the patient using this needle. Once lidocaine is drawn into the syringe, change the blunt needle tip to the 25 gauge anesthetizing needle. Create a wheal at the site of insertion, however, aspirate prior to pushing lidocaine to ensure you are not in a vessel. Once a wheal is created, you will anesthetize deeper along the tract of the catheter. Insert your needle vertically into the insertion site, aspirate to ensure no blood return, push medication, advance needle and repeat (Advance, Aspirate, Push Medication). Do this until you are closer to the depth of insertion required to cannulate the vessel (keep in mind the depth the vessel was at during initial ultrasound survey).

Cannulate:

1. Position the needle: Using the ultrasound, confirm your cannulation site. Again, the probe marker should face towards YOUR left hand side. Thus, moving the needle right or left will correlate with the orientation of the ultrasound image (if you move your needle towards your left, the needle will move to the left hand side of the ultrasound image). Position the probe so that the vessel is in the middle of the screen. If you press the M mode once, you will see a vertical line in the middle of the screen which can help you align the vessel. If your vessel is aligned properly, when you insert the needle right where the vertical mark on the probe is, you will be directly above the vessel. Ensure that the needle is directly perpendicular to your probe marker (the length of the probe and the length of the needle should make a T).

2. Cannulate: There are two cannulation techniques, the triangulation technique where you will insert the needle at a 45 degree angle, and the near vertical technique in which you will insert the needle at a 90 degree angle. Throughout the entire cannulation period, you will be aspirating. Penetrate the skin as your aspirate. Then, slowly move your probe away from you until you see your needle tip. Either move your probe or your needle, do not move both at the same time. Once you see your needle tip, start to advance your needle until you can no longer visualize your needle tip on the screen. Now, advance your probe again away from you until you see your needle tip reappear. Repeat this process until you penetrate the vein, see the needle tip within the center of the vessel lumen, and you have blood accumulating in your syringe with good flow while aspirating. Now you may drop the probe. Flatten your needle angle. Aspirate again to ensure good blood flow, and remove the syringe from the needle.

Guidewire: Thread the guidewire over the needle until you reach around 2-3 notch marks. The guidewire has a J tip thus in order to thread it through, you must pull back slightly to straighten the tip. If you are meeting resistance, do not keep threading and re-check your position with the ultrasound, as there is risk of lacerating the vessel. You can trouble shoot by aspirating to ensure good flow, and pulling back on the introducer needle as you may be against the vessel wall. Tip: Never let go of the guidewire! If you let go of the guidewire, it can be pulled into the vessel as the patient breathes and creates negative pressure. If the guidewire gets lost in the vessel, call vascular surgery immediately. All in all, you MUST have your hand on the guidewire at all times.

Confirm: Using the ultrasound, confirm your guidewire position in the vein in both the short and long axis view, and ensure that you did not penetrate the artery. Track the guidewire into the vein, ensure your tip is the center of the lumen, and that you did not penetrate the vein through to the other side. Capture pictures using the ultrasound to include in your procedure note. Tip: It is important to confirm before dilating the vessel as you should NOT dilate the artery. If the artery is dilated, patient is high risk for complications including hematoma, aneurysm, and bleeding. If you dilate the artery, call vascular surgery.

Remove the needle: Remove the needle leaving the guidewire in place. Always remember to have hands on the guidewire, so maneuver from above and below the introducer needle in order to remove.

Dilate: Take the scalpel. With the blade away from the catheter, nick the skin to allow the dilator to pass through the skin. Feed the dilator through the guidewire, and using a corkscrew motion, push the dilator into the skin around 3 cm to create a path from the skin to the lumen of the vessel. You will typically feel a give when you reach the vessel. Remove the dilator, again leaving the guidewire in place. Tip: Instead of using a flicking motion with the scalpel, insert the scalpel straight down a few cm to create the nick.

Catheter Insertion: Feed the catheter through the guidewire while holding onto the guidewire at the point where it penetrates the skin. Start to pull out the guidewire gradually through the lumen of catheter until the tip of the guidewire exits the brown colored port of the catheter. Grasp onto the tip of the guidewire as you advance the catheter into the vessel until its desired distance. This depends on location site and body habitus. The general rule is 14 cm R subclavian, 15 cm R IJ, 17 cm L subclavian, 18 cm L IJ, and 20 cm femoral. There are certain calculations you can do that are detailed below that help to approximate catheter length based on body habitus. Now that the catheter is in the vessel, pull out your guidewire. Cap all the ports. Flush all the ports of the catheter to ensure they do not get clogged when the blood in the catheter clots.

Secure: Hub the catheter where it exits the skin with the biopatch, ensure the biopatch is against the patient’s skin. You will suture the catheter at two points, once right above the biopatch using a 2 piece clip, and the second time at the blue winged portion of the catheter. There are two winged suture clips in the central line kit, one blue and one white. Clip the white one onto the catheter right above the biopatch, and snap the blue clip right on top of the white one so that the holes on either end are aligned. Suture both ends of the suture clip to the patient. Then, suture both ends of the blue winged portion of the catheter located more distally along the catheter. Clean and dry the site, and then apply the sterile dressing.

Confirm: If placing an internal jugular or subclavian line, confirm position of the central line tip using a CXR. Desired position of the tip is in the SVC just above the level of the carina.

Document: Write a procedure note including any complications or medications given during the procedure.