The Central Line Part 2: Technique & Procedural Steps

a blog series on emergency medicine procedures

In the last post (the central line part 1) we focused on the indications/contraindications and anatomic considerations. Here we focus on technique and procedural steps. Enjoy. 

 

HUNTING & GATHERING

*note: images shown in this section are institution-specific (Rhode Island Hospital Emergency Department) 

Find a computer with a functioning Topaz to obtain informed consent:

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Go to this corner in any critical care room (here is a closer look) and obtain a central line kit:

OR

Finally, obtain these items:

  • mayo stand
  • sterile gloves
  • chlorhexidine scrub
  • 2-3 sterile saline flushes
  • non-sterile marking pen
  • ultrasound machine and ultrasound probe cover
  • in kit: hat, gown, facemask

 

PREP

PRE-STERILITY:

  • Open kit and empty sterile contents onto the field
  • ULTRASOUND:
    • Plug in ultrasound machine. It WILL run out of battery if you don’t and the screen will shut off in the middle of the procedure
    • Test your US probe orientation: tap gently on left side of probe…this should match left side of your screen
    • Examine the target vein: is it compressible? Is it plump and easily visualized?
  • PATIENT:
    • Position the patient
    • Scrub target area with chlorhexidine
    • Mark the site

TIMEOUT! 

…and document it:

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STERILIZE.

Watch this video. 

From EMCrit.org, Scott Weingart, RACC Sterile Line Preparation

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The Central Line Part 1: The Basics

a blog series on emergency medicine procedures

In this first installment on central lines, we discuss central line indications/contraindications/alternatives, anatomic considerations, and the upsides and downsides of the 3 major sites (subclavian, internal jugular, and femoral)

Indications specific to the ER

  • Administration of harsh or concentrated fluids
  • High volume, high flow fluid administration
  • Emergency venous access
    • Alternatives: EJ, IO, ultrasound-guided peripheral IV
  • Conduit for transvenous pacer or dialysis catheter

Contraindications

  1. Soft tissue infection overlying site
  2. Traumatic or congenital distortions
  3. Superior vena cava syndrome
  4. Deep venous thrombosis in vessel of choice
  5. Coagulopathies
  6. Combative or uncooperative patients

troubleshooting

TROUBLESHOOTING: How to solve the above contraindications…

  • 1-4: move to another site
  • 5: consider reversal agents
  • 6: consider sedation and/or intubation, depending on the case
LOCATION

SUBCLAVIAN

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From Netter’s Atlas of Human Anatomy, 4th ed, 2006 

Pathway

Subclavian vein and IJ –> brachiocephalic vein + contralateral brachiocephalic vein –> SVC

Where it is

Posterior to medial 1/3 of clavicle AND anterior to 1st rib

Anatomic awareness Continue reading