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

The subclavian artery is posterior to thin anterior scalene muscle, which is posterior to the subclavian vein. The phrenic nerve is lateral to the anterior scalene muscle. The apex of the lung can extend to the 1st rib. Although the right lung apex is slightly more inferior as compared to the left lung, the LEFT subclavian is a more direct route to the SVC, resulting in less vascular complications and misplaced catheters

Subclavian Upsides

  • Utility in multi-trauma patient with cervical collar and possible pelvic fractures
  • Anatomic landmark placement (without ultrasound) –> faster placement
  • Most comfort and mobility for patients after placement
  • Lowest rates of catheter-related bloodstream infections as well as DVT in comparison with internal jugular and femoral (1)

Subclavian Downsides

  • Ultrasound more technically difficult compared to other sites
  • Risk of arterial puncture at a non-compressible site
  • Highest risk of pneumothorax (1)

INTERNAL JUGULAR

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

Pathway

(see subclavian)

Where it is

  • Aim at apex or middle of red triangle (see picture)
  • Triangle borders: medial 1/3 of clavicle, 2 heads of sternocleidomastoid muscle

Anatomic Awareness

Carotid sheath contents (from medial to lateral – caution with variants): Common and internal carotid artery, internal jugular vein. The vagus nerve is between and posterior to the artery and vein in most cases. The RIGHT internal jugular is a more direct route to the SVC.

IJ Upsides

  • Compressible site
  • Ultrasound is reliable and easy
  • Acceptable mobility for patients after placement

IJ Downsides

  • Carotid artery puncture (or worse: carotid artery dilation) can occur
  • Pneumothorax rates are moderate (1) 
  • Poor landmarks in obese or edematous patients (2) 
  • Difficult placement in uncooperative patients

FEMORAL

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

Pathway

Via adductor (Hunter’s) canal to just past the inguinal ligament: popliteal vein –> femoral vein + deep femoral vein –> common femoral vein –> (above inguinal ligament) –> external iliac vein –> —> IVC

Where it is

Femoral triangle borders: Inguinal ligament (superior), adductor longus muscle (medial), sarotorius muscle (lateral)

  • NAVEL (lateral to medial) (caution with variants): Nerve, artery, vein, EMPTY, lymphatics

Anatomic awareness

The femoral vein is just medial to the artery (caution with variants!). As the vein goes distal, it will usually wrap around posterior to femoral artery, so aim for it just below the level of the inguinal ligament for greatest success. (Ultrasound use can also improve success rate).

Femoral Upsides

  • Anatomy is simpler and less risky
  • Easy to access during chest compressions

Femoral Downsides

  • Higher rates of infection and DVT, but up for debate (3) (see prior post: You Put a Catheter Where?)
  • Contraindicated in suspected or confirmed pelvic trauma
  • Not recommended for ambulatory patients

PLEASE SHARE ANY OF YOUR OWN THOUGHTS ON CENTRAL LINE BASICS IN THE COMMENTS SECTION!

NOW ON TO PART II

Textbook References

McNeil C, Rezaie S and Adams B. Central Venous Catheterization and Central Venous Pressure Monitoring. Chapter 22, 397-431.e3. In: Roberts J, et al. Roberts & Hedges’ Clinical Procedures in Emergency Medicine. 6th Saunders; 2013.

Article References

  1. Parienti JJ, Mongardon N, Mégarbane B, Mira JP, Kalfon P, et al. Intravascular Complications of Central Venous Catheterization by Insertion Site. N Engl J Med. 2015 Sep 24;373(13):1220-9. PubMed PMID: 26398070.
  2. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. 2003 Mar 20;348(12):1123-33. PubMed PMID: 12646670.
  3. Marik PE, Flemmer M, Harrison W. The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis. Crit Care Med. 2012 Aug;40(8):2479-85. PubMed PMID: 22809915.

Image References

Netter, F. Mediastinum. Section 3, Thorax, Plates 230-241. In: Netter, F. Atlas of Human Anatomy. 4th Edition. Saunders; 2006.

Authorship

Faculty Reviewer: Gita Pensa MD  

 

Author: Jonathan Ameli MD

 

3 thoughts on “The Central Line Part 1: The Basics

  1. Great review Ameli. For the femoral approach, although crude, the “penile to venile” is also helpful to remember that the vein is more medial. When placing a blind femoral line I’ve found it helpful to imagine a line extending from the pubic symphsis to the ASIS, and place the needle under the inguinal ligament at the medial “third” of that line.

  2. Pingback: The Central Line Part 2: Technique & Procedural Steps | Brown Emergency Medicine

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