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:

This slideshow requires JavaScript.

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:

This slideshow requires JavaScript.

STERILIZE.

Watch this video. 

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

Older version of the above video. Skip to 07:00 (how to gown up yourself) and 10:00 (how to grab the US probe by yourself): 

From EMCrit.org, Scott Weingart, Sterile Line Placement

MISCELLANEOUS TIPS:

  • Flush all ports prior to beginning the procedure
  • Remove cap for distal, brown port and attach to a sterile saline flush. This is where your guidewire will emerge
  • Loosen the syringe from the introducer needle & adjust the guidewire tip to your liking (makes it easier to remove the syringe and advance the wire quickly after obtaining flash of blood)
  • Arrange the contents of your kit in the order you will use them…

Triple-Lumen Kit opened: 

triple lumen wide

Triple-Lumen Kit suggested order of usage (left to right): 

Triple Lumen Contents

Cordis Kit opened: 

cordis kit wide

Cordis Kit suggested order of usage (left to right): 

Cordis Contents

Primed Cordis

TECHNIQUE

ON GUIDEWIRE PLACEMENT

  • There are 2 ways to get the guidewire into the vessel:
    • Traditional (wire through needle)
    • Currently popular (wire through catheter)
  • Why traditional method?
    • A recent study shows wire through needle methods result in fewer puncture attempts ( 1 )
    • You cannot easily use the wire through catheter method for the following cases:
      • Subclavian and femoral
      • Obesity and thick tissue
  • Why choose the popular method?
    • You will be less likely to “lose your flash” of blood while searching for the guidewire
    • It allows you more time
    • The guidewire will arguably pass easier because there will be a decreased risk of hitting the vessel wall and getting “stuck”
  • What do I personally do?
    • I start with the traditional method. Difficulty passing the wire? I don’t force it. I try the popular method next. If I still fail, I move to another site, or ask for guidance from someone with more experience

Watch this video on the currently “popular” method:   

From Reuben Strayer, Wire Through Catheter Central Line Technique 

 

ON MICRO-SKILLS

Watch this video on micro-skills: 

From EMCrit.org, Scott Weingart, Central Line Micro-Skills

 

ON ULTRASOUND GUIDANCE

Watch this video on how to use ultrasound for central lines: 

ULTRASOUND USE FOR CVC (5 min Sono)

 

ON TECHNIQUE FOR THE 3 SITES OF CVC INSERTION

  • SUBCLAVIAN
  • INTERNAL JUGULAR
  • FEMORAL

 

SUBCLAVIAN

From EMCrit.org, Scott Weingart, Infraclavicular Subclavian Placement

NEJM Video on Central Venous Catheterization (Subclavian)

 

Technique tips and advice:

  • Numb the periosteum of clavicle where you plan to enter
  • The bevel should be pointing DOWN. This is unusual. It allows the guidewire to pass easier into the SVC
  • The right lung has the lower “pleural dome” theoretically decreasing the risk of pneumothorax, but the left side is a more direct route to the SVC
  • Patient positioning:
    • Trendelenburg
    • Head neutral or slightly turned away
    • Shoulder neutral, arm adducted
    • Exposing the clavicular more prominently by downward traction on the ipsilateral arm can help in challenging cases ( 2 ). A pillow placed on the back to expose the clavicle is NOT recommended, but a small towel roll on the ipsilateral shoulder has been shown to help
  • Location of puncture:
    • Deltopectoral triangle (borders: clavicle, pectoralis major, and deltoid). The 1st rib is posterior to the subclavian (theoretically protects the lung pleura)
    • Location of the vein: posterior to medial third of clavicle, aim for suprasternal notch
    • Go lateral (middle clavicle) rather than medial (toward the sternum)
    • Use a very shallow angle

subclav approach

From Roberts and Hedges’ Clinical Procedures in Emergency Medicine, 6th ed, 2013

As a bonus, here is information on the ultrasound-guided SUPRAclavicular approach to the subclavian central line: 

From Soundbytes, Sonosite, Phillips Perera MD RDMS FACEP 

 

INTERNAL JUGULAR

From EMCrit.org, Scott Weingart, Placing a Blind Internal Jugular Central Line

NEJM Video on Central Venous Catheterization (Internal Jugular w/US)

Technique tips and advice:

  • Right IJ is a more direct route to SVC
  • You can insert the needle into the IJ at a somewhat steep angle, but make sure you reduce the angle once the guidewire is being passed to increase chance of success
  • Patient positioning:
    • Trendelenburg
    • IJ is largest at end expiration
    • Intubated patient? Reversed. (largest at end inspiration)
    • Turn head away only 15-30 degrees
      • Extreme turning is NOT recommended. This actually increases the risk of carotid artery overlap!
  • Location of puncture:
  • IJ approach

From Roberts and Hedges’ Clinical Procedures in Emergency Medicine, 6th ed, 2013

This is the view you should obtain as you face the patient’s FEET on the patient’s RIGHT side (IJ is more often LATERAL): 

US IJ

From Roberts and Hedges’ Clinical Procedures in Emergency Medicine, 6th ed, 2013

 

FEMORAL

NEJM Video on Central Venous Catheterization (Femoral)

Technique tips and advice:

  • CLEAN the patient. CLEAN the groin, genitals, hip, belly, inner thigh, anterior thigh
    • Move items such as a foley to the other side
  • Patient positioning:
    • Rotate hip slightly with knee out
    • Reverse trendelenburg or neutral 
    • If needed, retract pannus with tape or assistant underneath the drape to better expose the femoral triangle
  • Location of puncture:
    • Vein can be superficial or deep depending on body type
    • Place your thumb on the pubic symphysis, and your index finger on the ASIS. Connecting these points is the inguinal ligament
      • The femoral artery will be in the middle, and the vein just medial to that (and 2 fingerbreadths below the ligament)
      • Look at this image:

fem approach

From Roberts and Hedges’ Clinical Procedures in Emergency Medicine, 6th ed, 2013

This is the view you should obtain as you face the patient’s HEAD on the patient’s RIGHT side (VEIN is more often MEDIAL): 

US Fem

From Roberts and Hedges’ Clinical Procedures in Emergency Medicine, 6th ed, 2013

 

LINE PLACEMENT CONFIRMATION

CONFIRMING YOUR CVC (5 min sono)
  •  After:
    • CXR
    • ABG: if venous, should have low O2 sats
    • CVP monitoring: pulsating? high pressures? Then may be arterial

 

SECURING THE LINE

Watch this video from Dr. George on how to correctly secure your line:

From Dr. Naomi George with permission 

 

Textbook References

McNeil CR, Rezaie SR, Adams BD. 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. Lee YH, Kim TK, Jung YS, Cho YJ, Yoon S, et al. Comparison of Needle Insertion and Guidewire Placement Techniques During Internal Jugular Vein Catheterization: The Thin-Wall Introducer Needle Technique Versus the Cannula-Over-Needle Technique. Crit Care Med. 2015 Oct;43(10):2112-6. PubMed PMID: 26121076
  2. Kitagawa N, Oda M, Totoki T, Miyazaki N, Nagasawa I, et al. Proper shoulder position for subclavian venipuncture: a prospective randomized clinical trial and anatomical perspectives using multislice computed tomography. Anesthesiology. 2004 Dec;101(6):1306-12. PubMed PMID: 15564937

Authorship

Faculty Reviewers: Gita Pensa MD  

Author: Jonathan Ameli MD

 

2 thoughts on “The Central Line Part 2: Technique & Procedural Steps

  1. Pingback: The Central Line Part 1: The Basics | Brown Emergency Medicine

Leave a Reply