11/13/24, 7\:19 PM Guide | Central line insertion (central venous cannulation)

Central line insertion (central venous cannulation)

Table of contents

Introduction

Central venous catheters (CVC) or central lines are intravenous devices inserted into a large central vein. They are most
commonly encountered in the intensive care and theatre settings, but may also be seen in surgical or medical wards.
This guide provides a step-by-step approach to inserting a central line into the internal jugular vein in an OSCE setting; it is
NOT intended to be used to guide patient care.

Indications

Indications for inserting a central line include\:
Infusions irritant to peripheral veins or dangerous on extravasation (e.g. parenteral nutrition, noradrenaline)
Monitoring central venous pressures
Diperipheral access
Continuous or intermittent haemodialysis
Replacement of large volumes in resuscitation
Measurement of mixed venous saturations or cardiac output
Long-term intravenous access

Anatomical sites

Central lines can be inserted at various anatomical sites, most commonly in the internal jugular (IJ) vein. In this case, the aim is
for the tip to be positioned in the superior vena cava or at the cavoatrial junction. Central lines can also be placed in the
subclavian or femoral veins.
The internal jugular vein is most often the
(particularly in theatre), the risk of site infection is less common than with femoral lines, the associated artery (carotid artery)
can be compressed if accidentally punctured, and it requires the least amount of operator skill.
Subclavian and femoral venous lines may be used in speci
Femoral vein\: inaccessible neck, e.g. suspected or con
Subclavian vein\: trauma patients with a pneumothorax, or where a CVC needs to be placed quickly without the use of
ultrasound (using an anatomical landmark technique)
For the purposes of this article, we will focus on the most commonly used internal jugular site. Peripherally inserted central
catheters (PICC lines) are beyond the scope of this article, but the tip's position is usually the same area as internal jugular lines.

Gather equipment

Gather the appropriate equipment to insert a central line\:
Chlorhexidine 2% stick
Sterile gloves
Sterile gown
Surgical mask
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Surgical hat
Sterile ultrasound probe cover
Elastic bands to secure probe cover
Sterile ultrasound gel
Sterile drape (with a preformed opening)*
Straight introducer needle/cannula 18G*
Guide wire*
Dilator(s)*
*
Central venous catheter (typically 16 cm for right IJ vein and 20 cm for left IJ vein) with colour-coded lumens
*
Scalpel
Straight silk sutures
Clear sticky dressing
*
*
Gauze
5 mL syringe*
20 mL sterile 0.9% sodium chloride
20 mL syringe
*
Bungs for the end of each lumen
*These items of equipment may be found in a CVC insertion pack.
Central lines come in various sizes and lengths, which is beyond the scope of this article. We will focus on the standard 16 cm
right-sided

Local anaesthetic

If the patient is not anaesthetised, local anaesthetic should be used\:
5 or 10 mL syringe
Blunt drawing up needle
Orange 25G needle or blue 23G needle, dependent on patient size
Local anaesthetic, e.g. 5 mL lidocaine 1%

Ultrasound

The insertion of a central line was previously carried out using the anatomical landmark technique with a seeker needle. Most
guidelines now recommend the use of ultrasound-guided insertion to ensure correct identi
placement of the wire, reducing complications.
1
A sterile ultrasound probe cover should always be used.

Introduction

Wash your hands using alcohol gel. If your hands are visibly soiled, wash them with soap and water.
Don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Brie
Example explanation
“ T h i s p r o c e d u r e i s t o p l a c e a c e n t r a l l i n e . T h i s i s a p l a s t i c t u b e w h i c h i s i n s e r t e d i n t o a b l o o d v e s s e l i n y o u r n e c k t h a t l e t s
u s g i v e y o u m e d i c a t i o n s a n d t a k e b l o o d s a m p l e s . F o r t h e p r o c e d u r e , y o u w i l l n e e d t o l i e
t i t l e d d o w n w a r d s , a n d I w i l l p l a c e a p l a s t i c d r a p e o v e r y o u r h e a d . I w i l l u s e l o c a l a n a e s t h e t i c t o n u m b t h e a r e a s o t h a t i t
w i l l b e m o r e c o m f o r t a b l e f o r y o u , b u t y o u m i gh t f e e l s o m e p r e s s u r e o n y o u r n e c k . I f y o u f e e l a n y p a i n , l e t m e k n o w .
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T h e m a i n r i s k s t o y o u i n c l u d e b l e e d i n g , i n f e c t i o n o r b r u i s i n g ( h a e m a t o m a ) , a i r i n t h e l u n g c a v i t y ( p n e u m o t h o r a x ) , d a m a ge
t o t h e o t h e r v e s s e l s a n d f a i l u r e o f t h e p r o c e d u r e . W e u s e a n u l t r a s o u n d m a c h i n e t o gu i d e t h e n e e d l e a n d r e d u c e t h e r i s k
o f c o m p l i c a t i o n s .
”
Gain consent to proceed with central line insertion.
Check if the patient has any allergies (e.g. latex, local anaesthetic).
Ask the patient if they have any pain before continuing with the clinical procedure.

Pre-procedure

Contraindications

Contraindications to inserting a central line include\:
Patient refusal (absolute)
Coagulopathy
Thrombocytopenia (consider pre-procedure platelet transfusion if \< 20 x 10⁹/L)
Patient unable to lie
Uncooperative patient
Morbid obesity
Altered neck anatomy
Overlying skin infection
Spinal immobilisation

Positioning

The internal jugular vein can sometimes be di
patients. The diameter can also change with the respiratory pattern.
2
The internal jugular vein lies anterior and lateral to the carotid artery in two-thirds of people , and there is a risk of accidental
arterial puncture. Therefore, it is important to give yourself the best chance of a successful venous puncture. This can be done
by optimally positioning the patient in a steep head-down position (provided they can tolerate it).

Monitoring

It is important to monitor the vital signs during the procedure, and particularly cardiac monitoring. If the guide wire or central
line is fed too far, it can enter the right atrium and stimulate the sinoatrial node, causing potentially dangerous arrhythmias.

Set up the sterile

You will need a non-sterile assistant to help you throughout the procedure. Before beginning, set up the sterile
1. Wash your hands and don an apron, surgical mask and hat.
2. Open the procedure pack on the clean top shelf of the trolley, opening the pack from the corners without touching the inner
surface of the
3. Use an aseptic non-touch technique (ANTT) to place the central line kit, chlorhexidine stick, sterile drapes, needles, syringes,
sterile ultrasound probe cover, sterile gauze, suture, and sterile dressing onto the sterile
4. Perform a surgical scrub and don your sterile gown and gloves.
5. Ask your assistant to pour 20 mL of 0.9% sodium chloride into a sterile pot.
6. Place a bung on each lumen of the central line (except the central lumen) and
ensure patency, and to prevent injection of air following insertion of the line.
7. Once
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8. Draw the guide wire back into its sheath until only the tip is seen.
9. Ask your assistant to open the local anaesthetic and draw 5 mL into your selected syringe.
10. Clean the patient's neck with the chlorhexidine stick and allow to dry.
11. Place the sterile drape over the patient's head, with the opening over the anatomical site of the internal jugular vein.
12. Open the sterile ultrasound probe cover, and place sterile gel on the inside surface where the probe will come into contact.
Grasp the probe from your assistant whilst maintaining sterility, and feed the cover as far as it will go over the probe. Secure
with the elastic bands.

Insert the central line

Central lines are inserted using the Seldinger technique, i.e. a guide wire is fed into the vessel through a needle, dilators are
placed over the wire, and then the line is fed over the wire. As a central line is at high risk of infection, the procedure should be
performed using full asepsis, with a sterile gown and sterile gloves.
1. Place sterile ultrasound gel on the patient's neck.
2. Scan the neck and identify the relevant anatomy of the internal jugular vein and carotid artery.
Identifying the internal jugular vein
Good knowledge of the neck anatomy is essential to avoid inadvertent puncture or damage to other structures,
particularly the carotid artery. The internal jugular vein is located lateral and super
Methods of di
A vein is compressible with the pressure of the ultrasound probe, whilst an artery is not
A vein is non-pulsatile, whilst an artery is pulsatile
Colour Doppler will typically show
reliable)
Held inspiration will increase the intrathoracic pressure and engorge the internal jugular vein
3. Inlocal anaesthetic.
4. Attach the straight introducer needle to a 5 mL syringe. Puncture the skin and advance the needle towards the vein under
ultrasound guidance. You should always be able to see the needle tip.
5. While advancing the needle, continuously aspirate the syringe (this can be di
you should be able to aspirate dark red blood into the syringe and see your needle tip within the vein.
6. Put down the ultrasound probe. Whilst holding the needle securely in place, untwist the syringe from the end of the needle.
Blood should continue to
7. Feed the guide wire through the needle and into the vein. This should feed easily with no resistance; if there is any resistance,
stop. Feed the wire to the appropriate distance (never to the hilt) using markings to guide the depth, while asking your
assistant to monitor the telemetry. If any ectopic beats or arrhythmias occur, withdraw the wire slightly and ensure the patient is
stable before continuing.
8. Hold the guide wire
go of the guide wire.
9. Before dilating the vessel, you must ensure that the guide wire is not within the artery. With the ultrasound, identify the guide
wire and use the techniques described above to con
ultrasound. A blood gas may be taken to con
10. Load the dilator onto the wire until it meets the skin. With the scalpel, make a 1 cm wide and 1 cm deep incision in the skin
at the entry point of the guide wire. Ensure the blade is facing away from the wire to avoid damaging it.
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11. Warn the patient of pressure, and then advance the dilator along the guide wire with continuous downward pressure in a
twisting motion. You may feel a slight give once the dilator has reached the vein.
12. Remove the dilator, keeping the wire in place.
13. Feed the central line over the guide wire. The wire will appear from the end of the central lumen, so avoiding clamping or
placing a bung on this is important. Never let go of the guide wire.
14. Feed the central line to the hilt, then remove the guide wire.
15. Place a bung on the central lumen. Ensure all lumens can be aspirated and then
16. Suture the line in place, apply a clear dressing and remove the sterile drape.

To complete the procedure...

Explain to the patient that the procedure is now complete.
Thank the patient for their time.
Allow the patient to reposition to a position that is comfortable for them.
Dispose of sharps, PPE and other clinical waste into an appropriate clinical waste bin.
Wash your hands.
Inform the nursing sta
until all checks are done; however, it may be used in an emergency), and ask them to perform a full set of observations.
Ensure that all lumens are closed to air and that there is no obvious bleeding from the insertion point.
Recheck the telemetry and ensure there are no arrhythmias.

Post-procedure checks

Chest X-ray
A chest X-ray is important post-procedure to conpneumothorax.
Waveforms and pressures
Transducing the line will display the waveform and vessel pressures. Arterial and venous pressures and waveforms are very
di

Documentation

Document the details of the procedure including\:
Your personal details including your name, job role and GMC number
The date and time the procedure was performed
That you have explained the risks and bene
The indication for the central line
The local anaesthetic used
The use of ultrasound guidance and the views of the wire prior to dilation
The site of insertion and number of attempts
The length and number of lumens of the central line inserted
What was used to ensure asepsis
How the line was secured and the type of suture used
Whether all lumens were
Any immediate post-procedure concerns or complications
What investigations have been requested, and who is responsible for checking the results

Complications

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There are several complications of central line insertion\:
Oozing or bleeding at the site of insertion\: this usually settles with direct pressure
Pain at the site of insertion
Displacement of the line
Entrainment of air\: a potentially fatal complication which can occur if the line is open to air and the patient inspires. The
negative pressure generated in inspiration draws air into the line, which can move into the superior vena cava or right atrium,
causing an incompressible air embolus.
Pneumothorax\: a well-recognised complication that can occur due to puncture of the pleura at the apex of the lung.
Suspect this if air is aspirated during the initial puncture.
Arterial puncture\: the carotid artery may be punctured with the introducer needle. If this occurs, remove the needle and
apply direct pressure to the neck. If there is ongoing bleeding or haematoma formation, discuss with vascular surgery and
haematology.
Arterial dilatation\: if the carotid artery is dilated and a central line is inadvertently inserted into it, leave the line in situ with
clear instructions and markings that it is not to be used and discuss urgently with vascular surgery.
Loss of wire\: if the wire is inadvertently lost or fed too far, it can settle in the venous system. This requires emergency
imaging and discussion with vascular surgery, and it is advisable to keep the patient in a lying position.
Infection\: central line sites should be inspected at least daily for evidence of thrombophlebitis. If infection is suspected,
discuss with microbiology and consider removing the line.

References

1. Bodenham, A., Babu, S., Bennett, J. et al. A s s o c i a t i o n o f A n a e s t h e t i s t s o f G r e a t B r i t a i n a n d I r e l a n d \: S a f e v a s c u l a r a c c e s s . 2016.
2. Umana, M., Garcia, A., Bustamante, L. et al. V a r i a t i o n s i n t h e a n a t o m i c a l r e l a t i o n s h i p b e t w e e n t h e c o m m o n c a r o t i d a r t e r y a n d t h e
i n t e r n a l j u g u l a r v e i n , A n u l t r a s o n o g r a p h i c s t u d y . 2015.

Reviewer

Dr Grace McCrystal
ST6 Anaesthetics
Source\: geekymedics.com
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