Central line indications|Central line insertion uses|What is a central line|Central line equipment list

 

Central line (central venous catheter) insertion

­­Central line insertion should be real-time ultrasound guided. The internal jugular is usually preferred to subclavian approach where possible as it is less likely to lead to pneumothorax Indications for central line (central venous catheter) insertion Administration of medications that require central access e.g. amiodarone, inotropes, high concentration electrolytes Fluid balance monitoring with CVP Intravenous access (long term or difficult peripherally)   Complications of central line (central venous catheter) insertion Haemothorax Pneumothorax Haematoma Inadvertent arterial puncture

Equipment required for central line (central venous catheter) insertion Ultrasound and sterile ultrasound sheath Sterile trolley Sterile field, gloves, gown and mask Seldinger central line kit Saline flush Chlorhexidine Lignocaine (4ml (2 vials) of 2% is reasonable) Suture Scalpel Sterile dressing Pressure bag to attach to monitoring

Contraindications to central line (central venous catheter) insertion Coagulopathy Local infection Avoid in raised intracranial pressure- aim for a femoral approach if required Patient non-compliance

Pre-procedure Consent patient if conscious otherwise document why the procedure is in the patients best interests Consent should include: Infection, bleeding (arterial puncture, haematoma, haemothorax), pain, failure, damage to surrounding structres (including pneumothorax), thrombosis. Set up sterile trolley Position patient with head down if they can tolerate it, with head facing away from side of insertion This ensures maximum venous filling Ultrasound area to define anatomy Having a nurse or assistant is helpful

Procedure for central line (central venous catheter) insertion Wash hands and don sterile gown and gloves Clean the area and apply sterile field. Make sure to have some spare gauze swabs ready. Apply sterile sheath to the ultrasound probe Confirm anatomy Under ultrasound guidance insert lignocaine cutaneously, subcutaneously and around internal jugular. Whilst lignocaine has time to work flush all lumens of the line and then clamp all lumens except the Seldinger port Ensure caps are available for the lumens Under ultrasound guidance take Seldinger needle attached to syringe and insert into the internal jugular vein When blood is freely aspirated remove syringe and immediately inset Seldinger wire. This should pass easily Keeping hold of the inserted wire, remove the needle. Ensure the wire stays in the vein as you do this Use scalpel to make an small incision in the skin (approx 3mm). This should be done cutting away from the wire so as not to damage it Pass the dilator over the wire and gently but firmly dilate a tract through to the internal jugular. At this stage there may be some bleeding so ensure to have some swabs ready Remove the dilator and pass the central line over the Seldinger wire. Do not advance the line until you have hold of the end of the wire Once the central line is in place, remove the wire Aspirate and flush all lumens and re clamp and apply lumen caps Suture the line to allow 4 points of fixation Dress with a clear dressing so the insertion point can be clearly seen

Post-procedure Attach central line to pressure bag to allow CVP monitoring Nursing staff can show you how to do this or will do it for you Run a blood gas to ensure a venous sample Chest x-ray to confirm placement and to check for pneumothorax Clear documentation of date of insertion and monitor for infection

In the event of failure Stop procedure Seek senior help

Top Tips for central line (central venous catheter) insertion Central lines can have multiple lumens. Most commonly 3,4 and 5 lumen lines are inserted. Confirm what the line will be used for and how many infusions a patient has to aid your selection of the line with the correct amount of lumens Always ensure you are happy with your anatomy before commencing the procedure Ensure your sterile trolley is well set up with the kit lined up in the order you will use things and a clear area for sharps. This will make your life easier. NEVER LET GO OF THE SELDINGER WIRE! Types of central lines The central line will be placed into 1 of the veins as described below. Which vein is used depends on your needs and overall health. The catheter is threaded through the vein until the tip sits in the large vein near the heart (vena cava). Types of central lines include: Peripherally inserted central catheter (PICC). This line is placed in a large vein in the upper arm, or near the bend of the elbow. Subclavian line. This line is placed into the vein that runs behind the collarbone. Internal jugular line. This line is placed into a large vein in the neck. Femoral line. This line is placed in a large vein in the groin.