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Central Line

NEJM Video Guide

Indications

  • Extracorporeal therapies: HD, CRRT, Plasma (PLEX) or RBC exchange transfusion

  • Venous access for: vasopressors, chemotherapy, parenteral nutrition, hemodynamic monitoring (CVP, ScvO2) and cardiac parameters (via PA catheter), inadequate peripheral access

Relative Contraindications

  • Increased bleeding risk, anatomic distortion at site selection, indwelling vascular hardware (pacemaker, HD access), vascular injury proximal to site, skin infection overlying selected site

  • Immediate complications: bleeding, malposition, arterial puncture, arrhythmia, pneumo- or hemothorax, air embolism, damage to surrounding structures (nerves, thoracic duct)

  • Delayed complications: infection, thromboembolism, myocardial perforation, venous stenosis

Pre-procedural considerations

  • Bleeding risk guidelines: Plts > 20k, INR \< 3

  • All patients need to have telemetry & pulse oximetry monitoring

  • With every pt, consider LENGTH, LOCATION, LUMENS, and LINE TYPE!

Central Line

Recommended Length

(for patient height >5’5”)
Right IJ or Subclavian 15 cm
Left IJ or Subclavian 20 cm
Femoral 25 cm
*Confirm length of catheter in your kit before you open/place the line!
Type of Line Uses Special Considerations
Triple Lumen (7Fr) Central access for vasopressors, caustic infusions Consider lumens needs; triple lumen is most versatile but can warrant dual lumen
MAC or Cordis* ‘Short and fat’ allowing rapid transfusion; MAC has two parts and can float a PA catheter through it MAC is placed with dilator still in introducer
Dialysis Catheter (Trialysis, 12 Fr) Dialysis line with two 12 Ga. Lumens for dialysis with a third 17 Ga. lumen for added access Two serial dilations
*Can place triple lumen in MAC for additional ports; lose ability to rapidly transfuse
Site Advantages Disadvantages
Internal Jugular Vein Minimal risk of PTX; improve target with positioning and use of US; easily compressible if bleeding occurs Risk of carotid puncture, difficult in obese pt; vein collapsibility with hypovolemia
Subclavian More comfortable for pts; landmark driven approach; lowest risk infection Increased risk of PTX, harder to control bleeding with pressure, technically more difficult
Femoral Easiest to access, no risk of PTX, can be placed during CPR and intubation

Procedural considerations

  • Numb pt right after draping, then set up everything to allow time for lidocaine to work

  • Set supplies up in exactly the order of use to ensure all are present and functioning

  • Cap side ports with blue claves (not included in Trialysis kit) prior to flushing

  • For IJ access, place pt in slight Trendelenburg position to engorge vein

  • While advancing needle, ensure constant negative pressure with aspiration of plunger and visualization of needle tip with US

  • Designate someone to watch tele while threading guidewire to monitor for arrhythmias; limit guidewire insertion depth to no more than 16 cm to reduce arrhythmia risk

  • Always ensure guidewire is secured while it is inside a vein

  • Always ensure target for venous cannulation is visualized and guidewire is placed correctly prior to dilation: 1) Compression of target vessel 2) Non-pulsatile dark blood return (unless on 100%FiO2, may be brighter red) 3) US visualization or needle and wire 4) can use pressure tubing and angiocath to confirm CVP or obtain venous O2 sat

Post-procedural considerations

  • Every IJ or subclavian central line needs a confirmation CXR to confirm no PTX

  • Ideal placement of distal tip: in SVC just outside the right atrium, approximately near/superior to carina and right tracheobronchial angle

Troubleshooting Complications:

- Arterial Access or puncture: immediately remove needle and hold
    pressure for 15 mins to prevent hematoma formation; if uncontrolled
    bleeding or artery was dilated, STAT vascular surgery consult

- Bleeding: place direct pressure; subclavian access precludes ability
    to compress and confers highest bleeding risk; if uncontrolled, STAT
    vascular surgery consult

- Pulmonary Complications: if free air aspirated into syringe,
    consider PTX vs poor seal of syringe & needle. Close attention to
    pulmonary complication & STAT CXR to assess PTX. If rapid
    deterioration, needle decompression and chest tube placement
    required

- Venous Air Embolism: can occur if air introduced to system during
    placement, flushing, or if left open to the atmosphere. Effects are
    variable, but if suspected, place pt in left lateral decubitus
    position to trap air in right apex and place pt on 100% O2 to speed
    resorption

- Arrhythmia: rationale for telemetry monitoring as guidewire can lead
    to atrial or ventricular arrhythmias; immediately withdraw wire to
    lesser depth; if arrythmia persists, abort procedure and treat
    patient and determine cause