Central Lines

Links:

Placement Video:
EMCrit Project

Complications:
Vascular Complications of Central Venous Catheter Placement: Evidence-Based Methods for Prevention and Treatment

Locations and Infection Rates:
The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters

TYPES OF LINES

 Central Venous Catheter (CVC)

  • usually triple lumen, routine central catheter for the ICU
  • administration of vasopressors, hypertonic saline (3%)
  • measurement of CVP

Dialysis Catheter (Quinton in our institutions)

  • dialysis or plasmapheresis catheter, can have a central port for central access
    • DO NOT use on an HD for care outside of a dialysis machine without the central port
    • Can also be tunneled (by surgery or IR) for semi-permanent placement (often then called a Permacath)

Introducer Sheath (large-bore, common trade name Cortis)

  • used for rapid resuscitation such as hemorrhage, or to “introduce” other equipment such as a PA-catheter or Transvenous Pacer

Hickman (tunneled catheter in subclavian)

  • for continuous infusions)

Portacath (completely under skin)

  • for chemotherapy or patients requiring recurrent access (like sickle cell)

Peripherally Introduced Central Cathether (PICC)

  • CVC introduced through deep vein on upper arm (eg brachial) ends at SVC
  • This insertion site can be kept longer than a traditional PIV and is great for patients who will require long-term infusions like antibiotics (you can administer pressors through a PICC)
    • Of note a “midline” enters in the same spot but is shorter and ends around the axillary vein

Arterial Line

  • Continuous monitoring of blood pressure
  • Reliable titration of pressors, inotropes, and antihypertensive infusions
  • Frequent arterial blood sampling

 SUPPLIES

line kit, chlorhexidine, lidocaine, face mask, cap, sterile gown, sterile gloves,  3+of saline flushes (remember the saline is sterile, but sometimes the syringe is not, not needed for arterial line), sterile caps, biopatch (blue to the sky), sterile probe cover, ultrasound

COMPLICATIONS

  • Pneumothorax/hemopneumothorax
  • Arterial puncture
  • Air embolism
  • Infection
  • Arrhythmia
  • Thrombosis
  • Compromise of circulation distal to arterial line (Example: Raynaud’s, thromboangiitis obliterans)

 TECHNIQUE

Hand-dominant IJ preferred (US-guided, compressible site, pt can walk with this site)

  1. CONSENT AND TIME-OUT
  2. Trendelenberg if possible
  3. Ultrasound to identify anatomy and insertion site, vein is compressible and artery is pulsatile and non-compressible
  4. Prep skin with chlorhexidine
  5. Put gel on probe (there has to be gel inside the probe cover and outside)
  6. Open kit and sterilly add equipment not in kit (flushes, biopatch, caps, etc)
  7. Don cap, mask, sterile gown, gloves
  8. Place sterile drape
  9. Place sterile probe cover over ultrasound probe, secure with rubber bands, and place sterile gel outside
  10. Re-clean site with chlorhexidine
  11. Identify insertion site with ultrasound
  12. Anesthetize insertion site with lidocaine
  13. Flush your catheter with saline to know it’s patent and working, cap/clip to ensure no air enters catheter after flushing
  14. Slide wire of guidewire until curved wire tip is straight
  15. Identify site with ultrasound and align vein in middle of ultrasound screen
  16. Insert syringe needle into vein under ultrasound guidance while maintaining negative pressure on syringe. Do not push down with ultrasound or you will compress the vein. You will see blood aspirate freely when you are in the lumen
  17. Hold the needle hub (stabilize it) with your non-dominant hand while unscrewing the syringe – carefully!
  18. Watch for non-pulsatile blood flow and insert your guidewire (if meeting resistance, remove guidewire and confirm that blood flow is still present)
  19. Remove needle once guidewire inserted and make small incision with scalpel (bevel-up) to facilitate insertion of dilator. NEVER LET GO OF GUIDEWIRE
  20. Thread dilator over guidewire, holding it proximally and using gentle twisting motion. NEVER LET GO OF GUIDEWIRE
  21. Remove dilator and then thread your triple lumen catheter until the wire emerges from a distal port/lumen. NEVER LET GO OF GUIDEWIRE
  22. Grab the wire when it emerges and advance catheter into vessel – then remove the wire – do not advance catheter unless you have control of guidewire from brown port!
  23. Flush ports either with caps or with clips. However you choose, always hold syringe upright so bubbles in syringe do not go in.  Always undo clip and reclip with syringe still attached so as not to introduce air.
  24. Suture catheter in place and place Biopatch, dress catheter site with Tegaderm
  • Arterial Line: Radial artery is preferred site
    1. CONSENT AND TIME-OUT
    2. Perform Allen’s Test prior to arterial line placement to ensure collateral circulation for hand
    3. Make sure pressure tubing with transducer is connected to bedside monitor (can ask nursing for help with this)
    4. Position arm straight, palm up – can use armboard to ensure arm is straight and wrist is dorsiflexed
    5. Prep skin with chlorhexidine
    6. Open kit and put in equipment not in kit
    7. Don cap, mask, sterile gown, gloves
    8. Place sterile drape
    9. Re-clean site with chlorhexidine
    10. Apply local anesthetic (can make a wheel with lidocaine)
    11. Gently palpate wrist for radial artery pulse
    12. Pull skin taut over the artery to stabilize it
    13. Puncture skin at about 45 degrees for radial artery
    14. Advance needle and catheter until flash of blood seen, then advance catheter only, into artery
    15. Connect to the pressure tubing that you set up earlier and observe the monitor for arterial waveform
    16. Secure the line with biopatch, tape, and Tegaderm
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