How to Insert a Central Line

Jonny Rajan is a Speciality Registrar Level 1 in Anaesthesia, University College London, London Kiran Kaur is a locum Consultant in Anaesthesia, University College London, London Sanjay Bajaaj is a Specialist Registrar in Anaesthesia, University College London, London Robert CM Stephens is a locum Consultant and Research Training Fellow in Anaesthesia, Institute o Child !ealth, University College London, London" INTR !"CTI N The a#ility to insert a $central line% &a catheter in a vein leading directly to the heart' is an essential s(ill or many physicians" Central venous catheters &C)Cs' help monitor central venous pressure in acutely ill patients, provide access when no peripheral veins are availa#le, and allow or administration o vasoactive and inotropic drugs that cannot #e given peripherally" Around *++,+++ C)Cs are inserted annually in the ,!S, with ailure rates estimated to #e as high as -./ in the literature" Central venous pressure measurement6 a luid resuscitation aid To ta(e Central venous gas measurements6 a luid resuscitation aid 7hen peripheral venous access is di icult 7hen vasoactive, inotropic or hypertonic agents are re8uired that should not #e administered peripherally &eg Adrenaline, ,oradrenaline or total parental nutrition' For haemodialysis, plasmapheresis, temporary cardiac pacing or chemotherapy Ta#le 1 Indications or C)0 lines and line siting C)C%s can #e situated in 1 sites &see Fig 1 and *'" The choice o C)C insertion sites will depend on the indications, ris( o complications and e2pertise o the doctor" It should #e remem#ered that &e2cept the e2ternal 3ugular' most central veins are o ten deep and have to #e located without the aid o direct vision" This is associated with damage to near#y structures, especially in the hands o an ine2perienced operator" Success ul catheteri4ation #y either the internal 3ugular or the su#clavian route there ore relies on a thorough understanding o the anatomy o the nec( and use o *5

ultrasound" The internal 3ugular vein is located at the ape2 o the triangle ormed #y the heads o the sternocleidomastoid muscle and the clavicle" The su#clavian vein crosses under the clavicle 3ust medial to the midclavicular point" Ultrasound &*5' guidance is recommended or C)C in #oth the elective and emergency situation" It allows precise location o the target vein, anatomical variation and throm#osis within the vein" Audio9guided 5oppler ultrasound is not recommended"

#i$ %& 'nato(y o) the ne*+ in relation to internal ju$ular ,ein *atheterisation&

#i$ -& Sites o) *entral ,enous line insertion& 0atients should #e assessed or contraindications" These include an uncooperative patient, uncorrected #leeding diathesis, s(in in ection over the puncture site, a pneumothora2 or haemothora2 on the contralateral side or the presence o only one unctioning lung" Factors that might increase the 2

di iculty o catheter insertion, such as a history o ailed catheterisation attempts or the need or catheterisation at a site o previous surgery, s(eletal de ormity, or scarring should also #e considered" 7hen a di icult catheteri4ation is anticipated, the importance o patient sa ety dictates that the procedure #e per ormed or supervised #y an e2perienced physician"

Fig 3. Ultrasound to guide CVC.

Figure 4. Ultrasound views of CVC showing right common carotid artery, (RCCA and com!ressed right internal "ugular vein, (R#$V.

./uip(ent )enous catheters &see ig ."' are availa#le that di er in length, internal diameter, num#er o access ports, material and methods o i2ation" Adult catheters or su#clavian or internal 3ugular lines are commonly *+ cm in length although, i the right sided nec( veins are cannulated shorter 1.cm catheters should #e used to prevent right atrial catheteri4ation"

#i$ 0& ./uip(ent in a C1C pa*+ #i$ 2& Co(parison o) C1C Insertion sites
Internal Ju$ular Sub*la,ian Compressi#ility o vessels in #leeding ;ase o access during active resuscitation ;ase o use with US guided techni8ues 0atient com ort and maintenance o dressing Arterial puncture Throm#osis and !aematoma !aemothora2 and 0neumothora2 In ection ris( :: : ::: :: ++ :: + :: : :: : ::: ++ : ++ : #e(oral ::: ::: ::: : +++ ::: :::

Te*hni/ue o) insertion The patient is consented then commonly positioned in the trendelen#erg position & eet up, head down to increase vein si4e' or internal 3ugular vein or su#clavian vein C)C insertion" For emoral vein C)C the supine position is adopted" Landmarks are then identi ied and ultrasound is then used to identify the desired vein and ad3acent arteries" Full sterile techni8ue &sterile gown and gloves, mas(, cap with ultrasound pro#e in sterile sheath' must #e used" The area should #e cleaned in a sterile ashion using an appropriate disin ectant, ollowed #y sterile draping" Lignocaine can then #e used to anesthetise the venepuncture area as well as the suture area" The artery is usually medial to the vein, smaller and pulsatile and unli(e the vein, is not compressi#le" The needle is advanced, under Ultrasound while applying negative pressure to the syringe until a lash o #lood is visuali4ed" The seldinger techni8ue &guidewire through the needle which is then withdrawn to leave the guidewire only' is then used to insert the catheter a ter which a chest radiograph is re8uired to con irm position and e2clude a pneumothora2 #i$ure 3& Co(pli*ations o) C1C& <alposition o the catheter !aematoma Arterial puncture 0neumothora2 !aemorrhage Sepsis Central 1enous pressure The central venous pressure &C)0' is e2pressed in cm!*= a#ove a point level with the right atrium" The normal value is +9> cm!*= and is measured with the patient lying lat" It gives a use ul indication o illing status and right ventricular preload" A volume challenge o *.+ mls o colloid over 1. minutes6 an increase in C)0 o less than .cm ! *= &or - mm!g', or one that is not sustained or more than 1+ minutes suggests hypovolaemia" Serial readings are much more use ul than a single reading" The presence o anatomical variants such as tricuspid regurgitation which may alter the #aseline C)0 Air em#oli Catheter em#olism Throm#osis !aemothora2 Cardiac tamponade Cardiac arrhythmias

reading o the patient must Causes o) a raise5 C14 in*lu5e Increased intrathoracic pressure

#e

ta(en

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Impaired cardiac unction & ailure, tamponade" =nly use ul or in ormation regarding the right side o the heart'" !ypervolaemia Superior vena cava o#struction Caues o) a 5e*rease5 C14 in*lu5e67 !ypovolaemia Reduced Mana$in$ intrathoracic the patient pressure with C14 &e"g" *annula inspiration' & 0atients should #e monitored or signs o complications" Central lines with drugs? luids etc" #eing in used should #e clearly la#elled in order to minimise the ris( o accidental #olus in3ection" Lines should #e regularly lushed to help prevent throm#osis and a .++ml #ag o +"@/ normal saline connected to the line should #e maintained at a pressure o -++mm!g" All connections must #e secure to prevent e2sanguination, introduction o in ection and air em#oli" Furthermore the insertion site should #e re8uently and care ully assessed or signs o in ection" The length o the indwelling catheter should #e recorded and regularly monitored" C)0 lines should #e removed when clinically indicated, and with the patient in the head down position i the nec( has #een used as the site o insertion" The tip should #e sent or micro#iological culture" Su((ary C)C is a common procedure per ormed #y a range o specialities" Ultrasound guidance is recommended" Administration o drugs and volume status monitoring is acilitated" It has numerous possi#le complications"