Indication for central line insertion
- Hemodynamic monitoring (Central venous pressure)
- Insertion of PA catheter
- Rapid fluid resuscitation or rapid blood
replacement therapy - Infusion of vasoactive substances, chemotherapy or hyperalimentation
- Transvenous pacing
- Aspiration of air embolism
- Temporary dialysis access
- Plasmapheresis
- Poor peripheral venous access
Absolute contraindications to central line insertion
- Patient refusal
- Infection at insertion site
- Anatomic obstruction (thrombosis, anatomic variance, carotid disease)
- Superior vena cava syndrome
Relative contraindications to central line insertion
- Coagulopathy
- Systemic infection
- RVAD
- Presence of pacing wires or other indwelling catheters at insertion site
Patient position (s) for central line insertion
- Supine
- Trendelenberg with head turned 45 degrees away from insertion site
During insertion prep, use chlorhexidine gluconate sterile prep for at least ____
30 seconds (then allow it to dry for 2 mins)
For kids, use iodine instead
Most common insertion site of central line for cardiac anesthesia
IJ vein
lower incidence of pneumothorax compared to SC vein cannulation
Where is the IJ located?
between the sternal and clavicular heads of the sternocleidomastoid muscle
Why is the right IJ preferred over the left IJ for central line insertion?
- Takes a straight course to RA, easier to portion at SVC-RA junction
- Has lower incidence of pneumothorax compared to the left (o/t lower dome of pleura on right side)
- Avoids thoracic duct injury
What is drawback to the IJ site for central line insertion?
More likely to become contaminated due to respiratory secretions
Rank the anatomical site in order of most likely to get infected for central lines
#1 Femoral (15.3%) #2 IJ (8.6%) #3 SC (4%)
Rank the anatomical site in order of most likely for arterial puncture for central lines
#1 Femoral (6.25%) #2 IJ (3%) #3 SC (0.5%)
Complications of central lines
- Hematoma
- Arterial puncture
- Infection
- Arrhythmia
- Cardiac perforation and tamponade
- Thoracic duct injury
- Pneumothorax (0.1-0.2% for IJ, 1.5-3.1% for subclavian)
- Hemothorax (with subclavian)
- Nerve injury
- Venous thrombosis, pulmonary emboli
For right IJ, the catheter should be secured at around ____ depending on patients
16 cm
Formula for Rt IJ:
Height/10cm
For right subclavian, the catheter should be secured at around ____ depending on patient’s height
15 cm
Formula for Rt SC:
(Height/10) - 2cm
For left IJ, the catheter should be secured at around ____depending on the patient
20 cm
Formula for Left IJ:(height/10) + 4 cm
For left subclavian, the catheter should be secured at around ____ depending on the patient
19 cm
Formula for Left SC:(height/10) + 2 cm
Steps for central line removal
- Place the patient in Trendelenberg position
- Ask the patient to exhale as the catheter is removed to prevent air embolism
- Apply pressure over the site for 1-2 minutes until hemostasis is achieved
Review slides 10-13 for insertion procedure
…..
How should the IJ appear on ultrasound?
- Superficial
- Larger
- Oval-shaped
- Compressible
If not using ultrasound, how would locate the IJ?
- Connect finder needle to syringe
- Start at the apex of the triangle, advancing towards the ipsilateral nipple at a 30-45 degree angle to the skin while continuously aspirating until blood flows freely into the syringe
How far should you advance guidewire? What is a concern with guidewire insertion?
- 6-8cm
- Watch for PVC’s, dysrhythmias
- If they occur, withdraw guidewire immediately
