Central Line

Initial Preparation:

Examine past medical history for contraindications (ie thrombosis).
Examine overlying skin over insertion site for burns/infection.
Obtain consent for procedure, risks to discuss with patient: Pain, central line associated blood stream infection, thrombosis, hematoma, arterial puncture, pneumothorax, air embolus, arrythmias (patient needs to be on cardiac monitor).
Determine best target site of cannulation.
If patient unable to tolerate pneumothorax = consider femoral.
If neck has challenging anatomy or patient moving = consider femoral.
If one side of neck has thrombus or infection = consider femoral.
If planning for dialysis line eventually = consider left IJ or femoral.
Lay the patient down with mild Trendelenburg.
On pocus: examine the IJ vein (must be collapsible).
- Follow its course and assess for any thrombosis. Note where the carotid is and attempt to pick a site where IVC and carotid are side by side, far away from the clavicle).

Remove the headboard of the bed + ensure all poles are out of your way. Place side table within arm’s reach near the head of the bed and have ultrasound machine screen easily viewable.
Patient in supine position with slight Trendelenburg and slide patient towards head of the bed to ensure good access to the neck.
If internal jugular vein demonstrates significant collapse with respiration consider placing patient at steeper angle of Trendelenburg or bolus IV fluids prior to procedure.
If placing a Right Internal Jugular Central line turn the patients head slightly to the left and apply chlorhexidine to area of interest (between sternocleidomastoid muscles, well above the clavicle).

Open central line kit on side table, put on mask and hairnet provided. Establish a sterile field on the side table. Drop your gloves sterile onto the table, drop the 3 Iv locks onto the table, drop the 3 sterile saline vials onto the table, drop the blunt tip needle, 5mL syringe, 25+ gauge needle.
Put on the sterile gown while maintaining sterility, have nursing colleague tie up back. Put on sterile gloves.
Prepare lidocaine: Obtain 1% lidocaine without epinephrine from nursing colleague, and have it prepared into the 25+ gauge needle.
Prepare central line: add the IV locks to the blue and white port, prime each of the lines with 0.9% saline, ensure that brown port is left open without a lock.
Prepare equipment: Remove cap from introducer needle, remove cap from the guidewire, keep scalpel ready, obtain dilator, sutures, needle driver.
Apply drape to patient, around target injection site.
Prepare ultrasound: With help of nursing colleague, apply sterile probe cover to linear probe, then add sterile gel to your probe.

Once again examine the relevant area of insertion and track the vein down and note its trajectory/anatomy. Apply lidocaine 1% superficially in the skin.
Insert needle at 15-30 degree angle to skin approximately 5mm proximal to the probe.
1. Once needle tip is visible, slide probe away (until needle tip is no longer seen), then move the needle towards probe.
2. Walk the needle towards the IJ vein.
3. While inserting needle pull back on syringe to have constant gentle back pressure.
Advance needle into IJ, with constant gentle suction on the syringe.
1. When the Internal Jugular Vein is entered there should be easy blood flow into the syringe.
2. Transfer hold of needle to non-dominant hand.
With dominant hand advance guidewire into the syringe and push through the hole at the blue end until 3 marks are seen (30cm).
1. Alternatively, can take off the syringe and insert wire directly into the clear needle port until 2 marks are seen (20cm).
Remove needle, keeping guidewire in place.
Confirm guidewire position in IJ in both cross sectional + longitudinal views.

Create a skin nick with the scalpel along the path of the wire (approx. 1cm).
Advance dilator over the wire a few cm until it enters the vein.
1. This is often felt as a release of resistance while advancing the dilator.
2. Then remove dilator.
With one hand on the wire always, slide the CVC catheter over the wire up to the skin.
Slowly bring the wire out through the catheter. Once the wire leaves the catheters brown port, hold onto the wire there then advance catheter fully into IJ vein past the skin.
Remove the wire.
Apply IV lock to the brown port + pull back into saline syringe, should have easy blood flow, then flush all 3 lines with saline. Ensure no air entering the lines.
Suture line in place on both sides, cover with Tegaderm.
Obtain CXR. Document procedure.
1. CXR: Assess for pneumothorax + ensure roughly correct position of line.
  1. Position: Catheter tip should be straight down, landing 1cm below the right tracheobronchial angle/above upper cardiac silhouette.

Procedural steps written by: Muralie Vignarajah MD

Staff Reviewed by: Dr. Jason Erb (Anesthesiology, Critical Care)