Continuing Education ActivityA central line is a large-bore central venous catheter that is typically placed using a sterile technique unless a patient is unstable, in which case sterility may be a secondary concern. Some indications for central venous line placement include fluid resuscitation, blood transfusion, drug infusion, central venous pressure monitoring, pulmonary artery catheterization, emergency venous access for patients in which peripheral access cannot be obtained, and transvenous pacing wire placement. This activity describes the indications and technique involved in central line placement and highlights the role of the interprofessional team in ensuring that the procedure is performed safely. Show
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Access free multiple choice questions on this topic. IntroductionA central venous line (CVL) is a large-bore central venous catheter that is placed using a sterile technique (unless an urgent clinical scenario prevents sterile technique placement) in certain clinical scenarios.[1][2][3][4] Anatomy and PhysiologyIn emergency medical practice, there are three possible sites for CVL placement in the adult patient. Each has advantages and disadvantages. The placement sites include the internal jugular vein, femoral vein, and subclavian vein. The right internal jugular vein and left subclavian vein are the most direct paths to the right atrium via the superior vena cava. The femoral veins are compressible sites and as such may be more appropriate for coagulopathic patients. The subclavian vein approach is at higher risk for pneumothorax than the internal jugular vein approach. Ultrasound guidance can be very helpful in all approaches and is the recommended approach. However, when ultrasound guidance is not feasible for various reasons, such as the emergency nature of a procedure, lack of equipment, or a patient's anatomy in a situation where there is limited room for the ultrasound transducer in the subclavian approach while manipulating the needle, CVLs may be placed using anatomical landmarks without ultrasound. IndicationsThere are many different indications for placing a CVL, but in emergency medicine, the most common indications include:
ContraindicationsContraindications include distorted local anatomy (such as for trauma), infection overlying the insertion site, or thrombus within the intended vein. Relative contraindications include coagulopathy, hemorrhage from target vessel, suspected proximal vascular injury, or combative patients. EquipmentMost central line kits include:
In addition, the operator will require a sterile gown, cap, sterile gloves, sterile gauze, sterile saline, face mask, and a sterile cleansing solution such as chlorhexidine. The operator should ensure that ultrasound, sterile ultrasound gel, and a sterile ultrasound probe are part of the setup as well. PreparationPlace the patient in the appropriate position for the site selected, then prepare the site in a sterile fashion using the sterile solution, sterile gauze, and sterile drapes. For the internal jugular and subclavian approach, place the patient in reverse Trendelenburg with the head turned to the opposite side of the site. For the femoral vein, place the patient in the supine position with the inguinal area exposed; this usually means the target leg should be bent at the knee with the lateral aspect resting on the stretcher or bed. It is recommended to place the patient on cardiopulmonary monitoring for the duration of the procedure. TechniqueThe steps are as follows:
ComplicationsPotential complications should be explained to the patient if possible while obtaining informed consent. Complications include pain at cannulation site, local hematoma, infection (both at the site as well as bacteremia), misplacement into another vessel (possibly causing arterial puncture or cannulation), vessel laceration or dissection, air embolism, thrombosis, and pneumothorax requiring a possible chest tube.[5][6][7] Clinical SignificanceClinical pearls for consideration:
Enhancing Healthcare Team OutcomesCentral lines are inserted by many healthcare professionals. However, the monitoring of these lines is usually done by the nurses. The site of entry has to be kept clean and the nurse has to monitor it for signs of infection. Depending on which location the line was inserted, complications also have to be monitored like a pneumothorax, hematoma, bleeding or extravasation. In general, healthcare workers should avoid lines in the groin for more than 24 to 48 hours as they are prone to infections and also make it difficult for the patient to ambulate or get out of bed. To ensure good practice and limit complications, most hospitals now have an interprofessional team of healthcare professionals who are in charge of central line insertion and monitoring, each one checking and communicating any issues noted to the rest of the team so corrective action can take place if necessary. Such universal practice has been shown to limit infections. [8][9](Level V) Review QuestionsFigureCentral line pericardium. Image courtesy S Bhimji MD FigureCentral line triple lumen. Image courtesy S Bhimji MD References1.Mitsuda S, Tokumine J, Matsuda R, Yorozu T, Asao T. PICC insertion in the sitting position for a patient with congestive heart failure: A case report. Medicine (Baltimore). 2019 Feb;98(6):e14413. [PMC free article: PMC6380712] [PubMed: 30732193] 2.Derderian SC, Good R, Vuille-Dit-Bille RN, Carpenter T, Bensard DD. Central venous lines in critically ill children: Thrombosis but not infection is site dependent. J Pediatr Surg. 2019 Sep;54(9):1740-1743. [PubMed: 30661643] 3.El Ters N, Claassen C, Lancaster T, Barnette A, Eldridge W, Yazigi F, Brar K, Herco M, Rogowski L, Strand M, Vachharajani A. Central versus Low-Lying Umbilical Venous Catheters: A Multicenter Study of Practices and Complications. Am J Perinatol. 2019 Sep;36(11):1198-1204. [PubMed: 30566998] 4.Kim IJ, Shim DJ, Lee JH, Kim ET, Byeon JH, Lee HJ, Cho SG. Impact of subcutaneous tunnels on peripherally inserted catheter placement: a multicenter retrospective study. Eur Radiol. 2019 May;29(5):2716-2723. [PubMed: 30560363] 5.Hicks BL, Brittan MS, Knapp-Clevenger R. Group Style Central Venous Catheter Education Using the GLAD Model. J Pediatr Nurs. 2019 Mar - Apr;45:67-72. [PubMed: 30503153] 6.Pare JR, Pollock SE, Liu JH, Leo MM, Nelson KP. Central venous catheter placement after ultrasound guided peripheral IV placement for difficult vascular access patients. Am J Emerg Med. 2019 Feb;37(2):317-320. [PubMed: 30471933] 7.Presley B, Isenberg JD. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jul 31, 2021. Ultrasound Guided Intravenous Access. [PubMed: 30252244] 8.Levit O, Shabanova V, Bizzarro M. Impact of a dedicated nursing team on central line-related complications in neonatal intensive care unit. J Matern Fetal Neonatal Med. 2020 Aug;33(15):2618-2622. [PubMed: 30612486] 9.Chick JF, Reddy SN, Yam BL, Kobrin S, Trerotola SO. Institution of a Hospital-Based Central Venous Access Policy for Peripheral Vein Preservation in Patients with Chronic Kidney Disease: A 12-Year Experience. J Vasc Interv Radiol. 2017 Mar;28(3):392-397. [PubMed: 28111198] Where should a central venous catheter be placed?A central venous catheter is a tube that goes into a vein in your arm or chest and ends at the right side of your heart (right atrium). If the catheter is in your chest, sometimes it is attached to a device called a port that will be under your skin.
What is the preferred site for central line insertion?ACCESS SITE Centrally inserted central venous catheters are primarily placed via the internal jugular vein, subclavian vein, or femoral vein. Alternative insertion sites include the external jugular vein, cephalic vein, and proximal great saphenous vein.
What is the recommended location for a central venous catheter CVC tip?Positioning the tip of a central venous catheter (CVC) within the superior vena cava (SVC) at or just above the level of the carina is generally considered acceptable for most short-term uses, such as fluid administration or monitoring of central venous pressure.
Which site is contraindicated for insertion of a central venous catheter?Contraindications include distorted local anatomy (such as for trauma), infection overlying the insertion site, or thrombus within the intended vein. Relative contraindications include coagulopathy, hemorrhage from target vessel, suspected proximal vascular injury, or combative patients.
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