What are the indication for a central venous line insertion?
- Hemodynamic monitoring
- Isertion of Pulmonary Arterial (PA) Catheter
- Rapid Fluid/Blood replacement
- Infusions of vasoactive, chemotherapy, hyperalimentation (Nutrients)
- Transvenous pacing
- Aspiration of Air embolism
- Temporary dialysis access
- Poor peripheral venous access
What are absolute contraindication for Central Venous Line placement?
- Patient refusal
- Infection at insertion site
- Anatomic obstruction (Thrombosis, anatomic variance, carotid disease)
- Superior vena cava syndrome
What are the RELATIVE contraindication for a Central Line placement?
- Systemic infection
- Presence of pacing wires or other indwelling catheters at insertion site
- Right ventricular assist device
T/F: Central Venous Line Placement is a sterile procedure.
What position should patient be in for Central Line Placement?
- Supine position/Trendelenberg postion
- Head positioned 45 degree away from cannulation site
T/F: Children less than two years of age may have insertion site of central line prepped with providone iodine.
What is the most common insertion site for a central line insertion?
-Right internal jugular vein
Where is the internal jugular vein located?
- Between the sternal and clavicular heads of the sternocleidomastoid muscle
- Lateral to carotid artery
What is the benefit of using the right internal jugular vein?
- Lower incidence of pneumothorax compared to subclavian site
- Right internal jugular vein takes a straight course to right atrium and easier to position at SVA-RA junction
- Right internal jugular vein catheterization has lower incidence of pneumothorax compared to left due to lower dome of pleura on right side
- Right internal jugular vein catheterization avoids thoracic duct injury on left
What is a complication using the right internal jugular vein instead of the subclavian site?
-Higher incidence of infection
What is the procedure for placing central line?
- Cleanse site (STERILE SITE)
- Wash hands
- Locate the apex of the triable formed by the two heads of the sternocleidomastoid muscle
- Ultrasound location
- Inject local anesthetic
- Connect finder needle to syringe and start at the apex of the triangle, advancing towards the ipsilateral nipple at a 30 to 45 degree angle while aspirating
- With an 18/20 Gauge needle and syringe perform same procedure as before
- After blood is feely asperated int the syringe, disconnect the syringe from the needle
- Confirm placement of needle is NOT in a artery by pulsing or using a sterile test catheter.
- Remove needle and leave catheter in place
- Insertion of a guidewire about 6-8 cm and watch for unstable rhythm
- Remove catheter only leaving guidewire in place
- Make small incision at guidewire
- Use a dilator over guidewire and advance until loss of resistance (approx one inch from skin)
- Remove dilator only
- Pass catheter over guidewire
- Remove guidewire and allow blood to catheter before clamping.
- Secure catheter to skin with suture
- Use dressing to keep site sterile
For right IJ the cateter should be secure at around __ cm depending on the patient’s height.
For right subclavian the catheter should be secured at around __ cm depending on the patient’s height.
For left IJ the catheter should be secured at around __ cm depending on the pater height.
For left subcalvian catheter should be secured at around __ cm depending on the patient height.
T/F: It is NOT necessary to confirm tip of central catheter is at SVC-RA junction.
T/F: If IV therapy is urgent and internal jugular catheterization was uncomplicated , you may begin use of catheter prior to chest x ray confirmation.
What are some complication of a central line?
- Arterial puncture
- Cardiac perforation
- Thoracic duct injury
- Nerve injury
- Venous thrombosis
- Pulmonary emboli