How to place a Central line: step by step tutorial

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Dr. Arzoo Sadiqi
Published at : 01 Feb 2021
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A central venous catheter, also known as a central line, is a catheter placed into a large vein. Catheters can be placed in veins in the neck, chest, groin, or through veins in the arms.

Indication: 1) Central venous access for infusion of vasoactive drugs, TPN, high dose KCl, etc. 2) Hemorrhagic disorder where large volumes blood/blood products needed 3)Measurement of central venous pressure 4) Need for frequent blood draws where peripheral access limited. 5) Lack of peripheral venous access

Complications: The risk of complications of central line placement varies with the experience of the operator and the conditions (emergency vs. elective) under which the line is placed. Risks associated with central venous catheterization include infectious, mechanical, and thrombotic complications. A chest radiograph should be obtained to confirm placement and to assess for complications. Mechanical complications include arterial puncture, hematoma, pneumothorax, hemothorax, arrhythmia, and improper location of the catheter, whether in an accessory vein or in the other vessels of the upper vascular system.

Prep and local anesthesia: Cleanse a 15-20 cm area over the side of the mid- to lower neck with povidone-iodine solution; the right side is preferred due to more direct line to the atrium and avoids injuring the thoracic duct. If you are using ultrasound guidance, do a quick look prior to preparing your sterile field to localize the IJ and its relationship to the carotid artery. The site of entry should be at the top of the triangle formed by the two heads of the sternocleidomastoid muscle and clavicle.

Sterile field: Drape the patient with the provided sterile paper/plastic drape with center cutout. Using the 25 ga needle, make a wheal under the skin at the desired spot, and anesthetize the subcutaneous tissue. Always pull back before injecting to avoid intravascular injection of lidocaine.

Using the 18 ga needle (largest needle in the kit) and a small syringe, enter the skin at the top of the jugular triangle. Insert the needle at 30 degrees. Gradually advance the needle, always gently pulling back on the plunger as you progress; a flash and easy withdrawal of dark blood, this indicates entrance into the vein. Insert guide wire into needle. Holding guide wire, remove needle from skin. Make a small nick with the number 11 blade where wire enters skin. Advance dilator over guide wire with a twisting motion; there will be resistance.
Remove dilator, holding guide wire and having some gauze 4x4 in your hand to apply pressure to a site that will now bleed after dilation.
Place catheter over guide wire; it should advance easily. Hold guide wire at skin entrance and feed it back through distal port of central line (brown cap). When wire comes out, grab it at the end and finish advancing catheter. Remove guide wire and flush line through all 3 ports. Suture catheter in place via flange with holes. Order a stat CXR to evaluate for line placement and complication. The tip of the catheter should be at the junction of the SVC and right atrium on chest xray.
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