Central Line Procedures

Central Venous Catheter infections in the United States are associated with increased hospital length of stay and excess healthcare costs, ranging from $25,000 to $56,000 per infection episode and occurring at a rate of 5.3 per 1000 catheter days in the intensive care unit.^1,2,3,4,5 The mortality rate associated with bloodstream infections is estimated to be between 12% and 25%.^6,7,8,9 The Centers for Disease Control have published guidelines for the prevention of Intravascular Catheter Related Bloodstream Infections (CRBSI), an important and preventable cause of nosocomial infection.¹⁰

These guidelines emphasize five distinct practices; among which the training and education of healthcare providers who place and care for catheters and the utilization of maximum sterile precautions are two important areas. Several studies have demonstrated impressive reductions in central line related infections from the applications of several of these strategies realizing significant reductions in mortality and cost.^11,12,13,14 Insertion practices that follow best practice guidelines are known to reduce CRBSIs and may subsequently affect morbidity and mortality of patients in whom central lines are necessary.¹⁰

The methods of training residents in placement of central venous catheters have historically been on live patients with the focus on proper placement of the catheter rather than on sterile technique. The Institute of Medicine’s report “To Err is Human” identified simulation as a means to enhance safety in the medical field.¹⁵ Simulation is defined as a strategy or technique to mirror or amplify a real clinical situation with guided experiences in an interactive fashion.^16,17 A simulator refers to a physical object on which a task may be replicated during the simulation.¹⁸ High fidelity simulators are those that may change and respond to the users and include, amongst others, realistic three-dimensional procedural simulators.¹⁹

There is ample evidence that simulation, whether employing standardized patients, mannequins, high fidelity simulators such as human patient simulators, or virtual environments, leads to improved task performance and increased learner confidence.^{10,21,22,23,24,25,26} Recent focus has been geared towards demonstrating that these gains translate into improved patient care and safety. A study of students learning the proper technique of cricoid pressure application using a mannequin simulator translated into improved performance in anesthetized patients.²⁷ Rosenthal and colleagues reported the effectiveness of high-fidelity simulation in training entering medical house staff on emergency airway management techniques.²⁸ Wayne et al, from Northwestern University, studied two cohorts of residents, one who had received traditional Advanced Cardiac Life Support (ACLS) training and the other who had performed ACLS scenarios on Human Patient Simulators. Simulator-trained residents showed significantly higher adherence to American Heart Association standards when following ACLS protocols in patients suffering cardiac arrest.²⁹ Dr. Wayne has recently presented work on a central line simulation program for all medicine and surgery residents at Northwestern University. Central line infection rate in both medical and surgical intensive care units were significantly reduced following simulation training in central venous access (publication pending) Other central venous access complications such as pneumothorax and carotid artery puncture were similarly reduced. A recent study of surgical residents who trained with central line simulation prior to ICU rotations revealed an improved resident performance with simulation.³⁰ As ultrasound has been demonstrated to increase the success of first-time central venous catheter placement and to decrease the risk of complications, it has become increasingly important for all residents to learn this technique.³¹

These mechanical complications associated with central venous access are less often focused on but also represent a significant source of morbidity and mortality. Reports of 5 to 19 percent of patients undergoing central venous catheterization may sustain mechanical complications, while thrombotic complications occur in 2 through 26 percent.^32,33,34 The aim of this program is to not only address the catheter related bloodstream infections but also attend to these other important complications of central venous access which can be significantly reduced leading to increased patient safety and decreased hospital costs.

• 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

• Infection at insertion site
• Anatomic obstruction (thrombosis, anatomic variance)
• Superior vena cava syndrome

Relative Contraindications

• Coagulopathy
• Systemic infection
• Presence of pacing wires or other indwelling catheters at insertion site
• Right ventricular assist device

• Maximal sterile barriers required: Sterile mask, sterile gloves, sterile gown, cap, full body (head to toe) sterile drape
• Monitors (pulse oximeter, ECG, blood pressure)
• PIV in place if possible
• Central line kit

• Obtain consent from patient when possible, explaining the risks and benefits of the procedure
• Place patient monitors on (pulse oximeter, blood pressure cuff, ECG)
• Obtain peripheral intravenous access when possible and connect to IV tubing and fluids
• Apply oxygen via face mask or nasal cannula if IV sedation is given
• Place patient in supine position and Trendelenberg position with head turned 45 degrees away from cannulation site
• Open central venous catheterization kit
• Wash hands
• Wear sterile mask and cap, wear sterile gown and gloves
• Use chlorhexidine gluconate sterile prep for at least 30 seconds (if internal jugular, prep from external auditory meatus to clavicle and to the trachea). For children < 2 months old, povidone iodine may be used.
• Allow chlorhexidine site to dry ( 2 minutes)
• Apply sterile full body drape

Internal Jugular Vein

• Located between the sternal and clavicular heads of the sternocleidomastoid muscle
• Lateral to carotid artery
• Lower incidence of pneumothorax compared to subclavian vein catheterization
• Right internal jugular vein takes a straight course to right atrium, easier to position at SVC-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
• More likely to become contaminated due to respiratory secretions

Subclavian Vein:

• Located under clavicle, passes over first rib and apical pleura, parallel to subclavian artery
• Lower incidence of infection compared to internal jugular catheterization
• Higher comfort level in awake patients
• More accessible if trauma patient is in a cervical collar

External Jugular Vein:

• More difficult to pass wire to the subclavian vein due to presence of valve approximately 4 cm above clavicle

Femoral Vein:

• Higher incidence of infection compared to subclavian vein catheterization or internal jugular vein catheterization³⁵

Axillary Vein:

• The axillary vein has been used to place central venous catheters, however there is limited data on infection rates³⁶

• Locate the apex of the triangle formed by the two heads of the sternocleidomastoid muscle

• With an assistant, place gel and sterile ultrasound probe cover on the ultrasound probe, attach rubber band to secure
• Visualize the internal jugular vein located lateral to the carotid artery if using ultrasound. The internal jugular vein should be more superficial, larger, oval-shaped and compressible as compared to the carotid artery which is smaller, round and not compressible. If not able to visualize the internal jugular vein, it may be compressed (try lighter pressure) or the patient may be severely hypovolemic
• Inject local anesthetic skin wheal at insertion site (lidocaine 1%, 1-2 cc)
• If not using ultrasound, connect finder needle to syringe and 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
• Using an 18 or 20 gauge needle and syringe, perform the same procedure as above until blood is aspirated freely into the syringe.

• Turn head away from the side to be cannulated, position arms at the side
• Locate the midpoint of the clavicle (mid-way between the sternal notch and AC joint) and insert needle 1 cm lateral and inferior to the clavicle
• Using an angle of 10-15 degrees beneath the clavicle, use an 18 or 20 gauge needle and aim medially in the direction of the suprasternal notch, attempting to first aim for the clavicle then “walk” the needle below the clavicle
• Once the clavicle is passed, continue to advance in a plane almost parallel to the skin approximately 2-3 cm until venous blood is freely aspirated into the syringe
• Common pitfalls³⁷
  • Needle inserted too closely to the clavicle itself results in too steep an angle for cannulating the vein beneath the clavicle so needle does not advance between clavicle and first rib
  • Needle is inserted through the periosteum of clavicle
  • Needle trajectory is too shallow
  • Improper landmark identification
  • Needle aimed too cephalad towards apex of lung, attempting to avoid pneumothorax but misses the vein superiorly
• After blood is freely aspirated into the syringe, disconnect the syringe from the needle
• Confirm that arterial pulsations are not present and that venous blood is present. If any doubt, connect the sterile tubing to the catheter to test. Blood should not flow higher than the cm of central venous pressure expected. If shunting is present, venous blood may appear brighter than normal. In certain conditions (tricuspid regurgitation, atrial fibrillation, the central venous pressure may appear to be pulsatile).
• Remove the needle while leaving the catheter in place and pass the guidewire about 6-8 inches in while watching the ECG for PVC’s and dysrhythmias. If the patient develops an unstable rhythm, withdraw the wire immediately
• Remove the catheter while leaving the wire in place
• Using a scalpel, make a small incision at the wire
• Use the dilator over the wire and advance only just beyond the skin until a loss of resistance (about 1 inch)
• Remove the dilator while leaving the wire in place
• Pass the catheter over the wire
• Remove the wire, then as blood flows into the catheter, clamp each port
• Use a sterile syringe with saline to aspirate the air from each port and flush with saline
• Secure the catheter with sutures at the skin
• For right IJ, the catheter should be secured at around 16 cm depending on the patient’s height (height/ 10 cm)³⁸
• For right subclavian, the catheter should be secured at around 15 cm depending on the patient’s height (height/10)- 2 cm
• For left IJ, the catheter should be secured at around 20 cm depending on the patient (height/10) + 4 cm³⁹
• For left subclavian, the catheter should be secured at around 19 cm depending on the patient (height/10) + 2 cm
• Secure catheter with a sterile tegaderm dressing

• Order chest x-ray to confirm tip of catheter at SVC- RA junction
• If catheter needs to be adjusted, use sterile technique including full gown and gloves, full-body drape
• If IV therapy is urgent and internal jugular catheterization was uncomplicated, may begin use of catheter prior to chest x-ray confirmation⁴⁰
• Examine the catheter insertion site daily to monitor for infection
• If removal of the catheter is planned, 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
• Complete Central Line Insertion Practices form (CLIP)

• Hematoma
• Arterial puncture (3% for IJ, 0.5% for subclavian, 6.25% for femoral)³⁴
• Infection (8.6 per 1000 catheter days for IJ, 4 per 1000 catheter days for subclavian, 15.3% per 1000 catheter days for femoral)
• Arrhythmia
• Cardiac perforation and tamponade
• Thoracic duct injury
• Pneumothorax (0.1-0.2% for IJ, 1.5-3.1% for subclavian)
• Hemothorax (0.4-0.6% for subclavian)
• Nerve injury
• Venous thrombosis, pulmonary emboli

• Subclavian central line is recommended for all adults
• Internal jugular is acceptable for central lines of < 72 hour duration, or if there is a contraindication to subclavian line
• Guide-wire/sheath exchange can be used to replace a malfunctioning non-tunneled central line if no evidence of infection is present
• Routine exchange of central line over a guide wire to prevent infection is no longer recommended
• CLIP surveillance by CDC is required due to Senate Bill 739 (September 2006)

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