Central Line placement By Clare Di Bona November 2015

Indications IV Access CVP monitoring Dialysis Transvenous pacing Difficult peripheral access Irritant drugs Chemo TPN Vasoactive drugs ie noradrenaline Calcium chloride KCL CVP monitoring Dialysis Transvenous pacing

Contraindications/precautions Coagulopathy Benefit versus risk Femoral and IJV less risky than subclavian (can’t apply direct pressure over puncture site) Respiratory failure Difficult to lie flat therefore probably better to use the femoral approach Raised ICP Cannot tilt head down better to use the femoral approach Other Obstructed vein (thrombus, tumour) Overlying skin infection, burn Uncooperative patient…seriously reconsider or sedatives or after intubation if required

Complications/consent Sometimes the patient is not fit to consent ie altered GCS, hypoxic, low BP….in this case act in the best interests of the patient Otherwise it helps to keep the patient calm if you describe the procedure simply and talk frankly about risk versus benefits

Complications/consent Pneumothorax (highest subclavian) Infection Thrombosis including DVT Hemorrhage including haemothorax and haematoma formation Arrhythmia on insertion guide wire Guide wire embolus Other: Air embolus, discomfort, unsuccessful procedure

Procedure Preparation Patient: Is the patient stable ie can you lie them flat for a long period Space at the head of the bed, exposure of the area Staff: Need a dedicated nurse to help you draw up Equipment US machine positioned, turned on and set correctly CVC line, cleaning equipment, local anaesthetic, suturing material, dressings, sterile gowns, drape, US probe cover, syringes for local and NS, drawing up needles

procedure -Prepare yourself: wash hands-surgical wash, place on gown and gloves using aseptic technique -Prepare the Equipment: Line it up in order, draw up local and Normal saline in separate syringes (different sizes and different colours!!), Prime the line, leave the brown portal open, remember all bungs need to be primed too -Trendelenburg position patient, head to the left (get nurse to help) -Prepare the patient: clean (circle from middle out-repeat three times), drape -Prepare the US probe (cover) -Use landmarks (triangle formed by clavicle, lateral and medial head of sternocleidomastoid muscle target is the apex) -Give local anaesthetic to the skin

Procedure -At the apex of the triangle insert needle from the CVC kit (wide bore) to locate the IJV under US guidance by advancing and aspirating (head towards the ipsilateral nipple) -Once blood is aspirating unscrew the syringe and hold needle in place, use thumb to cap it to prevent air embolism -Thread through the guidewire to 20cm (2 black lines go through) -Take out the needle -Use scalpel to open the skin around the insertion of the wire (don’t cut wire!) -Thread over the dilator then take it out -Thread over the line….length=height/10 around 15-17cm for an adult. NEVER LOSE SITE OF THE WIRE MAY HAVE TO PULL WIRE OUT A LITTLE IF IT GETS LOST IN THE CVC LINE

Procedure -Take the wire out -Cap the brown port initially with thumb to prevent air embolus, then with bung -Check all ports by aspirating and flushing with normal saline -Suture in central line and place dressing over the top -Check positioning Use US to visualise the wire in the vein CXR to check at junction of SVC and heart and to make sure no PTX Blood gas if still unsure -Document in notes: consent, procedure, depth of CVC

VIDEO https://www.youtube.com/watch?v=Lb1Z3bndmA8