CENTRAL LINES:
PLACEMENT AND PROBLEMS
- Immediate Questions When Line's Not Working
- Differential Diagnosis
- Plan
- Internal Jugular Insertion
- Subclavian Insertion
- Other Lines
- Complications
A.
Does it fluxuate with respiration? A CVP should have a slowly undulating wave form that varies with the patient's respirations, if properly positioned in the chest.
B. Does it flush and can it be aspirated?
C. When was the last chest x-ray? The tip should be in the superior vena cava.
A. Catheter in incorrect position.
B. Kinked catheter.
C. Other mechanical problems.
D. Infected catheter. Any question of sepsis originating in a central venous line requires expeditious evaluation. The best technique involves drawing cultures through the catheter, removing the line, and culturing the tip. And, often the IV team will have a protocol for declotting lines.
A. Unless the line is infected, it can be changed over a guide wire. All line manipulations should be performed using sterile technique with the patient in Trendelenburg (head-down) position to prevent air embolus.
B. A line thought to be clotted can often be declotted safely with a syringe. The catheter can be gently aspirated or flushed with a 1 cc tuberculin syringe.
A. Materials for central line placement are available in a kit, which you can obtain on the hospital unit.
B. IJ lines have less risk of pneumothorax and are preferred if hyperinflation or mechanical ventilation are present. Because direct pressure can be applied, the IJ line also is preferred if coagulopathy is present. For IJ lines use a 25 gauge needle and 1% lidocaine to raise a small skin wheal. Change to a 22 gauge needle to anesthetize the deeper layers, and then use gentle aspiration, with the same needle, to initially locate the internal jugular vein. Direct the needle through the skin wheal, directed toward the ipsilateral nipple and at a 30 degree angle to the frontal plane. If the vein is not entered, withdraw the needle slightly and redirect it 5 to 10 degrees more laterally. Subclavian Insertion:
A. Materials for central line placement are available in a kit, which you can obtain on the hospital unit.
B. Subclavian lines usually are more comfortable for the patient and easier to fix to the skin. However, it results in a pneumothorax in 1 to 2% of insertions.
C. Most commonly for subclavian lines, the patient is placed in Trendelenburg position, with a roll between the scapulae. This presumably makes the clavicles flatten and vein more prominent and simplifies puncture. The artery is above and behind the vein, so slow entry will allow going into the vein before the artery. The needle is passed below the clavicle and aimed toward the sternal notch, with the bevel upward. Turn the bevel to 3:00 when the vein is entered.
Femoral lines are acceptable when there is no upper body alternative and when rapid access is needed during cardiopulmonary resuscitation.
