In emergency medical practice, there are three possible sites for CVL placement in the adult patient. Each has advantages and disadvantages. The placement sites include the internal jugular vein, femoral vein, and subclavian vein. The right internal jugular vein and left subclavian vein are the most direct paths to the right atrium via the superior vena cava. The femoral veins are compressible sites and as such may be more appropriate for coagulopathic patients. The subclavian vein approach is at higher risk for pneumothorax than the internal jugular vein approach. Ultrasound guidance can be very helpful in all approaches and is the recommended approach. However, when ultrasound guidance is not feasible for various reasons, such as the emergency nature of a procedure, lack of equipment, or a patient's anatomy in a situation where there is limited room for the ultrasound transducer in the subclavian approach while manipulating the needle, CVLs may be placed using anatomical landmarks without ultrasound.
There are many different indications for placing a CVL, but in emergency medicine, the most common indications include:
Contraindications include distorted local anatomy (such as for trauma), infection overlying the insertion site, or thrombus within the intended vein. Relative contraindications include coagulopathy, hemorrhage from target vessel, suspected proximal vascular injury, or combative patients.
Most central line kits include:
In addition, the operator will require a sterile gown, cap, sterile gloves, sterile gauze, sterile saline, face mask, and a sterile cleansing solution such as chlorhexidine. The operator should ensure that ultrasound, sterile ultrasound gel, and a sterile ultrasound probe are part of the setup as well.
Place the patient in the appropriate position for the site selected, then prepare the site in a sterile fashion using the sterile solution, sterile gauze, and sterile drapes. For the internal jugular and subclavian approach, place the patient in reverse Trendelenburg with the head turned to the opposite side of the site. For the femoral vein, place the patient in the supine position with the inguinal area exposed; this usually means the target leg should be bent at the knee with the lateral aspect resting on the stretcher or bed. It is recommended to place the patient on cardiopulmonary monitoring for the duration of the procedure.
The steps are as follows:
Potential complications should be explained to the patient if possible while obtaining informed consent. Complications include pain at cannulation site, local hematoma, infection (both at the site as well as bacteremia), misplacement into another vessel (possibly causing arterial puncture or cannulation), vessel laceration or dissection, air embolism, thrombosis, and pneumothorax requiring a possible chest tube.
Clinical pearls for consideration:
Central lines are inserted by many healthcare professionals. However, the monitoring of these lines is usually done by the nurses. The site of entry has to be kept clean and the nurse has to monitor it for signs of infection. Depending on which location the line was inserted, complications also have to be monitored like a pneumothorax, hematoma, bleeding or extravasation. In general, healthcare workers should avoid lines in the groin for more than 24 to 48 hours as they are prone to infections and also make it difficult for the patient to ambulate or get out of bed. To ensure good practice and limit complications, most hospitals now have an interprofessional team of healthcare professionals who are in charge of central line insertion and monitoring, each one checking and communicating any issues noted to the rest of the team so corrective action can take place if necessary. Such universal practice has been shown to limit infections. (Level V)
|||Mitsuda S,Tokumine J,Matsuda R,Yorozu T,Asao T, PICC insertion in the sitting position for a patient with congestive heart failure: A case report. Medicine. 2019 Feb; [PubMed PMID: 30732193]|
|||Derderian SC,Good R,Vuille-Dit-Bille RN,Carpenter T,Bensard DD, Central venous lines in critically ill children: Thrombosis but not infection is site dependent. Journal of pediatric surgery. 2018 Dec 27; [PubMed PMID: 30661643]|
|||El Ters N,Claassen C,Lancaster T,Barnette A,Eldridge W,Yazigi F,Brar K,Herco M,Rogowski L,Strand M,Vachharajani A, Central versus Low-Lying Umbilical Venous Catheters: A Multicenter Study of Practices and Complications. American journal of perinatology. 2018 Dec 19; [PubMed PMID: 30566998]|
|||Kim IJ,Shim DJ,Lee JH,Kim ET,Byeon JH,Lee HJ,Cho SG, Impact of subcutaneous tunnels on peripherally inserted catheter placement: a multicenter retrospective study. European radiology. 2018 Dec 17; [PubMed PMID: 30560363]|
|||Hicks BL,Brittan MS,Knapp-Clevenger R, Group Style Central Venous Catheter Education Using the GLAD Model. Journal of pediatric nursing. 2018 Nov 29; [PubMed PMID: 30503153]|
|||Pare JR,Pollock SE,Liu JH,Leo MM,Nelson KP, Central venous catheter placement after ultrasound guided peripheral IV placement for difficult vascular access patients. The American journal of emergency medicine. 2019 Feb; [PubMed PMID: 30471933]|
|||Presley B,Isenberg JD, Ultrasound Guided Intravenous Access 2018 Jan; [PubMed PMID: 30252244]|
|||Levit O,Shabanova V,Bizzarro M, Impact of a dedicated nursing team on central line-related complications in neonatal intensive care unit. The journal of maternal-fetal [PubMed PMID: 30612486]|
|||Chick JF,Reddy SN,Yam BL,Kobrin S,Trerotola SO, Institution of a Hospital-Based Central Venous Access Policy for Peripheral Vein Preservation in Patients with Chronic Kidney Disease: A 12-Year Experience. Journal of vascular and interventional radiology : JVIR. 2017 Mar; [PubMed PMID: 28111198]|