Central Line Placement

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:

1. Infiltrate the skin with 1% lidocaine for local anesthesia around the site of the needle insertion.
2. Use the bedside ultrasound to identify the target vein.
3. If using landmarks for the subclavian vein CVL, the needle should be inserted approximately 1 cm inferior to the junction of the middle and medial third of the clavicle. If using landmarks for the femoral line CVL, the needle insertion site should be located approximately 1 cm to 3 cm below the inguinal ligament and 0.5 cm to 1 cm medial to where the femoral artery is pulsated.  
4. Insert the introducer needle with negative pressure until venous blood is aspirated. For the subclavian CVL, insert the needle at an angle as close to parallel to the skin as possible until contact is made with the clavicle, then advanced the needle under and along the inferior aspect of the clavicle. Next, direct the tip of the needle towards the suprasternal notch until venous blood is aspirated.  Whenever possible, the introducer needle should be advanced under ultrasound guidance to ensure the tip does not enter the incorrect vessel or puncture through the distal edge of the vein.
5. Once venous blood is aspirated, stop advancing the needle.  Carefully remove the syringe and thread the guidewire through the introducer needle hub.
6. While still holding the guidewire in place, remove the introducer needle hub.
7. If possible, use the ultrasound to confirm the guidewire is in the target vessel in two different views.
8. Next, use the scalpel tip to make a small stab in the skin against the wire just large enough to accommodate the dilator (and eventually, the central venous catheter). Insert the dilator with a twisting motion.
9. Advance the CVL over the guidewire. Make sure the distal lumen of the central line is uncapped to facilitate passage of the guidewire.
10. Once the CVL is in place, remove the guidewire. Next, flush and aspirate all ports with the sterile saline.
11. Secure the CVL in place with the suture and place a sterile dressing over the site.

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.[5][6][7]

Clinical pearls for consideration:

• A chest X-ray should be performed immediately for the internal jugular and subclavian lines to ensure proper placement and absence of an iatrogenic pneumothorax. 
• Be sure you are withdrawing venous blood before dilation and cannulation of the vessel.  
• If internal jugular CVL attempt is unsuccessful, move to the ipsilateral subclavian vein. Never attempt the opposite side without a chest X-ray or ultrasound first to avoid bilateral pneumothoraces. 
• Never let go of the guidewire as it may migrate distally into the vessel. Never force the wire on insertion because it may cause damage to the vessel or surrounding structures. Forcing the wire could also cause it to kink making removal difficult or impossible.
• Always place your finger over the open hub of the needle to prevent an air embolism.
• Always confirm placement with ultrasound, looking for reverberation artifact of the needle and/or tenting of the vessel wall. Needles cannot be visualized on ultrasound. Wires can be visualized so the operator can confirm at that step as well.
• A venous blood gas can be aspirated off a femoral line to ensure it is not arterial.

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. [8][9](Level V)