Central lines

Indications

  • Inadequate peripheral access
  • Administer noxious meds to avoid peripheral vein irritation - pressors, chemo, TPN, etc.
  • Hemodynamic monitoring - ScvO2, CVP, etc.

Types of central lines

Central line type Indications
PICC
(peripherally inserted central catheter)

Easier; more comfortable for pt (located in upper arm)
Commonly used for home antibiotic therapy

AVOID in dialysis pts due to risk of thrombosing off future fistula site
TLC (triple lumen catheter), Hohn - non-tunneled Common central lines with multiple lumens to draw blood/administer meds
Trialysis Larger triple lumen catheter that accommodates dialysis/high flow
Cordis (introducer) Large bore single lumen - "introduce" other catheters through it (e.g. Swan Ganz), or use for high volume fluid resusc

Tunnelled (Hickman, Broviac)

Port-a-cath

Semi-permanent implanted central lines.

Tunnelled lines are still partially external (e.g. can get tugged on).
A port is completely internalized but needs to be accessed through a needle poke. However can remain accessed for up to 7 days at a time.
  • Flow rate depends on catheter size and length. So PICC (small, long distance from insertion site to SVC) has slower rate than a TLC and is less preferred for high volume fluid resuscitation.
  • How to insert a central line
  • Typical central line length rule of thumb
    • R IJ - 15 cm
    • L IJ - 20 cm
    • Femoral - 30 cm
  • Removing a central line
    • Place patient in Trendelenberg for IJ/SC (still at risk of air embolism)
    • Tell patient to hum continuously (increases intrathoracic pressure to reduce venous air entry)
    • Remove line quickly, inspect end of line to make sure it is intact
    • Place an occlusive dressing and hold pressure for ~ 5 min

Central line locations

Location Pros Cons

Internal jugular
Located between two heads 'V' of SCM above clavicle, anterolateral to carotid, deep to platysma

  • Start at apex (superior) of SCM junction; lower placement has higher risk of pneumothorax
  • Trendelenberg (head down) position engorges veins and reduces risk of air embolism
 Most commonly used, reliable access and positioning in SVC  

Subclavian
Insert needle at bend of clavicle pointing to sternal notch, advance just posterior to clavicle (keep needle at shallow angle to the skin) - keeps needle high/away from pleural space

  • Alternatively, insert 2-3 cm below bend of clavicle, pointing to 1 fingerbreadth above sternal notch, at 20 degree angle to the skin)
  • Prevents 'bouncing' off the clavicle periosteum which can be very painful
  Lowest rate of central line infection

Difficult to hold pressure, so coagulopathy is a relative contraindication

Higher potential risk of PTX, so avoid in resp. compromise

Femoral
Femoral vein lies medial to artery

  • Artery is half-way between ASIS and pubic symphysis
 Easier to access (don't need to Trendelenberg or lay flat)

Hinders mobility

With proper aseptic technique, no increased risk of infection compared to SC/IJ


IJ landmarks

Landmarks for IJ

Landmarks for subclavian

Plain films to confirm positioning

  • Good interactive quiz here
  Good Bad
R IJ

Tip at cavo-atrial junction (~ 1 cm below R main bronchus); should not enter RA or RV (can cause arrhythmia)

R IJ correct

Cannulated the carotid, oops (more medial course than expected for IVC)

R IJ - carotid cannulation
L IJ  
Subclavian

 Catheter passes below level of clavicle (but a/w a PTX here)

L subclavian (with PTX)

In subclavian artery (passes above clavicle) instead of vein; can also travel upwards into carotid artery
Swan Ganz

Terminate in main pulmonary artery

Too far in to R pulmonary artery - can cause injury
Femoral    

Complications

  • Venous air embolism (acute hypotension, hypoxemia, cardiovascular collapse)
    • Trendelenberg patients for IJ/SC lines (access point below the heart) to facilitate venous filling and reduce risk of venous air embolism
    • If suspect air embolism, occlude air source, turn patient to left lateral decubitus (right side up) to prevent air from traveling from right heart to pulmonary arteries
    • Call code, IVF, 100% O2, intubate, call cardiology for emergent echo to locate air embolus and aspirate
  • Malpositioning
    • Ideally should terminate in SVC or cavoatrial junction (higher flow; medications are less irritating to the vessel)
      • ~1 cm below R main bronchus
    • If line is in heart, can cause ectopy/arrhythmias
    • If line is too peripheral, can cause thrombus/irritation of vessel
    • Can retract a line, but can't advance after it's in (guidewire is out)
    • Sometimes can flip up from SVC into the jugular (e.g. coughing causes pressure changes)
      • If this is identified, shouldn't use it until fixed
      • Can sometimes spontaneously resolve. Or can use power flushes (e.g. short impulses from a saline flush to create higher pressure in the jugular and cause catheter tip to flip back down).
    • Arterial cannulation
      • Needle stick - hold pressure. If cannot hold pressure (e.g. subclavian artery), call vascular surgery
      • Dilation - occlude end of dilator (do not remove) and call vascular surgery (now have large defect in arterial wall)
  • Pneumothorax
    • Give 100% non-rebreather O2 and repeat chest x-ray in few hours; most small/asymptomatic ptx will spontaneously resolve
    • If symptomatic/hemodynamically unstable, consider chest tube or needle decompression
  • Kinking
  • Venous injury - hemothorax, mediastinal hematoma
author: admin | last edited: Jan. 8, 2019, 7:38 p.m. | pk: 81

  1. https://psnet.ahrq.gov/webmm/case/51/crossing-the-line
  2. https://www.radiologymasterclass.co.uk/tutorials/chest/chest_tubes/chest_xray_central_line_anatomy
  3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3190489/
  4. https://depts.washington.edu/simcentr/cvc/extern_cvc_md/story_html5.html?lms=1