Central line placement

Indications:

• Placement of venous access line when other peripheral sites are unavailable
• Placement of a large-bore venous catheter in an emergent situation to deliver a high flow of fluid or blood products (the flow rate is determined by the caliber and length of the catheter, shorter and greater caliber catheters delivering greater volumes over equivalent amounts of time)
• Central venous pressure measurement
• Administration of sclerosing agents such as chemotherapeutic agents, hyperalimentation fluids, etc.
• As an alternative to repetitive venous cannulations
• For placement of pulmonary wedge catheters
• For placement of trans venous pacemakers
• For performance of hemodialysis or plasmapheresis

Contraindications:

• Infection over the insertion site
• Distortion of landmarks from any reason
• Suspected injury to the superior vena cava (eg., SVC syndrome)
• Coagulopathies including anticoagulation therapy
• Pneumothorax or hemothorax on the contralateral side
• Inability to tolerate pneumothorax on the ipsilateral side
• Uncooperative patients
• Patients unable to tolerate a Trendelenberg position
• Prior injury to that vein (choose the one on the other side)
• Morbid obesity
• Recently discontinued subclavian catheter at the same location
• Planned mastectomy on the side of subclavian insertion
• Patients receiving ventilatory support with high end expiratory pressures (temporarily reduce the pressures)
• Patients with vigorous, ongoing cardiopulmonary resuscitation
• Children less than 2 years (higher complication rates)
• Fracture or suspected fracture of ipsilateral upper ribs or clavicle

Complications, Prevention and Management:

·        Pneumothroax

o       Prevention: Remove patient from ventilator before advancing the needle, choose the right side rather than left, avoid multiple attempts when possible

o       Management: Check postprocedure x-ray, if pneumothorax arrange for thorcostomy depending on the size of the pneumothorax

• Hemothorax - as above
• Bilateral Iatrogenic complications

o       Prevention: If attempted catheterization is unsuccessful, try the ipsilateral internal jugular or subclavicular approach before trying contralateral subclavian catheterization

• Catheter embolization

o       Prevention: Never withdraw a catheter past a needle bevel which might shear off the catheter

o       Management: x-ray the patient and contact specialist who can remove the embolized catheter

• Infection

o       Prevention: Never choose an insertion site that goes through infected tissue; use antimicrobial-impregnated catheters; avoid the use of antibiotic ointments (increase of fungal contamination and antibiotic resistant bacteria)

• Cardiac dysrhythmia

o       Prevention: if available, have someone watch monitor for dysrhythmia while the catheter is advanced (this comes from direct contact of the catheter tip with the myocardium of the right atrium)

o       Management: reposition the catheter; treat dysrhythmia according to ACLS protocols.

• Air embolism

o       Prevention: Maintain a Trendelenberg position, ask the patient to exhale while you are advancing the catheter, maintain a "closed system

o       Management: Place the patient in a left lateral decubitis, head down position to minimize the chances of an air embolism to the brain.