Icahn School of Medicine at Mount Sinai, New York, NY, USA
OVERALL BOTTOM LINE
Providers need to optimize central venous catheter and arterial catheter insertion in critically ill patients.
Strict sterile technique during insertion is crucial for minimizing infection, the most serious and frequent complication associated with line placement.
In general, central venous and arterial lines should be removed as soon as possible to minimize the risk of infection.
Central venous access
Indications
Difficult venous access, frequent blood sampling.
Rapid administration of fluids and blood products (resuscitation).
Administration of fluids and medication caustic to small veins (e.g. vasopressors, chemotherapy, total parenteral nutrition).
Renal replacement therapy, plasmapheresis.
Transvenous pacemaker, pulmonary artery catheter.
Venous access sites
Internal jugular (IJ), subclavian medial (SM) or lateral (SL), and femoral (F) veins.
Catheter types (Figure 3.1)
Multilumen or single lumen (central venous access catheters).
Dialysis (large bore, double, or multilumen catheters).
Introducer (large bore for rapid resuscitation access, temporary pacemaker, or pulmonary artery catheter insertion).
Procedure
Prior to procedure, ensure that the patient’s name, procedure, and site of insertion are confirmed with the patient’s nurse.
Pre‐procedure US: the vein is visualized under US when using the IJ, SL, or F veins for access. (Note: the SM vein approach places the needle tip under the clavicle, hence it is not possible to visualize cannulation of the subclavian vein under US when using this approach.) Scan above, at, and below site of planned insertion (or lateral to medial with SL approach) with compression to check for thrombosis (Figure 3.2) or stenosis. Video 3.1 demonstrates the appearance of the vessels when performing the SL approach. On the viewer’s left, cephalad (towards the head, i.e. closer to the clavicle) is the subclavian artery (SA); to the viewer’s right, caudad (towards the feet, i.e. closer to the lung) is the subclavian vein (SV) (since the vessel has not yet passed the first rib, technically speaking it may be called the axillary vein). Note that the SV is compressible and non‐pulsating. Also note the twinkling horizontal line about 0.5 cm below the SV coming in from the right side with respiration: this is the pleural line.
For any neck line insertion (IJ or SM/SL sites) pre‐scan (US) the pleura on the side of planned insertion for the presence and degree of lung sliding. (See Chapter 4, Videos 4.1 and Video 4.2.) This can improve the accuracy of post‐procedure US to assess for pneumothorax.
Optimize site of insertion by selecting a plane where the artery is not directly beneath the vein (IJ insertion) or directly overlying the vein (F insertion) if possible. For IJ lines, turning the patient’s head toward the side of insertion may move the IJ to a more lateral position relative to the carotid artery. For F lines, moving the US superiorly toward the inguinal ligament will locate the vein medial to the artery. Moving the US down the leg (away from the inguinal ligament in the direction of the knee) will locate a position where the artery is overlying the vein, making access more difficult. Also, flexion of the lower extremity at the knee with lateral rotation may also help to move the femoral vein more medially from under the femoral artery. US will demonstrate whether this maneuver is effective or not.
Select the depth on the US machine (Figure 3.3) where both vein and artery can be easily visualized at their largest on the screen, i.e. minimum depth needed (a rough guide is approximately 2–3 cm for IJ, 4–5 cm for SL [for SL this includes visualization of the pleural line], and 3–5 cm for F). (Note: this requires a transverse orientation of the US probe. A longitudinal orientation will only show the vein, not the artery, unless the artery is directly beneath the vein. The transverse approach is preferred to prevent inadvertent arterial puncture, especially in less experienced or in‐training practitioners.)
Clean site of insertion plus a diameter of approximately 15 cm with chlorhexidine gluconate and isopropyl alcohol (e.g. Chloroprep).
Wash hands and put on cap, mask, sterile gown, and sterile gloves.
Prepare sterile field: drape patient with sterile sheets and drapes so that only prepped area is exposed.
Place sterile US gel into sterile US probe cover, then insert US into sterile covering; fasten covering with rubber bands.
Place sterile US gel onto insertion site.
Draw up 5–10 mL 1% lidocaine and label syringe.
Flush all ports of the catheter with sterile saline; for triple lumen catheters, clamp blue and white ports, but leave brown port unclamped; for dialysis catheters, clamp red port, but leave blue port unclamped (guidewire exits this port).
Remove and gently but firmly replace the introducer (i.e. insertion) needle onto the syringe ensuring the needle is not jammed onto the syringe.
Remove cap off guidewire (GW) and retract GW into plastic sheath until 2 mm is exposed.
Place gauze on sterile field near insertion site.
Draw sterile saline into syringe in preparation to flush all ports post‐insertion.
Set up tools on sterile table in the order in which they will be used: lidocaine, insertion needle and syringe, GW, skin dilator, scalpel, catheter, needle holder, suture.
Hold US probe in the non‐dominant hand, select insertion site, inject 3–10 mL lidocaine with dominant hand, and place lidocaine syringe into sharps sponge.
Hold US with non‐dominant hand; hold insertion needle and syringe with dominant hand (Video 3.2).
As soon as insertion needle pierces the skin, introduce negative pressure by pulling the plunger on the syringe.
Slowly advance syringe at a 70–80° angle under US guidance (Figure 3.4).
As soon as blood is aspirated into the syringe and introducer needle tip is visualized inside the vein near the center (Video 3.3: see at
