What is the proper protocol for inserting a central line?

From the Guidelines

Central line insertion should be performed using strict sterile technique, with ultrasound guidance, and a maximal sterile barrier to minimize infection risk and mechanical complications, as recommended by the most recent and highest quality study 1. To complete a central line insertion, the following steps should be taken:

• Obtain informed consent and gather necessary equipment, including sterile gown, gloves, mask, cap, ultrasound machine, central line kit, chlorhexidine solution, and lidocaine.
• Position the patient appropriately, using Trendelenburg for internal jugular or subclavian approaches, and supine for femoral.
• Perform a time-out to verify patient identity and procedure.
• Use ultrasound guidance to identify the target vessel and surrounding structures.
• After donning sterile attire and creating a maximal sterile barrier with full-body drapes, prep the site with 2% chlorhexidine-alcohol solution and allow it to dry completely.
• Administer local anesthesia with 1-2% lidocaine.
• Under ultrasound guidance, insert the introducer needle into the vessel, confirming placement with blood return.
• Thread the guidewire through the needle, remove the needle, and make a small skin incision.
• Dilate the tract, then thread the catheter over the guidewire to the appropriate depth.
• Remove the guidewire while occluding the catheter hub.
• Secure the catheter with sutures, apply a sterile dressing, and obtain a chest X-ray to confirm proper placement and rule out pneumothorax for thoracic approaches.
• Document the procedure thoroughly, including any complications. Key considerations include:
• Avoiding the femoral vein for central venous access in adult patients, due to the increased risk of infection and thrombosis 1.
• Using a subclavian site, rather than a jugular or femoral site, in adult patients to minimize infection risk for nontunneled CVC placement 1.
• Using ultrasound guidance to reduce the number of cannulation attempts and mechanical complications 1.
• Using a CVC with the minimum number of ports or lumens essential for the management of the patient 1.
• Promptly removing any intravascular catheter that is no longer essential 1.

From the Research

Proper Protocol for Inserting a Central Line

The proper protocol for inserting a central line involves several key steps and considerations, as outlined in various studies 2, 3, 4, 5, 6.

• Pre-procedural preparation: Providers should be familiar with the operation of their specific ultrasound machine prior to initiation of a vascular access procedure 2.
• Use of ultrasound guidance: Real-time, two-dimensional ultrasound guidance with a high-frequency linear transducer is recommended for central venous catheter (CVC) insertion, regardless of the provider's level of experience 2.
• Evaluation of anatomical variations: Providers should evaluate the target blood vessel size and depth during preprocedural ultrasound evaluation and use two-dimensional ultrasound to evaluate for anatomical variations and absence of vascular thrombosis during preprocedural site selection 2.
• Visualization of needle tip and guidewire: Providers should visualize the needle tip and guidewire in the target vein prior to vessel dilatation 2.
• Use of a standardized procedure checklist: A standardized procedure checklist that includes the use of real-time ultrasound guidance can help reduce the risk of central line-associated bloodstream infection (CLABSI) from CVC insertion 2.
• Aseptic technique and maximal sterile barrier precautions: Providers should use real-time ultrasound guidance, combined with aseptic technique and maximal sterile barrier precautions, to reduce the incidence of infectious complications from CVC insertion 2.

Specific Techniques for Central Venous Access

• Internal jugular vein catheterization: Real-time ultrasound guidance is recommended for internal jugular vein catheterization, which reduces the risk of mechanical and infectious complications, the number of needle passes, and time to cannulation and increases overall procedure success rates 2.
• Subclavian vein catheterization: Providers who routinely insert subclavian vein CVCs should use real-time ultrasound guidance, which has been shown to reduce the risk of mechanical complications and number of needle passes and increase overall procedure success rates compared with landmark-based techniques 2.
• Femoral venous access: Real-time ultrasound guidance is recommended for femoral venous access, which has been shown to reduce the risk of arterial punctures and total procedure time and increase overall procedure success rates 2.

Post-Procedure Care

• Ruling out pneumothorax: Post-procedure pneumothorax should be ruled out by the detection of bilateral lung sliding using a high-frequency linear transducer before and after insertion of internal jugular and subclavian vein CVCs 2.
• Detection of catheter tip misplacement: Providers should use ultrasound with rapid infusion of agitated saline to visualize a right atrial swirl sign (RASS) for detecting catheter tip misplacement during CVC insertion 2.
• Maintenance and care of central lines: Ensuring proper maintenance and care of a CVAD falls within nursing practice, and interventions can significantly reduce the patient's risk of central line-associated bloodstream infection 3.