What are the steps and considerations for placing a central line?

Central Line Placement: Procedure, Challenges, and Best Practices

When placing a central venous catheter, use real-time ultrasound guidance with strict aseptic technique including maximal barrier precautions to minimize complications and infection risk. 1

Pre-Procedure Preparation

Site Selection

• Preferred insertion sites (in order of preference):
  • Internal jugular vein (lowest infection risk for upper body sites)
  • Subclavian vein (low infection risk but higher mechanical complications)
  • Avoid femoral site when possible due to higher infection risk 1
  • Right-sided placement generally preferred to reduce risk of malposition 2

Equipment Preparation

• Ensure standardized equipment set is available 1
• Select appropriate catheter:
  • Choose smallest size catheter appropriate for clinical situation
  • Select catheter with minimum number of lumens needed 1
  • Consider antimicrobial-coated catheters for high-risk patients 1

Patient Preparation

• Position patient in Trendelenburg position for neck/chest access when clinically appropriate 1
• For femoral access, consider head-up (reverse Trendelenburg) position 1

Infection Prevention Measures

Maximal Sterile Barrier Precautions

• Hand hygiene before procedure (alcohol-based product or soap and water) 1
• Wear sterile cap, mask covering mouth and nose, sterile gown, and sterile gloves 1
• Use large sterile full-body drape 1, 3
• Cover ultrasound probe and cable with sterile cover 1

Skin Preparation

• Use alcoholic chlorhexidine solution (minimum 2% CHG) for skin antisepsis 1
• Allow antiseptic solution to completely dry before puncture 1
• If chlorhexidine contraindicated, use povidone-iodine or alcohol 1

Ultrasound-Guided Insertion Technique

Step 1: Identify Anatomy

• Use ultrasound to identify vein, artery, and surrounding structures 1, 2
• Examine in both short-axis (transverse) and long-axis (longitudinal) views 1
• Check for anatomic variations 1

Step 2: Confirm Vein Patency

• Use compression ultrasound to exclude venous thrombosis 1
• Use color Doppler to differentiate between venous and arterial vessels 1, 2

Step 3: Real-Time Ultrasound Guidance

• Align insertion site, needle, and ultrasound screen in line of sight 1
• Visualize needle tip throughout procedure to avoid posterior wall puncture 2
• Base number of insertion attempts on clinical judgment 1

Step 4: Confirm Wire Position

• Verify guidewire is in vein using both short-axis and long-axis views before dilator insertion 1, 2

Step 5: Catheter Placement

• Thread catheter over guidewire using Seldinger technique 1
• For subclavian approach, use thin-wall needle technique 1
• For jugular/femoral approach, select technique based on operator experience 1

Step 6: Confirm Catheter Position

• Verify catheter is in vein using ultrasound in both views 1, 2
• Confirm tip position with chest X-ray (ideal position: lower third of SVC) 2

Post-Procedure Care

Dressing and Securement

• Apply sterile, transparent dressing over insertion site 1
• Replace dressing no more than once weekly unless soiled or loose 1
• Use sutureless securement device 1

Maintenance

• Clean catheter access ports with appropriate antiseptic before each access 1
• Cap stopcocks or access ports when not in use 1
• Replace administration sets at least every 7 days (24 hours after blood products) 1
• Perform daily assessment of catheter necessity 1

Common Challenges and Complications

During Insertion

• Arterial puncture: Use ultrasound to confirm vessel identity before puncture 2
• Difficult cannulation: Consider alternative sites if multiple attempts unsuccessful 1
• Anatomical variations: Pre-procedure ultrasound mapping helps identify variations 1

Post-Insertion Complications

• Pneumothorax: More common with subclavian approach; confirm with chest X-ray 2, 4
• Malposition: Verify tip position with imaging 2
• Infection: Monitor for signs of infection; remove catheter if CLABSI suspected 1
• Thrombosis: More common with femoral placement and larger catheters 4

Quality Improvement Strategies

• Use a checklist or protocol for placement and maintenance 1, 5
• Have an assistant during placement 1
• Implement bundle approach for insertion and maintenance 1, 5
• Conduct surveillance of central line-associated bloodstream infections 1
• Provide education and competency assessment for all healthcare providers involved 1

Strict adherence to all components of central line bundles significantly reduces infection rates, with studies showing up to 66% decrease in central line-associated bloodstream infections when all elements are followed 1, 5.