What is the proper procedure for inserting a central line?

Central Line Insertion Procedure

The proper procedure for inserting a central line requires real-time ultrasound guidance with strict aseptic technique, including maximal barrier precautions, to minimize complications and infection risk. 1

Pre-Procedure Preparation

• Ensure proper education and training for all personnel involved in central venous catheter placement 2

• Gather standardized equipment set including:

  • Ultrasound machine with sterile probe cover
  • Central line kit with appropriate catheter size (select smallest size appropriate for clinical situation) 2, 1
  • Sterile supplies for maximal barrier precautions
  • Chlorhexidine-containing antiseptic solution (>0.5%) 2

• Implement maximal barrier precautions:

  • Hand hygiene (soap and water or alcohol-based hand rubs) 2
  • Sterile cap, mask covering both mouth and nose 2
  • Sterile gown and gloves 2
  • Full-body patient drape 2
  • Eye protection 2

Site Selection and Patient Positioning

• Select insertion site based on clinical need 2:

  • Prefer internal jugular vein (first choice) due to lower insertion-related complications 1
  • Subclavian vein (second choice)
  • Avoid femoral vein when possible (higher infection/thrombosis risk) 1
  • Right-sided placement generally preferred to reduce malposition risk 1
  • Avoid contaminated sites (burns, infections, inguinal area, adjacent to tracheostomy or surgical wounds) 2

• Position patient appropriately:

  • Trendelenburg position for neck/chest access when clinically feasible 2, 1
  • Reverse Trendelenburg for femoral access 1

Skin Preparation

• Apply alcoholic chlorhexidine solution (>0.5%) for skin antisepsis 2
• Allow antiseptic to completely dry before puncture 1
• If chlorhexidine is contraindicated, use povidone-iodine or alcohol 2, 1

Ultrasound-Guided Insertion Technique

1. Vessel Identification:

   • Use real-time ultrasound guidance for vessel localization and venipuncture (mandatory for internal jugular vein) 2
   • Examine in both short-axis (transverse) and long-axis (longitudinal) views 1
   • Use compression ultrasound to exclude thrombosis and color Doppler to differentiate veins from arteries 1

2. Venous Access:

   • For subclavian approach, use thin-wall needle (Seldinger) technique 2
   • For jugular/femoral approach, select thin-wall needle or catheter-over-needle technique based on clinical situation and operator experience 2
   • Visualize needle tip throughout procedure to avoid posterior wall puncture 1

3. Wire and Catheter Placement (Seldinger Technique):

   • After successful venipuncture, thread guidewire through needle 3
   • Verify correct guidewire position in vein using ultrasound 1
   • Remove needle while maintaining guidewire position
   • Make small skin incision at entry site if needed
   • Thread dilator over guidewire to create tract
   • Remove dilator while maintaining guidewire position
   • Thread catheter over guidewire to desired depth
   • Remove guidewire while maintaining catheter position
   • Aspirate and flush all lumens to confirm patency

4. Confirmation of Placement:

   • Verify catheter tip position with chest X-ray or other imaging methods 1
   • Ideal tip position: lower third of superior vena cava, at atrio-caval junction, or upper right atrium 1

Catheter Securement and Maintenance

• Apply sterile transparent dressing over insertion site 2, 1
• Secure catheter with sutureless securement device 1
• Replace dressing weekly (or when soiled/loose) 2, 1
• Clean access ports with appropriate antiseptic before each use 1
• Perform daily assessment of catheter necessity 1
• Maintain catheter patency through routine flushing 1

Complication Prevention and Management

• If arterial puncture occurs, leave the dilator or catheter in place and immediately consult surgical specialists 2
• Monitor for signs of infection and remove catheter if CLABSI is suspected 1
• Consider antimicrobial-coated catheters for high-risk patients 2, 1
• Daily skin cleansing with 2% chlorhexidine-impregnated wash cloth can reduce infection risk 2

Critical Pitfalls to Avoid

• Failure to use real-time ultrasound guidance (increases complication risk) 1
• Inadequate sterile barrier precautions (increases infection risk) 4
• Improper patient positioning (increases risk of air embolism) 1
• Multiple insertion attempts (increases complication risk) 2
• Improper catheter tip position (increases thrombotic complications) 1
• Delayed catheter removal when no longer needed (increases infection risk) 2, 1

Implementation of a comprehensive care bundle for central line insertion has been shown to significantly reduce central line-associated bloodstream infections (CLABSIs) 5, making strict adherence to these guidelines essential for patient safety.