What are the key components and best practices for central line placement?

Central Line Placement: Best Practices and Technique

Real-time ultrasound guidance should be used for central venous catheter placement, particularly for the internal jugular vein, to reduce complications and increase safety. 1

Preparation and Equipment

• Gather necessary equipment including sterile drapes, personal protective equipment (hat, mask, sterile gloves, sterile gown), ultrasound machine with high-frequency linear probe, sterile ultrasound probe cover, sterile gel, and central venous catheter kit 2
• Use a standardized equipment set and follow a checklist or protocol for central line placement 1
• Position the patient appropriately:
  • Trendelenburg position for internal jugular or subclavian approach to increase venous filling 1
  • Reverse Trendelenburg position for femoral vein approach 1
  • For internal jugular vein access, minimize head rotation to reduce arterial-venous overlap 1

Systematic Six-Step Approach to Central Line Placement

Step 1: Identify Anatomy and Localize the Vein

• Use ultrasound to identify the target vein, adjacent artery, and surrounding anatomic structures 1
• Check for anatomic variations, which occur in a significant proportion of patients 1, 2
• Use both short-axis (transverse) and long-axis (longitudinal) views of the vessels 1
• Perform this step before prepping and draping the puncture site 1

Step 2: Confirm Patency of the Vein

• Use compression ultrasound to exclude venous thrombosis 1
• Apply color Doppler imaging and Doppler flow measurements to confirm vein patency and quantify blood flow 1, 2

Step 3: Use Real-time Ultrasound Guidance for Vein Puncture

• Implement strict aseptic technique including:
  • Large sterile drape over puncture site
  • Hat, mask, sterile gloves, sterile body gown
  • Sterile ultrasound probe cover and sterile gel 1
• Use chlorhexidine-containing solution with alcohol for skin preparation 1
• Position yourself to have the insertion site, needle, and ultrasound screen in your line of sight 1
• Use the "single-operator technique" - hold the ultrasound probe with non-dominant hand while advancing the needle with dominant hand 1
• Choose either short-axis/out-of-plane or long-axis/in-plane approach based on experience and clinical situation 1
• Constantly identify the needle tip during approach and puncture 1

Step 4: Confirm Needle Position in the Vein

• Verify that the needle tip is placed centrally in the vein before advancing the guidewire 1
• Do not rely solely on blood color or absence of pulsatile flow for confirming venous placement 1
• Use ultrasound, manometry, or pressure-waveform analysis to confirm venous access 1

Step 5: Confirm Wire Position in the Vein

• Confirm correct guidewire position in both short-axis and long-axis ultrasound views 1
• For thin-wall needle technique, always confirm venous residence of the wire after threading 1
• For catheter-over-needle technique, wire confirmation may not be needed if:
  • Catheter enters vein easily AND
  • Manometry/pressure-waveform confirms venous location AND
  • Wire passes through catheter without difficulty 1

Step 6: Confirm Catheter Position in the Vein

• Verify correct catheter position in the vein using ultrasound in both short-axis and long-axis views 1
• Confirm final catheter tip position at the cavoatrial junction as soon as clinically appropriate, typically via chest radiograph 1, 2
• Verify that the guidewire has been completely removed from the patient by confirming its presence in the procedural field 1

Site Selection Considerations

• Base catheter insertion site on clinical need, practitioner experience, and skill 1
• Select an upper body insertion site (internal jugular or subclavian) when possible to minimize thrombotic complications compared to femoral site 1
• Choose a site that is not contaminated or potentially contaminated (avoid burned/infected skin, inguinal area, areas adjacent to tracheostomy or open surgical wounds) 1
• Select the smallest catheter size appropriate for the clinical situation 1

Technique-Specific Recommendations

• For subclavian approach, use a thin-wall needle (Seldinger) technique rather than catheter-over-needle (modified Seldinger) technique 1
• For internal jugular or femoral approach, select either thin-wall needle or catheter-over-needle technique based on clinical situation and operator experience 1
• Limit the number of insertion attempts based on clinical judgment 1

Management of Complications

• If unintended arterial cannulation with a large-bore catheter occurs, leave the catheter in place and consult a vascular surgeon or interventional radiologist immediately 1
• If the complete guidewire cannot be located in the procedural field, order chest radiography to check for wire retention in the vascular system 1
• Monitor for common complications including pneumothorax (0.4% prevalence with subclavian approach) and accidental arterial puncture (1.3% with subclavian approach) 3
• Central line-associated bloodstream infections can be minimized through proper maintenance and care after placement 4

Common Pitfalls and How to Avoid Them

• Relying solely on anatomic landmarks without ultrasound guidance increases complication risk, especially with anatomic variations 1
• Failure to confirm venous placement can lead to arterial dilation/cannulation - always verify with ultrasound, manometry, or pressure waveform 1
• Excessive head rotation during internal jugular vein access increases overlap with carotid artery - minimize rotation 1
• Inadequate aseptic technique increases infection risk - always use maximal barrier precautions 1
• Retained guidewires are preventable - always verify complete removal of wire 1
• Catheter tip malposition can cause complications - confirm final position with imaging 1, 2