What are the steps for placing a central line?

Steps for Placing a Central Line

Central line placement should follow a systematic six-step approach using real-time ultrasound guidance to reduce complications and increase success rates. 1, 2

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 1, 2
• Position the patient appropriately: Trendelenburg position for internal jugular or subclavian approach to increase venous filling; reverse Trendelenburg for femoral approach 3, 1
• For internal jugular vein access, minimize head rotation to reduce arterial-venous overlap 3, 1

Six-Step Approach to Central Line Placement

Step 1: Identify Anatomy of Insertion Site and Localize the Vein

• Use ultrasound to identify the target vein, adjacent artery, and surrounding anatomic structures 3, 1
• Check for anatomic variations using both short-axis (transverse) and long-axis (longitudinal) views 3, 2
• Perform this step before prepping and draping the puncture site 3

Step 2: Confirm Patency of the Vein

• Use compression ultrasound to exclude venous thrombosis 3
• Apply color Doppler imaging and Doppler flow measurements to confirm vein patency and quantify blood flow 3

Step 3: Use Real-time Ultrasound Guidance for Puncture

• Implement aseptic technique: large sterile drape, sterile barriers (hat, mask, gloves, gown), sterile ultrasound probe cover, and sterile gel 3
• Position yourself so the insertion site, needle, and ultrasound screen are in your line of sight 3
• Use "single-operator technique" - hold ultrasound probe with non-dominant hand while advancing needle with dominant hand 3
• Choose either short-axis/out-of-plane or long-axis/in-plane approach 3
• Constantly visualize the needle tip during approach and puncture 3, 4

Step 4: Confirm Needle Position in Vein

• Verify that the needle tip is placed centrally in the vein before advancing the guidewire 3
• Visualize the needle tip in both short-axis and long-axis views if possible 3, 4

Step 5: Confirm Wire Position in Vein

• Confirm correct guidewire position in both short-axis and long-axis ultrasound views 3
• Ensure the guidewire is fully visible and accounted for during the procedure 5

Step 6: Confirm Catheter Position in Vein

• After catheter placement, confirm correct position in the vein using ultrasound in both short-axis and long-axis views 3
• Verify final catheter tip position at the cavoatrial junction via chest radiograph 2

Common Pitfalls and How to Avoid Them

• Relying solely on anatomical landmarks significantly increases complication risk, especially with anatomic variations 1, 4
• Failing to verify venous placement can lead to accidental arterial cannulation - always confirm with ultrasound, manometry, or pressure waveform 1, 4
• Incomplete visualization of the needle tip can lead to posterior vessel wall puncture - maintain needle tip visualization throughout the procedure 3, 4
• Guide wire loss is a serious complication - always maintain control of the guidewire and verify complete removal 5
• Inadequate sterile technique increases infection risk - strictly adhere to maximal barrier precautions 3, 4

Special Considerations

• For patients with difficult vascular access, ultrasound guidance significantly reduces procedure time and number of attempts 6
• Consider using echogenic needles, plastic needle guides, or ultrasound beam steering when available to increase success rates 4
• If unintended arterial cannulation occurs with a large-bore catheter, leave the catheter in place and consult vascular surgery or interventional radiology immediately 1
• For suspected pneumothorax, use ultrasound to detect bilateral lung sliding before and after insertion of internal jugular and subclavian vein catheters 4