What is the recommended assessment and plan for central line placement?

Assessment and Plan for Central Line Placement

Pre-Procedural Assessment

Use real-time ultrasound guidance for all central line placements to reduce complications and improve success rates. 1, 2

Patient Evaluation

• Verify indication for central line and document that peripheral access is inadequate or inappropriate 1, 2
• Assess coagulation status and correct any bleeding disorders or thrombocytopenia before proceeding 3
• Review patient anatomy for prior central lines, thrombosis history, or anatomic variations 1
• Identify immunocompromised status (cancer patients, neonates) as this may warrant antibiotic prophylaxis on a case-by-case basis 1

Site Selection Strategy

• Avoid femoral sites due to increased infection and thrombosis risk, especially in ICU patients 2
• Prefer internal jugular or subclavian veins for most indications 2
• Avoid subclavian sites in patients requiring future hemodialysis due to stenosis risk 2
• Position patient in Trendelenburg (head-down) to increase internal jugular vein filling and cross-sectional area 1, 4
• Minimize head rotation during internal jugular access to reduce carotid-jugular overlap 1, 4

Pre-Procedure Ultrasound Assessment (Before Sterile Prep)

• Identify vein anatomy using both short-axis (transverse) and long-axis (longitudinal) views to map vessel relationships 1, 4
• Check for anatomic variations which occur frequently and can complicate placement 4
• Confirm vein patency using compression ultrasound to exclude thrombosis 1, 4
• Use color Doppler imaging to definitively differentiate vein from artery and quantify blood flow 1, 4
• Note: In hypotensive patients (SBP <60 mmHg), arteries may also be compressible, creating potential confusion 4

Procedural Plan

Maximal Sterile Barrier Precautions (Non-Negotiable)

Apply maximal sterile barriers for every central line insertion to reduce catheter-related bloodstream infections. 1, 2

• Perform hand hygiene with alcohol-based product or soap and water 2
• Wear full sterile barriers: hat, mask covering mouth and nose, sterile gown, sterile gloves 1, 2
• Use large full-body sterile drape covering the patient 1, 2
• Cover ultrasound probe and cable with sterile cover/shield 1
• Use sterile ultrasound gel as conductive medium 1

Skin Preparation

• Apply chlorhexidine-containing solution (minimum 2% CHG) with alcohol for all adults, infants, and children 1, 2
• For neonates, use chlorhexidine based on clinical judgment and institutional protocol due to potential skin reactions 1
• If chlorhexidine contraindicated, use povidone-iodine or alcohol 1
• Allow antiseptic to dry completely before puncturing skin 2

Six-Step Ultrasound-Guided Insertion Technique

Step 1: Real-Time Needle Guidance

• Position yourself so insertion site, needle, and ultrasound screen are in your line of sight 1, 4
• Hold ultrasound probe with non-dominant hand while advancing needle with dominant hand 1, 4
• Use either short-axis/out-of-plane OR long-axis/in-plane view for needle visualization 1, 4
• Constantly visualize needle tip throughout entire approach to the vein 1, 4

Step 2: Confirm Needle Position

• Verify needle tip is centrally positioned in the vein before advancing guidewire using real-time ultrasound 1, 4
• Confirm venous (not arterial) placement using ultrasound, manometry, or pressure waveform analysis 4

Step 3: Confirm Guidewire Position

• Visualize guidewire in both short-axis and long-axis views after advancement 1, 4
• If complete guidewire cannot be located in procedural field, order chest X-ray to check for wire retention 4

Step 4: Confirm Catheter Position

• Visualize catheter in both short-axis and long-axis views after placement over guidewire 1, 4
• Verify catheter tip position between lower third of superior vena cava and upper third of right atrium using intraoperative fluoroscopy, post-operative chest X-ray, or intracavitary ECG 1, 2

Catheter Selection Considerations

• Consider antimicrobial-coated catheters (chlorhexidine-silver sulfadiazine or antibiotic-impregnated) as they reduce catheter colonization 1
• Note: Chlorhexidine-coated catheters carry rare risk of anaphylaxis 1
• Evidence for reduced bloodstream infection with coated catheters is equivocal 1

Post-Procedural Management

Immediate Post-Procedure

• Monitor vital signs (temperature, pulse, blood pressure, respiratory rate) every 4 hours after placement 2
• Apply sterile transparent dressing over insertion site 2
• If unintended arterial cannulation with large-bore catheter occurs, leave catheter in place and immediately consult vascular surgery or interventional radiology 4

Dressing and Maintenance

• Replace transparent dressings no more than once weekly unless soiled or loose 2
• Perform routine flushing with saline after any infusion or blood sampling 2
• Replace administration sets and needleless connectors at least every 7 days (within 24 hours after blood products or lipid emulsions) 2

Infection Prevention Bundle

• Consider daily chlorhexidine bathing for ICU patients over 2 months of age to reduce infection risk 2
• Perform hand hygiene before every catheter manipulation 2, 5
• Clean injection ports with 70% alcohol before accessing the system 3
• Evaluate daily for continued need and remove as soon as no longer necessary 5

Critical Pitfalls to Avoid

Sterile technique breaks during placement are associated with 71% of central line-associated bloodstream infections in trauma patients. 6

• Never compromise on maximal sterile barriers, even in emergency situations—this is the single most important factor in preventing infections 6, 7
• Changing a "dirty" line within 24 hours does not reduce infection risk—proper initial technique is essential 6
• Do not routinely administer prophylactic IV antibiotics except for immunocompromised patients or high-risk neonates on a case-by-case basis 1
• Do not use heparin immediately before or after lipid-containing infusions due to precipitation and emboli risk 3
• Hand hygiene is the single most crucial nursing intervention to prevent infections 5

Quality Assurance

• Use standardized equipment sets and checklists for placement and maintenance 1, 2
• Ensure trained assistant is present during placement 1
• Empower staff to stop procedures if protocols are not followed 2
• Track compliance with bundle elements using checklists 2