Week 2 - Central Line an Arterial Line Placement Flashcards
What are the indications for a central line?
Rapid Resuscitation
Hemodynamic monitoring
Inability to access peripheral veins
Admin of vasoactive drugs
What are the contraindications to placing a central line?
Patient is coagulopathic
Infection, trauma or venous thrombosis at selected site
-IJ, Subclavian, or Femoral
Which site is preferred for central line placement?
IJ
- usually easiest access in surgical cases
- less risk for pneumothorax
What is the generalized steps of an IJ central line placement?
- Gather equipment
- Position pt
- Find anatomical landmarks, may use US
- Sterile prep and drape
- Prepare kit: flush lines, check guide wire, localization if awake
- Insert finder needle or catheter into IJ using US – verify placement with US
- Thread guide wire, remove catheter or finder needle being careful to leave guide wire in place, place skin nick, thread dilator over wire and remove, then thread catheter over wire never taking your hand off the guide wire
- Confirm placement: manometer or pressure transducer, X-ray post op
What are the insertion landmarks for an IJ central line?
Superior apex of the triangle formed by the TWO heads of the SCM muscle and the clavicle
What is the optimal position for IJ central line placement?
Trendelenburg position 15 degrees
30-45 degree head turn away
Note: carotid goes underneath the IJ as head is externally rotated
How do you verify the IJ location using US?
-Orient the probe, marker to the left as you stand at the HOB, notice screen indicator dot on the left side of the screen
- IJ will usually lie lateral and superficial to the carotid
- IJ is more compressible than carotid
- Doppler may be used to confirm blood flow direction
How do you use US to guide needle placement during central line placement?
- Place IJ in center of US field
- Needle angled 40-60 degrees from plane of neck about 1 cm back from the middle of probe
- Soft tissue depression should be seen on initial needle placement directly over the target vessel
- Advance needle in small increments visualizing needle indenting the wall of the IJ and then a flash should be seen as needle enters IJ
- Probe may be turned long axis view to see needle tip in IJ
- IV extension or wire sheath manometer can also be used to verify venous placement
- Guide wire can then be passed and long axis view used to visualize guide wire in vein
What are possible complications of central line placement?
Carotid puncture
Air embolism
Pneumothorax
Hematoma
Infection
Thrombosis
What are the different arterial line placement techniques?
Catheter-over-needle (simple long IV catheter)
Seldinger Technique (guide wire)
Combination of the two
What is the optimal position for arterial line insertion?
Dorsiflex the wrist to approx 30-45 degrees and support the wrist in this position with a rolled towel
- avoid hyper-dorsiflexion of the wrist because this may compress the radial artery
- maintain this position by taping the patients hand and finders to the work surface
Describe the catheter over needle approach to arterial line placement
- Palpate radial artery
- Catheter introduced at 30-45 degree angle
- Observe hub for flash of bright red blood
- Advance needle over catheter
- If resistance felt, reposition needle until free flow of blood and try to advance
- After catheter has been advanced into artery, remove needle and attach catheter to pressure monitoring tubing
Describe the Seldinger technique to arterial line placement
- Attach syringe to finder needle
- Palpate radial artery
- Puncture skin at 30-45 degree angle with gentle negative pressure on syringe until free flow of blood
- If initial return of blood ceases, the vessel may have been punctured on the posterior aspect – withdraw until return of blood flow
- Remove syringe and advance guide wire into artery after free flow of blood is obtained
- Remove the needle
- Slide catheter over wire into artery
- Remove wire and attach catheter to pressure monitoring tubing
Describe the combined wire and catheter over needle technique (modified Seldinger) to arterial line placement
- Assemble catheter and wire by connecting wire assembly to needle
- Make sure guide wire moves smoothly and that it is fully retracted
- Palpate and puncture artery as in the catheter over needle technique advancing until flash of blood present
- Stabilize needle and advance wire into artery
- Grasp the hub of the catheter and advance into artery over the wire
- Withdraw the needle and guide wire together as one unit
