CENTRAL LINE INSERTION478 Practical Procedures
3 Position the patient for the route chosen and identify the anatomical
landmarks, or preferably use ultrasound guidance.
4 Wash hands well and wear sterile gown and gloves. Use strict aseptic
technique to prepare and check central line equipment, in particular that the
guidewire passes through the large-bore needle.
5 Draw up 10 mL normal saline and prime the central line ports and tubing.
6 Clean a wide area of skin around the insertion site with chlorhexidine and
cover the sterile area with a large fenestrated drape.
7 Infiltrate the skin and deeper tissues with 5 mL 1% lignocaine (lidocaine). Work
around the site and towards the vein drawing back on the syringe plunger prior
to injecting each time, to ensure that the vein has not been penetrated.
8 IJV insertion
(i) Turn the patient’s head 30–60° to the contralateral side to
improve access to the IJV, but avoid turning the head too far
laterally, as this increases the risk of arterial puncture.
(ii) Stand at the head of the patient and palpate the carotid artery at
the level of the cricoid cartilage, at the apex of the triangle formed
by the heads of the sternocleidomastoid.
(iii) Keeping a finger over the artery, insert the needle bevel up at an
angle of 30–40° one finger-breadth lateral to the artery. Aim for
the ipsilateral nipple in men and the ipsilateral anterior superior
iliac spine in women.
(iv) Always direct the needle away from the artery and keep the artery
guarded under your finger. The vein is usually only 2–3 cm under
the skin, so if the vein is not entered, re-direct the needle tip
more laterally.
9 SCV insertion
(i) Turn the head away from the side to be cannulated. Normally,
the right subclavian is cannulated, as the thoracic duct is on
the left and may occasionally be damaged during cannulation,
resulting in a chylothorax.
(ii) Improve access to the vein by caudal traction on the ipsilateral
arm, or by placing a roll under the ipsilateral shoulder.
(iii) Stand beside the patient on the side to be cannulated. Identify
the mid-clavicular point and the sternal notch. Insert the needle
through the skin 1 cm below and lateral to the mid-clavicular
point.
(iv) Keeping the needle horizontal, advance just under the clavicle
aiming for the sternal notch. If the needle hits the clavicle ‘walk
off the bone’ moving inferiorly, and direct slightly deeper to pass
beneath it.
(v) Do not pass the needle further than the sternal head of the
clavicle.