Emergency Medicine

CENTRAL LINE INSERTION

Practical Procedures 479

10 Femoral vein insertion
(i) Palpate the femoral artery two finger-breadths below the inguinal
ligament using the non-dominant hand.
(ii) Insert the needle, bevel up, one finger-breadth medial to the
femoral pulse and aim towards the umbilicus at an angle of
20–30° to the skin. In adults, the vein is normally found 2–4 cm
beneath the skin
(a) reduce the elevation on the needle to 10–15° in small children
as the vein lies more superficial.
(iii) Keep a finger over the artery during the procedure to reduce the
risk of arterial puncture. The right leg is therefore easier to access
for the right-handed operator.

11 Use a 10 mL syringe with large-bore insertion needle attached and aspirate
gently until the vein is entered.

12 Once blood is aspirated, remove the syringe and thread guidewire through the
needle and into the vein. The wire should advance easily and needs no force.
(i) Do not over-insert or force the wire, as it may cause cardiac
arrhythmias (with SCV and IJV), kink or even perforate the
vessel wall.

13 Use one hand to secure the guidewire and remove the needle. Make a
2–3 mm skin incision where the wire penetrates the skin and thread the
dilator over the wire and into the vein with a light twisting motion. Push it
firmly through the skin as far as it will go.

14 Remove the dilator, being careful not to dislodge the guidewire, and thread
the central venous catheter (CVC) over the guidewire towards the skin. Hold
the catheter steady when the tip is 2 cm above the surface of the skin, and
slowly reverse the guidewire up the catheter tube away from the patient, until
the wire tip appears from the line port (i.e. the central port).

15 Holding the proximal portion of the wire protruding from the catheter port,
advance the catheter through the skin, over the wire and into the vein. Do
not allow the wire to be pushed further into the vein while advancing the
catheter.

16 Withdraw the wire and close off the insertion port. Check that blood can be
aspirated freely from all lumens of the catheter and then f lush with saline.

17 Secure the catheter in place with sutures and cover with a sterile dressing.
Tape any redundant tubing, carefully avoiding kinking or loops that may
snag and pull the catheter out.

18 With IJV and subclavian lines, order a CXR to confirm the position of the
catheter tip and to exclude a pneumo- or haemothorax.
(i) The tip of the central venous pressure (CVP) line should lie in the
superior vena cava just above its junction with the right atrium,
around the level of the carina.