The Massachusetts General Hospital Handbook of Neurology

Authors: Flaherty, Alice W.; Rost, Natalia S.

Title: Massachusetts General Hospital Handbook of Neurology, The, 2nd Edition

Copyright 2007 Lippincott Williams & Wilkins

> Table of Contents > Procedures > Central Venous Line

Central Venous Line

A. See also

Venous Access, p. 226.

B. Indication

Pressors, Nipride, nitroglycerine >400 g/min.

C. Check

PT, PTT before placing line.

D. Consent

Complications = bleeding, clot, infection, PTX, air embolus, nerve damage.

E. Need

Central line kit, 10 cc heparin 100 U/cc (not 1,000), sterile gloves, sterile sponges, Betadine, suture, dressing. Prepare replacement caps for all ports, sterile gown, sterile towels, mask.

F. IJ (internal jugular) vs. SC (subclavian) access

Internists like IJs because they are safer a laceration can be compressed. Surgeons like SCLs because they are quicker. Neurologists like SCLs they want to avoid a carotid stick, or possible obstruction to endovascular approach. And because the neck is sacred it's the only thing that keeps the head attached to the body.

G. Preparation

• Positioning: Clear space behind bed. Put pt. in Trendelenburg to keep air bubbles from brain. Towel roll between pts. shoulders. Tape open heparin flush bottle upside down to IV pole for easy sterile access.

• Sterility: Iodine prep from ear to sternal notch for IJ; consider prepping SCL region too. Open towels; use their drape to cover pts. abdomen. Open kit, extra gloves, sutures onto field. Drape pt. sterilely, leaving enough room to identify landmarks. Then put on sterile gloves and gown.

• Needle prep: Remove cap from brown port, for wire to go through. Do not let line touch any nonsterile surface. Place needles on syringes, line, suture, and extra gauze within reach. Xylocaine to skin. Then fill that syringe with heparin flush. Leave a few cc to suck air out of catheter.

H. Internal jugular

Easiest from right of pt.

• Find vein: Use small needle. Anesthetize. Stand on R side of pt., feel carotid, aim with syringe on small needle through the triangle between the bellies of the sternocleidomastoid to the ipsilateral nipple. Aspirate as you go in until you hit IJ and get blood.

• Thread wire: Slip syringe on larger needle (with catheter) next to the smaller one, while aspirating. Withdraw the smaller needle; withdraw

  P.224

  larger syringe leaving catheter in place, thread wire down catheter and tube down wire to SVC (about 15 cm). Always hold the wire with one hand.

• Insert line: Remove needle from wire, cut down along wire with scalpel, insert and remove dilator. Thread line down over wire. At some point, you will need to start pushing wire back up into line. Go about 15 cm, to SVC. Remove wire. As wire passes brown port clamp, clamp it to avoid air embolus before you screw on cap. Use heparin syringe to suck air from each port and then flush port.

• Secure line: Anesthetize and suture line, tying to inner holder only; then clip outer holder on. (This allows moving line without resuturing.) Suture far end too. Cover with iodine gel, gauze, Tegaderm.

• Check line: Stat CXR with immediate read to check line placement (should be in superior vena cava) and r/o PTX.

I. Subclavian

Easiest from left of pt.

• Find vein: Use medium needle. Find middle third (angle) of clavicle, start about 2 cm away, aim straight at lower edge with lidocaine needle; march down it, injecting and pulling back, until you are underneath. Insert the large needle, noting position of bevel (up). Hold needle with left hand, aspirate with right. Consider putting little finger in sternal notch as landmark. March the same way, aspirating with large needle, until you are under the clavicle; then rotate syringe so that you are parallel with clavicle and bevel is pointing down towards toes. Keep against clavicle, advance aspirating, until you are in vein.

• Thread wire, insert line, and secure line: Follow IJ protocol above, but go 17 cm for L subclavian.

J. Taking line out

• Need: Suture removal kit, chuck, pt. in Trendelenburg position.

• Procedure: Have pt. exhale slowly as you withdraw the line, to prevent air emboli.