1. Gather supplies
a. Ultrasound with high frequency linear (vascular) probe
b. Standard central line kits should have the majority of the supplies you will need including:
Triple lumen central line
Guide wire
Introducer needle/syringe
Lidocaine/small gauge needle/syringe
11 blade scalpel
Dilator
Chloraprep
c. At Temple the rest of the supplies should be in the central line set up kit including:
Full body drape
Gowns
Sterile ultrasound probe cover and sterile gel
Sterile flushes
Line caps
Sterile dressing
Scissors
Suture
2. Evaluate the anatomy on both sides to determine the ideal access site
a. If both sides look equally accessible, the left subclavian is preferred as it has a more direct path to the SVC
b. The main difference between a blind and an ultrasound guided subclavian is that you will be starting your insertion at a more lateral site in the axillary vein so that you have room to follow your needle before the subclavian vein dives under the clavicle and obstructs your view
c. You can identify the axillary vein by following the subclavian vein laterally from the clavicle
d. You can confirm that the vessel you are following is venous by pressing down with the probe to collapse the vein
Alternatively, use Doppler flow to assess for pulsatile flow in the artery
f. Take note of the anatomical structures around the axillary vein.
The vein is adjacent to the artery
g. Artery is usually slightly cephalad
Deep to the vein and artery you can see the pleural line, which should be echogenic. Beneath that you will see the dark space that is the lung tissue
3. Prep the patient, get sterile, and prepare all of your central line equipment
4. Place the line
a. Place a wheel of lidocaine at the point you plan to enter the skin and later suture the line
b. Line up the axillary vein with the mark in the middle of the probe
c. Insert the needle into the skin in the middle of the probe (there should be a mark here)
d. Pull back on the plunger of the syringe as you enter the skin
e. Find the tip of your needle in the soft tissue, and slowly advance your probe until the needle tip falls out of the screen. Hold your probe still at this point, and then advance your needle tip back into the screen in the plane of the probe. Do this until you break through the wall of the vein and see your needle tip in the lumen
f. When you see your needle in the lumen you should note flash in the syringe
g. Drop the probe at this point, disconnect the syringe
h. Thread the wire through the needle into the vessel
If you hit resistance at any point with the wire, you should withdrawal the wire, place the probe back on the patient to verify the tip of the needle is still in the lumen of the vein
i. After threading the wire, remove the needle, place the probe back on the patient in the longitudinal plane of the vessel and look for the wire crossing into the vessel, you should be able to see that the wire is in the lumen and has not punctured the back wall of the vessel and ended up in the soft tissues, the artery, or punctured the lung
j. Use the scalpel to knick the skin over the guide wire
k. Dilate the soft tissues with the dilator, then remove the dilator
l. Thread the catheter over the wire
m. Remove the wire
n. Confirm free flow in all ports
o. Suture the line into the skin
p. Place the biopatch and sterile dressing
q. Obtain a chest XR to confirm placement and check for any complications
For a more detailed video about the steps of central line placement you can watch this EM Crit video on YouTube
https://www.youtube.com/watch?v=nlZQlvie6A8
-Claire Shaffer, MD