V. Dimov, M.D., Clinical Assistant Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio; B. Altaqi, M.D., Assistant Clinical Professor of Medicine, University of Louisville, Kentucky
See the slide show or click on the images below for step-by-step instructions. A free PDA version of this procedure guide is available from MeisterMed, iSilo reader for PDA is required to view the images.
Venous access is needed for intravenous fluids or antibiotics and a peripheral site is unavailable or not suitable
Central venous pressure measurement
Administration of certain chemotherapeutic drugs or total parenteral nutrition (TPN)
For hemodialysis or plasmapheresis
Uncorrected bleeding diathesis
Skin infection over the puncture site
Distortion of anatomic landmarks from any reason
Pneumothorax or hemothorax on the contralateral side
Positive end-expiratory pressure (PEEP) mechanical ventilation
Only one functioning lung
Explain the procedure to the patient and obtain a written informed consent, if possible. Explain the risks, benefits and alternatives (RBA).
Fig. 1, 2. Ultrasound machine (SiteRite II).
Fig. 3, 4, 5. Ultrasound screen and dept adjustment switch.
Get to know the equipment in the standard central line placement kit. We will use the terms central line and triple lumen catheter (TLC) interchangeably in this article.
Fig. 6. Equipment needed for TLC.
Fig. 7. Open one of the individual packages that come with the SiteRite machine and inspect the content. Each package is one-time-use only.
Fig. 8, 9, 10, 11. Open the standard TLC placement kit and inspect the content. You have to know what each part of the kit is used for.
Fig. 12, 13. Take a look at the guide wire.
Fig. 14, 15. Lidocaine is used for local anesthesia.
Fig. 16, 17, 18, 19. Fill the wells of the kit with normal saline and flush the TLC.
Fig. 20, 21, 22, 23, 24. Check the needles and syringes (three of each).
Fig. 25, 26. Inspect the patient, check the anatomical landmarks.
Fig. 27, 28, 29. Disinfect the skin and apply the local anesthesia.
Fig. 30. Apply the sterile ultrasound gel on the skin.
Fig. 31, 32, 33, 34. Put the sterile plastic cuff around the non sterile ultrasound probe.
Fig. 35, 36. Inspect the head of the ultrasound probe, position the groove to point upwards.
Fig. 37, 38, 39. Monitor the ultrasound screen during the procedure. Once you have found the IJ vein, proceed as usual (described in the captions on the photos).
Fig. 40, 41. Start the "real thing" - look for the vein with the big needle (strategy one), or with the smaller guide needle first (strategy two).
Fig. 42, 43, 44, 45, 46. Thread in the guide wire.
Fig. 47, 48
Fig. 49, 50, 51, 52. Pass the dilator over the guide wire.
Fig. 53, 54, 55, 56. Pass the TLC over the guide wire.
Fig. 57, 58, 59.
Fig. 60, 61. Flush the TLC to make sure that all 3 ports are patent.
Fig. 62, 63, 64. Suture the TLC in place.
Do not forget to put the needles in the sharp objects collector box. Order a CXR to rule out a pneumothorax and write a procedure note.
Introduction of infection
Write a procedure note which documents the following:
Indications for the procedure
Relevant labs, e.g INR/PTT, platelet count
Procedure technique, sterile prep, anesthetic, amount of fluid obtained, character of fluid, estimated blood loss
Central Line Placement (with and without ultrasound guidance). A Chapter in MeisterMed's Procedure Series for PDA. V. Dimov, B. Altaqi, 2/20/2007.
Central Venous Catheterization. NEJM, 2007 (paid subscription required).
Ultrasound Guidance of Central Vein Catheterization - The evidence base of the procedure is discussed in the patient safety report of the Agency for Healthcare Research and Quality (AHRQ).
Ultrasound-Guided Central Venous Cannulation. Society of Cardiovascular Anesthesiologists.
Handheld “Vein Finder” for Faster, More Accurate Injections. Georgia Institute of Technology.
Central Venous Access. eMedicine, July 29, 2005.
Central Venous Catheterization: Concise Definitive Review. Medscape, Critical Care Medicine, 05/16/2007 (free registration required).
Placement of a Femoral Venous Catheter. NEJM, 06/2008.
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