Central Line Procedure Overview

Introduction

• Discussion on central line placement with Dr. Frankel as a model.
• Focus on the right internal jugular central line.
• Importance of preparation and patient positioning.

Patient Preparation

• Move bed to allow ample room at the head.
• Elevate bed for a comfortable height.
• Place patient in Trendelenburg position to engorge neck veins.
• Remove headboard, slide the patient up, and tilt the neck gently.

Identifying Landmarks

• Use ultrasound for placing the central line.
• Traditional method: two heads of the sternocleidomastoid muscle form a triangle for vein location.
• External jugular visible but not the target.

Equipment Preparation

• Use a central line kit, but verify its contents.
• Additional items needed: ultrasound, sterile probe cover, dressing, and possibly a compass pressure transducer.
• Familiarize with kit contents: drape, prep stick, lidocaine syringes, finder needles, guide wire, dilator, knife, saline flushes, caps, suture needle driver, catheter fastener, sterile dressing, and probe cover.

Procedure Steps

1. Prep and Drape
   • Follow sterile technique when prepping and draping.
   • Prime equipment like the catheter and guide wire.
2. Ultrasound Guidance
   • Use ultrasound to confirm site before puncture.
   • Apply sterile gel and cover probe.
   • Confirm site again with ultrasound.
3. Needle Insertion and Guide Wire
   • Inject lidocaine.
   • Insert finder needle under ultrasound guidance until venous blood appears.
   • Stabilize needle, feed guide wire through it.
   • Confirm wire placement with ultrasound.
4. Catheter Insertion
   • Make small skin incision with an 11 blade.
   • Dilate skin and subcutaneous tract with dilator.
   • Feed catheter over wire and insert to desired depth.
5. Final Checks
   • Secure catheter with fastener and suture.
   • Apply sterile dressing.
   • Call for x-ray to confirm placement.

Alternative Central Line Sites

• Left Internal Jugular: Similar technique but sharper turn into SVC.
• Subclavian Lines: Increased comfort, lower infection risk; risk of pneumothorax.
  • Can be blind or ultrasound-guided.
• Femoral Line: High infection risk but usable in emergencies.

Tips and Considerations

• Confirm placement of guide wire via ultrasound and other indicators.
• Always control the guide wire to prevent it from being sucked into the vein.
• Adjust catheter depths based on patient height.
• Common insertion depths: right IJ at 16 cm, left IJ at 19 cm.
• Use personal tips and experience to improve technique.

Conclusion

• Encouragement to comment on tips or questions.
• Plans to revisit and expand on central line topics in future content.
• Final note: "dominate the day."