Central Line Insertion

Introduction

Preparation

Tilt the head end of the bed down by 10°–15°.
Draw up 10 ml of lidocaine; raise a bleb on the skin with a blue 27-gauge needle.
Infiltrate local anaesthetic all around the site, working down toward the vein. Pull back on the plunger before injecting each time to ensure that you don't inject into the vein.
Open the central line pack and take all of the items out. Ensure that the wire moves freely on its reel – you will need to advance the wire one-handed.
Flush each port of the central line with saline or heparin saline, and close off each line except the distal (usually brown) line; the wire threads through this line.
Attach a syringe to the large needle provided

Procedure

Palpate the carotid artery with your left hand, covering the artery with your fingers. Insert the needle 0.5–1 cm laterally to the artery, aiming at a 45°angle to the vertical. In men, aim for the right nipple; in women, aim for the iliac crest. Advance slowly, aspirating all the time, until you enter the vein. If you fail to aspirate blood after entering 3–4 cm, withdraw, re-enter at the same point, but aim slightly more medially
When the needle is in the vein, ensure that you can reliably aspirate blood. Remove the syringe, keeping the needle very still, and immediately put your thumb over the end of the needle.
Insert the wire into the end of the needle, and advance the wire until at least 30 cm are inserted.
Keeping one hand on the wire at all times, remove the needle, keeping the wire in place. Make a nick in the skin where the wire enters the skin. Insert the dilator over the wire and push into the skin as far as it will go. Remove the dilator.

Insert the central line over the wire. Keep one hand on the wire at all times. When the central line is 2 cm away from the skin, slowly withdraw the wire back through the central line until the wire tip appears from the line port. Hold the wire here while you insert the line. Leave a few centimetres of the line outside the skin. Withdraw the wire and immediately clip off the remaining port.
Attach the line to the skin with sutures. Tie loosely so as not to pinch the skin; this causes necrosis and detachment of the line. Clean the skin around the line once more, dry, and cover with occlusive dressings.
Ensure that you can aspirate blood from each lumen of the line, then flush each lumen with saline or heparin saline.

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