In emergency medical practice, there are three possible sites for CVL placement in the adult patient. Each has advantages and disadvantages. The placement sites include the internal jugular vein, femoral vein, and subclavian vein. The right internal jugular vein and left subclavian vein are the most direct paths to the right atrium via the superior vena cava. The femoral veins are compressible sites and as such may be more appropriate for coagulopathic patients. The subclavian vein approach is at higher risk for pneumothorax than the internal jugular vein approach. Ultrasound guidance can be very helpful in all approaches and is the recommended approach. However, when ultrasound guidance is not feasible for various reasons, such as the emergency nature of a procedure, lack of equipment, or a patient's anatomy in a situation where there is limited room for the ultrasound transducer in the subclavian approach while manipulating the needle, CVLs may be placed using anatomical landmarks without ultrasound.
There are many different indications for placing a CVL, but in emergency medicine, the most common indications include:
Contraindications include distorted local anatomy (such as for trauma), infection overlying the insertion site, or thrombus within the intended vein. Relative contraindications include coagulopathy, hemorrhage from target vessel, suspected proximal vascular injury, or combative patients.
Most central line kits include:
In addition, the operator will require a sterile gown, cap, sterile gloves, sterile gauze, sterile saline, face mask, and a sterile cleansing solution such as chlorhexidine. The operator should ensure that ultrasound, sterile ultrasound gel, and a sterile ultrasound probe are part of the setup as well.
Place the patient in the appropriate position for the site selected, then prepare the site in a sterile fashion using the sterile solution, sterile gauze, and sterile drapes. For the internal jugular and subclavian approach, place the patient in reverse Trendelenburg with the head turned to the opposite side of the site. For the femoral vein, place the patient in the supine position with the inguinal area exposed; this usually means the target leg should be bent at the knee with the lateral aspect resting on the stretcher or bed. It is recommended to place the patient on cardiopulmonary monitoring for the duration of the procedure.
The steps are as follows:
Potential complications should be explained to the patient if possible while obtaining informed consent. Complications include pain at cannulation site, local hematoma, infection (both at the site as well as bacteremia), misplacement into another vessel (possibly causing arterial puncture or cannulation), vessel laceration or dissection, air embolism, thrombosis, and pneumothorax requiring a possible chest tube.
Clinical pearls for consideration:
Central lines are inserted by many healthcare professionals. However, the monitoring of these lines is usually done by the nurses. The site of entry has to be kept clean and the nurse has to monitor it for signs of infection. Depending on which location the line was inserted, complications also have to be monitored like a pneumothorax, hematoma, bleeding or extravasation. In general, healthcare workers should avoid lines in the groin for more than 24-48 hours as they are prone to infections and also make it difficult for the patient to ambulate or get out of bed. To ensure good practice and limit complications, most hospitals now have a team of healthcare professionals who are in charge of central line insertion and monitoring. Such universal practice has been shown to limit infections. (Level V)
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