Central Line
Insertion
Secure central venous access for vasopressors, resuscitation, dialysis & monitoring — the ultrasound-guided internal jugular approach, done safely.
🔴 The one rule that prevents disaster
Confirm the guidewire is in the vein — not the artery — before you dilate. Use ultrasound (long-axis) and/or manometry. Arterial dilation of the carotid or subclavian is catastrophic. Use maximal sterile barrier precautions, Trendelenburg to prevent air embolism, and never let go of the wire.
- Vasopressor / inotrope infusion
- Poor / failed peripheral access
- Large-volume or rapid resuscitation
- Haemodialysis · RRT · plasmapheresis
- TPN or irritant / vesicant infusions
- CVP / ScvO₂ monitoring
- Transvenous pacing · PA catheter
- Repeated venous sampling
- Overlying infection / cellulitis
- Target-vein thrombosis or stenosis
- Severe coagulopathy (relative)
- Distorted anatomy · prior surgery / radiation
- Uncooperative patient (relative)
- SVC obstruction
- Subclavian: avoid in coagulopathy (non-compressible) & precarious respiratory state
- Int. jugular — US-friendly, compressible, low pneumothorax. ED 1st line.
- Subclavian — lowest infection & DVT, but ↑ pneumothorax
- Femoral — fast in arrest; avoid where possible
- CVC kit — catheter, introducer needle, J-tip guidewire, dilator, #11 blade, syringes
- US machine + linear probe + sterile sheath & gel
- Maximal sterile barrier — cap, mask, sterile gown & gloves, full-body drape
- Chlorhexidine 2% in alcohol
- 1% lignocaine + syringe
- Sterile saline to prime & flush all lumens
- Suture / securement + chlorhexidine dressing
- Pressure tubing / manometry to confirm venous
Real-time ultrasound
Standard of care for IJ. Reduces failed attempts, arterial puncture & misplacement. Identify vein vs artery first.
🟢 LITFL · ATS · meta-analyses
Maximal sterile barrier
Cap, mask, sterile gown & gloves, full-body drape + chlorhexidine. The core of the CLABSI bundle.
🟢 IHI / CDC bundle
Confirm wire is venous
Before you dilate — confirm the wire sits in the vein (long-axis US) ± manometry. Arterial dilation can kill.
🟢 ASRA · PubMed (US wire confirm)
Trendelenburg + CXR
Head-down fills the IJ/SC vein & prevents air embolism. Post-procedure CXR confirms tip & excludes pneumothorax.
⚪ Standard practice · radiology
Position & pre-scan
- Supine, Trendelenburg, head turned slightly away
- Pre-scan both IJs — size, patency, vein vs artery
Sterile barrier
- Cap, mask, gown, gloves; full-body drape
- Chlorhexidine prep; sterile probe sheath
Local anaesthetic
- Infiltrate 1% lignocaine at skin & track
US-guided puncture
- Vein = compressible, non-pulsatile
- Needle under direct vision → aspirate dark blood
Confirm venous
- Dark, non-pulsatile blood
- Manometry / transduce if any doubt
Thread guidewire
- Seldinger — advance the J-wire
- Watch ECG; withdraw if ectopics
Confirm wire in vein
- Long-axis US — wire inside the vein
- NOT carotid / subclavian artery
Nick & dilate
- Small skin nick with #11 blade
- Dilate the tract over the wire
Railroad catheter
- Advance over wire; remove wire
- Aspirate & flush all lumens
Secure & CXR
- Suture; chlorhexidine dressing
- CXR — tip at cavoatrial junction; exclude pneumothorax
External educational video — tap to play an embedded YouTube clip by Dr Ki-Jinn Chin (not produced by ED AI Tutor). Watch on YouTube ↗ · always confirm technique against your local protocols.
Confirm it's venous
- Dark, non-pulsatile blood on aspiration
- Manometry — low, non-pulsatile column (not a bright pulsatile geyser)
- Long-axis US — wire sits within the vein
- If any doubt: do not dilate — transduce or re-image
Tip position on CXR
Watch for & after
- Pneumothorax — CXR or US lung sliding (IJ/SC)
- Air embolism — keep head-down; occlude open hubs
- Arrhythmia — wire/tip too deep → withdraw
- Aspirate & flush all lumens; correlate function
- Daily line review — remove ASAP
- Arterial puncture / dilation feared
- Pneumothorax / haemothorax
- Air embolism
- Arrhythmia (wire too deep)
- Infection / CLABSI
- Venous thrombosis
- Malposition · nerve injury · wire loss
- Pre-scan both IJs — pick the bigger, patent vein
- Vein = compressible & non-pulsatile; artery = not
- Confirm the wire is venous before dilating
- Never let go of the guidewire
- Watch the ECG — withdraw the wire for ectopics
- Trendelenburg fills the vein & prevents air embolism
- Maximal sterile barrier, every time
- Always CXR after IJ/SC — tip + pneumothorax
- Remove the line as soon as it's not needed
- Femoral is often preferred in arrest / small children — compressible, away from the airway
- Right IJ also used; ultrasound strongly preferred
- Use the smallest appropriate catheter; weight-based depth
- Confirm tip position on CXR; vessels are small & collapse easily
| Weight | Catheter |
|---|---|
| Neonate / < 5 kg | 4 Fr |
| 5 – 15 kg | 4 – 5 Fr |
| > 15 kg / adult | 5 – 7 Fr |
Guide only — confirm with Broselow / local & RCH / Starship guidance.
ED AI Tutor — ED Procedures Series · v0.1 · For clinician education only. Not a substitute for clinical judgment, local guidelines or senior oversight. Always verify catheter sizes, depths and contraindications against current institutional protocols.
