Placement of central venous catheters is a fundamental procedure for critical care, allowing infusion of nasty meds, reliable venous access, and high-volume fluid resuscitation. The basic technique has been described many places, although perhaps we’ll do our own tutorial sometime. The subtler maneuvers that help smooth over everyday challenges and add the last 1% to your game are harder to come by, however, usually passed down by bedside demonstration and word-of-mouth instruction.
Let’s discuss a few tricks and concepts you may not have encountered. I am indebted to David Lichtman and the procedure service at Hopkins for many of these pearls.
1. Don’t touch something without doing something
Novice proceduralists are notorious for taking three hours to place a routine line. If you stick your head into the room, you’ll discover why: they are sorting through their kit like a monkey investigates a box of used electronics, picking things up and then immediately putting them down again. This is because they haven’t yet internalized their process, so they don’t know what they want to use until they see it.
The fix: don’t touch something without doing something to it. Either throw it away (if it’s not needed), prepare and position it for full readiness (retract the wire, flush the lumens, prep your syringe), or use it. Discard, prep, or use. No other options. This way, even if you blindly wander through your whole kit, you’ll only do it once.
2. Stick as low as possible
For internal jugular and femoral lines, generally speaking, the lower the better.
Most often you see IJ lines placed somewhere in the mid-neck. With an ultrasound, this is easy to do, but has two downsides: it is hard to dress cleanly, and also tends to “piston” the line in and out of the SVC whenever the patient rotates their head. You’re better off sticking the IJ as low as possible, just above the clavicle. This is more challenging, because you quickly lose sight of the vessel, and the lung is closer and easier to nick, but you get a more stable line, and a cleaner, flatter site away from facial hair and secretions. It becomes an almost-subclavian.
Along the same theme, femoral lines are most often placed in the crease of the hip, where the vessels are most superficial and the pulses palpable. With ultrasound, however, you can move more distally. The vessels quickly dive deep, and in larger patients may become unreachable, but patients with a reasonable body habitus will usually permit a femoral line several centimeters down the leg, or even further. Although this is more work, and occasionally you’ll experience difficulty threading your wire (due to accessing a smaller, more valvular vein), the result is a much cleaner, more easily-dressed site, away from the moist, stool- and urine-contaminated groin.
3. Minimize punctures for bleeding-prone patients
Patients prone to bleeding, such as those with coagulopathies, low platelet counts, or undergoing anticoagulation, warrant a technique that uses only a single puncture of the skin.
Use a micropuncture needle if available. Do not infiltrate lidocaine beforehand; instead, load your micropuncture needle directly onto a syringe full of lidocaine. Under ultrasound, advance into the skin, aspirating as you go, and injecting a small bleb of lidocaine every few millimeters. Enter the vessel—you will not inject lidocaine here, but even if you do, it should not be a harmful dose—and introduce your wire as usual. Do not make a scalpel-nick; dilate directly from the wire.
Once the line is placed, do not suture the hub, which creates multiple needlesticks that may bleed forever. Instead, use a sutureless securement device (such as the StatLock).
4. Embrace the side position for upright IJs
IJ lines are often the easiest to teach, since ultrasound makes them so approachable. However, compared to the elegant subclavian, they lend themselves to awkward and inelegant positions.
Reaching the head of the bed and situating the patient sufficiently near the edge can be challenging in the ICU. Solution: don’t bother. Stand at the side of the bed instead, as if performing a subclavian. This is easy for left IJs (for right-handers), although harder for right IJs as it involves crossing the hands.
The great benefit here is that it facilitates leaving patients seated upright. Patients with pulmonary edema may not tolerate lying supine, never mind in Trendelenburg. Keep them upright and do your IJ from the side (these patients are often fluid overloaded and the vessel will be plump); you simply must maintain scrupulous care to cover your ports and avoid air embolism. (At the expert level, with some additional safeguards, you can even place these on patients seated in a chair!)
Sometimes, a compromise can be reached by leaving the patient seated partially upright, but placing the entire bed into Trendelenburg—aka the Pringle maneuver.
5. Obtain an intra-procedural x-ray for perfect placement
Various techniques can be performed to verify venous placement of a line, but most of us still use a chest x-ray to confirm tip placement close to the right atrium-SVC junction. Unfortunately, this often tells the story “too late.” If the line is deep, the dressing must be taken down and the line withdrawn, which is an inconvenience, and it will never be as sterile as it was. If too shallow, you must rewire it, which is dirtier still.
A better maneuver: order your portable x-ray early. If you time it correctly, the tech will arrive moments after you place your catheter. While you remain sterile, they can slip their plate under the drape, snap an x-ray, and—if your equipment allows—you can check placement immediately on their portable display. Make any necessary adjustments and repeat.
6. Master the art of draping
Several techniques can improve your drapery skills.
For conscious patients, don’t drape first, even though the drape may be on top of your kit. Move it away until your equipment is fully prepared, then drape last. This minimizes their claustrophobic time under the sheet.
When initially placing your drape, fold it in your hand like a book. This allows you to see your placement and position it perfectly over your site. Fold vertically for subclavians and femorals; for an IJ, fold diagonally for the best fit into the neck crease. Good positioning and adherent edges make a big difference to a clean, sterile procedure.
Once a full-sized drape is placed, you can have your assistant lift the far edge of the drape (e.g. the left side if placing a right-sided line) and hang it onto the hook of a nearby IV pole. This creates a “tent,” similar to the one anesthesiologists live behind. It gives the patient more air and gives the nurse—or the x-ray tech—easy access to the patient.
7. Master the art of suturing
You can suture better.
Do not suture directly onto your catheter. Instead, take a bite of the skin, and tie an “air knot” onto nothing. At first, tie this over a spacer—the dilator is the perfect size—allowing you to cinch down onto something which can then be extracted, leaving a small gap. (Eventually, you will be able to tie these without the spacer.) Once you’ve tied an air knot with 4–5 throws, take your tails and tie those onto the catheter.
The advantage? Now you can crank down as hard as you want, fully securing your knot, without cinching down onto the skin itself. This avoids ischemia, a real possibility from too-tight knots, and also makes them easier to remove, since there will be enough slack to get scissors into.
If you are not fully advancing your catheter to the hub, and are hence using the two-part clip device to hold your position at the skin, be smart. Place the first rubber piece onto the catheter and suture one side only. Then, clip on the outer piece, and place a second suture through both pieces on the opposite side. The advantage: if you check your placement and discover that your line needs to be withdrawn, none of these sutures need to be cut. Simply take down your dressing and flip up the outer piece of the clip (it will hinge over its single suture). This will free the catheter to slide within the inner piece. Once repositioned, snap the outer piece back down. (These clips are not 100% reliable, so you should also be suturing the wings on the hub itself. Hence, unless you can elegantly rearrange the new slack, those may still need to be cut.)
8. Master your dressings
Leave your site as clean as possible to limit infection risk.
Once you have sutured your line, hold pressure for at least several seconds; otherwise your suture-points may “ooze,” ruining your dressing. Then clean the entire area with chlorhexadine, including each piece of the hardware. If grossly bloody, clean first with a saline-damp gauze, otherwise you will quickly soil your chlorhexadine.
Wait until your chlorhexadine dries. This is to allow kill time, but also because dressings do not stick to wet surfaces. If using a Biopatch, place this next.
Finally, the most essential step: prep the skin. Tincture of benzoin, “barrier cream” (used by nursing), or other preps are available. Some are bacteriostatic, but most importantly, they are sticky, and help your dressing actually stay in place. Without this, particularly in moist areas, dressings tend to fall off immediately, and a non-occlusive dressing is not a dressing at all. Prep all around the site and carefully place your dressing to cover all puncture points.
What do you think about these tips? Any arguments? Have some of your own? Post in the comments!
For conscious patients, I take a second nasal cannula, crank it up to 10L, and tape it to the patient’s chin. The cool air blowing over their face reduces the heat and claustrophobia caused by the drape.
I like it! Although I do wonder if your drapes is not well-adhered (especially dor IJ sites) if the “breeze” might tend to introduce some contamination to your field.