📿 Chapter 136: Central Venous Line

Indications · Sites (femoral, IJ, subclavian) · Seldinger technique · Ultrasound guidance · Central line bundle · Complications (pneumothorax, infection, thrombosis) · CVP monitoring

🔍 Core Concepts: Central Venous Line

📌 Indications
Vasoactive/inotropic drugs, TPN, CVP monitoring, hemodialysis, difficult IV access, transvenous pacing, massive resuscitation.
📍 Common Sites (order of preference in children)
Femoral (easy access, compressible, but higher infection), Internal jugular (ultrasound-guided), Subclavian (lower infection but pneumothorax risk).
🔧 Seldinger Technique
Needle → wire → dilator → catheter. Ultrasound guidance reduces complications. Confirm tip position with X-ray (SVC/IVC-RA junction).
🛡️ Central Line Bundle
Hand hygiene, maximal sterile barrier (cap, mask, sterile gown, large drape), chlorhexidine skin antisepsis, daily review of necessity, avoid femoral if possible.
⚠️ Complications
Pneumothorax (subclavian/IJ), arterial puncture, hematoma, infection (CRBSI), thrombosis, arrhythmia (wire too far), malposition.
📊 CVP Monitoring
Reflects right atrial pressure. Normal 2-8 mmHg. Trend more important than absolute value. Femoral lines overestimate CVP (below renal veins → higher saturation).
🧼 Line Care
Transparent dressing, daily inspection, hub disinfection with alcohol before access, remove as soon as not needed.

🩺 Stepwise Central Venous Catheter Insertion (Seldinger)

1
Prepare & consent
Explain procedure, obtain consent. Ensure correct site selection. Use maximal sterile barrier (cap, mask, sterile gown, gloves, large drape). Chlorhexidine skin prep.
2
Ultrasound guidance (if available)
Identify vein (collapsible, non-pulsatile) vs artery (pulsatile, non-compressible). Mark site. Use sterile probe cover.
3
Needle insertion & wire placement
Local anesthesia. Insert introducer needle at 30-45° (femoral/IJ) or horizontal (subclavian). Aspirate venous blood (dark, non-pulsatile). Advance guidewire with minimal resistance. Monitor ECG for arrhythmias (wire too deep).
4
Dilatation & catheter insertion
Small skin nick. Pass dilator over wire (screw motion). Remove dilator. Thread catheter over wire. Remove wire. Aspirate all ports (confirm venous blood). Flush with saline.
5
Secure & confirm position
Suture catheter. Apply sterile transparent dressing. Obtain chest X-ray (for IJ/subclavian: tip in SVC above RA; femoral: tip in IVC/RA junction). Transduce to confirm CVP waveform.