Internship & Residency
Central Line Placement

Dr. Karl Newman

Central venous catheter or "central line" placement is an essential skill learned by medical and surgical trainees. Although challenging, this maneuver often provides the only form of IV access for patients, and it can be life-saving.

This month, QFever!'s I&R correspondent, Dr. Karl Newman, shares some of his central line secrets.

---

Ah, central lines!

How many times has a nurse come up to you on rounds and said: Mr. Smith's IV just came out for the 96th time… I think he needs a central line!!

If you're like me, you tell her you'll come back and put it in after Radiology Rounds. As long as she doesn't realize that Radiology Rounds only happen on the second Tuesday of the month, you're fine!

But what if the nursing staff does catch on? What if it is the second Tuesday of the month? In such situations, you may actually need to crack open one of those dusty ol' kits from the stockroom, blow your nose, meditate, bathe, and... get ready to put in a central line!

Step 1: Jugular? Femoral? The Vein That Comes Out On Your Forehead When You're Pissed?

Huh? Sure. Deciding where to place the central line is the first question.

Placing it carefully on the patient's windowsill allows you to tell the nursing staff that you're gonna put it in any time now. Eventually their patience will run out though, and you'll need to put it in the patient.

You need to put it in one of the big veins in the neck or groin. Which always makes me wonder… if these things are so damn big, how come you can't see Sylvester Stallone's subclavian vein in the Rambo movies, when all his other, supposedly smaller veins are standing out all over the place? Ah well, a question for another day!

So you can put this catheter in the neck, under the clavicle, or in the groin. But how do you choose? All these vessels have pros and cons… for example, internal jugular catheters can cause a pneumothorax, but are easier to keep clean than femoral ones.

Given that you're screwed whatever you do, I usually just play Rock-Paper-Scissors with the medical student… I win, we do the neck; he wins, we do the subclavian. And of course, if we both win, we go for the groin (the patient's, not each others'!)

2. Find the Vessel

Wha...? Yeah! Here's where you gotta know your anatomy. Sure, I hear ya. Learned it for the USMLEs, and it's all long gone. Fair enough. But you still gotta learn the importance of anatomical landmarks. I always try to look for accessory nipples, since their prescence means your patient is a witch or a warlock, and can use magical spells and potions to help make sure you hit the vessel.

Start by getting the patient to turn his or her neck to the side. The internal jugular lies at a point midway between the heads of the sternomastoid muscle, just above the clavicle. See it? Yeah? Yeah, right. Fine. Whatever!

OK, now use a small "finder" needle to locate the vessel. Pull back on the syringe…if you get bright red, pulsatile blood, consider a different career, ya clumsy jackass.

Pull out and apply pressure. Try again… this time, it's a rich, yellow substance… tastes like… custard! Mmmm! Just like Momma used to make it!

3. Insert and Secure That Line

Whazzat? Sure thing. Once you know where the vessel is, you can insert the big-ass needle that comes in that kit. Thread the guidewire down through the needle, and dilate up the incision. Pass the central line in over the wire, and remove the wire.

The central line should still be visible. If you've threaded the whole damn thing down into the person's neck, call a good lawyer and pray to God/Allah/Yahweh/The Snake Prince of Darkness. What the hell were you thinking? Makes for a great X-ray though, eh?!

Quick note: Remember that "flush with heparin" has nothing to do with hospital plumbing. Trust me on this.

Now, secure the line. If you're uncomfortable with your suturing skills, use some duct tape or twine.

4. Time for Da Chest X-Ray!

I always remember about pneumothoraxes using this handy little 'pmnemonic':

The only thing that rhymes with Pneumothorax
Is the Dr. Seuss book The Lorax

If there is a pneumo there, don't panic. If it's a small one, it'll probably go away by itself. If it's big, the patient may require a chest tube. A large pneumothorax may result in a resonant "percussion note" when the patient is struck with a mallet or drumstick. Avoid drumming on the patient repeatedly, however, as this can cause bruising (just ask my Uncle Morty!).

Subcutaneous air from a pneumo can result in crepitus, which is a crunchy feeling that occurs when you press on the patient. The only other thing that causes this is a massive snack-food overdose.

Well, you did it! now you can pat yourself on the back for a job well done, and head back to your call-room for some well deserved rest. So until next time, I'm issuing a call to the next generation of medical trainees to:

Turn on, tune in, and don't drop a lung!

Just tell 'em Dr. Karl sent ya!

---