Definition
It refers to insertion of a central venous catheter (IV catheter designed for the purpose) into a large central vein with the catheter terminus usually near the right atrium.
Purpose
- To obtain measurements of central venous pressure.
- To administer drug preparations harmful to smaller lumen peripheral veins (e.g., potassium chloride, dopamine, etc.)
- To administer large amounts of fluids in short time (e.g., for hypovolemia patients).
- To have a long-term IV access.
- To administer parenteral nutrition.
- To administer chemotherapy.
- For insertion of a pacing wire.
Contraindication
- Mastectomy on the same side of the client’s body.
- Known allergy to tubing.
- Central Venous Catheters (CVC)
The major types of central venous catheters include:
- Non-tunneled central catheters
- Tunneled central catheters
- Peripherally inserted central catheters
- Implantable ports.
The type of CVC to be used depends on:
- Type of drug administered
- Previous devices and complications
- Length of therapy (short-term/long-term)
- Patient preference.
Single and multi-lumen catheters are available in all the types of central venous catheters.
Catheters have openings at different positions along their length
- Proximal (nearest to patients’ external surface)
- Medial (in the middle)
- Distal (farthest away from patient’s external surface). 3
This decreases the risk of drug and fluid incompatibilities which can be harmful to the patient.
Catheters also have clamping devices and “on-off” switches, used when disconnecting lines to prevent air emboli formation .
Central Venous Catheter Insertion Sites
The aim is to place a catheter into the superior or inferior vena cava, just above the right atrium. The sites of choice are the
- Subclavian vein
- Jugular vein.
These allow easiest access and impede patient’s mobility least. Other potential sites are the:
- Brachial vein
- Femoral vein
- Median and basilic vein.
Articles
- Sterile gloves.
- Dressing pack containing gallipots, swabs, kidney tray.
- Sterile gown.
- Mask.
- Sterile prep solution (betadine alcohol).
- 10 mL syringe for anesthetic.
- Local anesthetic (1% lidocaine).
- 20 mL syringe (to aspirate and flush the line).
- Sterile normal saline (as flush solution).
- Central line pack-includes introducer needle, and syringe-a long Venflon for external jugular cannulation, wire,
- Sheathed blade, dilator line, flexible line, half-clamp and rigid suture clamp.
- 2-0 suture material with curved cutting needle (might be included in the kit).
- Mefilm dressing (Transparent, flexible and breathable dressing).
- Three-way taps (for a triple-lumen line).
Procedure
| Nursing action | Rationale | |
| 1 | Before procedure Explain to patient how the procedure will be carried out and the sensation he would feel during insertion. Obtain verbal consent. | Reduces patient’s anxiety and enhances cooperation. |
| 2 | Check physician’s written order for type of catheter and number of lumens. | Ensures accurate type and style of catheter is inserted |
| 3 | Assemble articles at the bedside and make provisions for privacy. | Provides for smooth performance of the procedure. |
| 4 | During procedure Wash hands, don sterile gloves. | Reduces spread of microorganisms. |
| 5 | Position patient to lie flat with a slight head-down tilt. Turn head to left and slightly up. | Helps easy identification of land marks for cannulation of central vein. |
| 6 | Clean the neck and upper chest with betadine followed by alcohol and drape with sterile towel. | Minimizes risk of contamination, helps create a sterile field to work. |
| 7 | Assist physician with administration of local anesthesia. | Minimizes pain sensation for patients. |
| 8 | Attach a 10 mL syringe to the needle. Physician inserts the needle into the select central vein. The needle is advanced while aspirating continually. | Easy aspiration of dark-colored venous blood indicates that the needle is in the correct location. |
| 9 | Once the physician is reasonably certain that the needle is within the lumen of the vein, the syringe is removed and the guidewire is inserted in the needle. | |
| 10 | Once the wire is positioned, physician withdraws the needle. Provide physician with a #11 scalpel blade (if not supplied in the kit) Physician makes a small nick in the skin over the guide wire. | Small nick over the guidewire permits insertion of dilating device. |
| 11 | Physician passes the dilating device down the wire and inserts it fully into the vessel lumen. Nurse assists by holding the patients head steady | |
| 12 | Physician removes the dilating device and inserts the central venous catheter by passing it down the guide wire and into the vessel. | |
| 13 | Physician removes the guidewire and confirms the position of catheter by aspirating blood from the catheter. | |
| 14 | Provide physician with sterile normal saline/heparin flush solution to flush the catheter to keep the lumen patent | |
| 15 | Assist physician to secure the catheter in place with sutures. | Sutures ensure positioning of the catheter |
| 16 | Provide physician with three way taps to attach to each lumen. Ensure every port is flushed. | Prevents clogging of catheter lumens. |
| 17 | Assist physician in applying sterile Mefilm dressing over the catheter insertion site. | Sterile dressing minimizes entry site infections. |
| 18 | After procedure Reposition the patient. Discard waste, wash and replace reusable articles | |
| 19 | Arrange for a portable chest X-ray to be obtained if prescribed by physician. | Chest X-ray helps ensure proper central venous catheter placement. |
| 20 | Record in the nurses notes, date and time of catheter insertion type of catheter inserted, the insertion site, chest X-ray result and how the client tolerated the procedure. | Helps communicate information to health professionals. |
Geriatric variation
Elderly clients may not tolerate lying supine, while the central venous catheter is being inserted. Variation of client positioning may be made.
Paediatric variation
As children have smaller veins, shorter and smaller number catheters need to be selected.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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