Insertion technique

The Seldinger technique (described below) is safer than the 'catheter-over-needle' technique and should generally be used in ICU patients.

1. Use aseptic technique throughout. Clean area with antiseptic and surround with sterile drapes. Anaesthetise local area with 1% lidocaine. Flush lumen(s) of catheter with saline.

2. Use metal needle to locate central vein.

3. Pass wire (with 'J' or floppy end leading) through needle into vein. Only minimal resistance at most should be felt. If not, remove wire and confirm needle tip is still located within vein lumen. Monitor for arrhythmias. If these occur, wire is probably at tricuspid valve. Usually responds to retracting wire a few cm.

4. Remove needle leaving wire extruding from skin puncture site.

5. Depending on size/type of catheter to be inserted, a rigid dilator (± preceded by a scalpel incision to enlarge puncture site) may be passed over the wire to form a track through the subcutaneous tissues to the vein. Remove dilator.

6. Thread catheter over wire. Ensure end of wire extrudes from catheter to prevent accidental loss of wire in vein. Insert catheter into vein to depth of 15-20cm. Remove wire.

7. Check for flashback of blood down each lumen and respiratory swing, then flush with saline.

8. Suture catheter to skin. Clean and dry area. Cover with sterile transparent semipermeable dressing.

9. A CXR is usually performed to verify correct position of tip (junction of superior vena cava and right atrium) and to exclude a pneumothorax. Unless in an emergency situation, a satisfactory position should generally be confirmed before use of the catheter.

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