Central Line Placement/ Removal

Patient Considerations

• Indicated for difficulty obtaining peripheral IV access (Central Line), chronic antibiotic therapy, TPN, chemotherapy; end-stage renal failure

• Disease Specific Considerations: malignancy, chronic illness/infection, renal failure

Surgical Procedure:

• Duration: 20-90 min

• Position: supine, arms usually tucked. Make sure IV remains patent. Surgeon will ask for Trendelenburg to increase preload volume, thereby filling the jugular veins for better visibility on ultrasound and improve chances access.

• Antibiotic: usually Cefazolin 30mg/kg is acceptable, ask surgeon. Double check medical record to ascertain if patient is currently on antibiotic therapy and the last dose.

• EBL: minimal, single IV access usually sufficient (however, be cognizant of blood loss throughout the procedure. There can be a considerable amount lost after removing the wire and exchanging/ threading the catheter. Particularly with subclavian access it is not possible to occlude the vessel to minimize blood loss.)

• Equipment: standard monitors, **monitor ECG for arrhythmias/ectopy as the guide wire is passed. Special consideration for the use of fluoroscope to guide placement and X-ray to confirm placement=have lead apron + thyroid shield for protection.

Case Planning

• Specific or Unique Room Set-Up Requirements

  • Airway:

    • GETA is preferred for pediatric central line placement.

    • Flexible LMA may be used for line removal.

  • Drugs/Infusions: local anesthetic, Propofol, fentanyl. Paralytics not necessary, but patient movement should be avoided with deep anesthesia as to avoid inadvertent puncture of other vessels or pleura (subclavian approach).

  • Monitors: standard, **monitor ECG for arrhythmias/ectopy as the catheter travels within the cardiac chambers.

Anesthetic Considerations

• Induction: mask induction vs IV induction

• Positioning: supine, Trendelenburg (see notes above)

• Maintenance

  • Maintenance of Anesthesia

    • Hemodynamic/Physiologic goals: maintain hemodynamic stability. Appropriate fluid resuscitation will assist with access.

  • Surgical Considerations. (see notes above)

• Emergence/Disposition: awake or deep

• Post-Op Pain Management:

  • Local anesthetic per surgeon, consider short acting narcotics and NSAIDs/Acetaminophen

Case-Specific Complications: infection, pneumothorax, thrombosis, arterial puncture, local bleeding