You will need your central line kit and full sterile procedure equipment plus:

High frequency (linear) probe

(linear) Sterile ultrasound sheath cover and sterile gel packet

It is best to approach CVC placement in the same manner every time so you develop a streamline process that is efficient and avoids errors of omission:

Choose your vessel.

This will likely be situation dependent. For example, if your patient is in a c-collar or has a very short neck, you may want to avoid the internal jugular. Or if it is a crashing patient, the femoral vein might be ideal since it requires less set up time and is technically easier to cannulate. The subclavian approach is an excellent line but probably should be performed once you have a bit of experience with ultrasound guidance under your belt.

Evaluate the vein with ultrasound.

It would be a shame to completely set up your sterile field and drape, only to find out that there is abnormal anatomy or clot in the vein preventing you from obtaining access. For this reason it is critical to evaluate your target vein prior to prep. Be sure to identify your target and compress the vein completely to ensure that there is no clot within the lumen. If you are having trouble distinguishing vein from artery here are a few tips:

Valsalva : Have the patient bear down. This will increase intra-thoracic pressure, decrease venous return, and therefore plump up your vein as you are viewing it under ultrasound.

: Have the patient bear down. This will increase intra-thoracic pressure, decrease venous return, and therefore plump up your vein as you are viewing it under ultrasound. Augmentation and Doppler: You can turn on color doppler to assess flow through vessels on your screen. The artery will have a pulsatile flow pattern while the vein will appear as more of a mosaic, continuous flow. If you are having trouble seeing flow through the vein, try squeezing the extremity distal to your vein (augmenting the flow) and you will see increased color through the vein.

Prep for your procedure.

Proper sterile technique is of upmost importance when placing a CVC as blood stream infections are not uncommon. Complete surgical prep is necessary including a full surgical sterile drape, full personal sterile equipment and proper prep of the patient with chlorhexidine. You will also need to use a sterile ultrasound probe cover and sterile ultrasound gel packet. As you know, placing the sterile US probe cover can be tricky if your alone. Refer to our previous post on how to prep for sterility, as well as how to properly set up your US machine.

Dynamic ultrasound guidance for placement.

The argument for short axis versus long axis technique for CVC placement continues to wage on. Many ultrasound operators prefer the short axis view as they are most familiar with this technique and initially it requires less dexterity. However the long axis view provides better full needle visualization as it enters the vein lumen. A recent study that was just published, looking at long axis versus short axis for IJ & subclavian CVC placement, found that the long axis view was more efficient and required less redirection for internal jugular cannulation. It also found that during subclavian CVC cannulation, there were fewer posterior wall penetrations. That being said, it seems that long axis should result in fewer complications such as arterial puncture or pneumothorax, though this really has not been confirmed in a solid study. Ideally, you really should be familiar with both approaches.

Once you are familiar with ultrasound guidance for procedures, the technique for needle guidance and cannulation is similar across the the various central venous access points other than anatomy and probe placement. The Sonosite videos for internal jugular, subclavian, and femoral CVC cannulation are excellent for this purpose and are only 1.5 minutes each. They demonstrate the short axis technique however long axis would only require rotating the probe 90 degrees while directly over the vein. Check out each of these for proper probe placement and pertinent ultrasound anatomy.