EMERGENCY DEPARTMENT · WALL POSTER

Central Venous Catheter (CVC) — Triple Lumen Catheter

STEPS · ◆ KEY STEP — LOGGED WITH ITS TIME

SITE, POSITION & PREP

Right IJ or femoral as first choice. After a failed IJ attempt, make the next attempt on the same side.
Supine, head neutral, Trendelenburg for IJ or subclavian. Pre-scan the vein.
Full sterile prep and drape; sheath the probe; flush all lumens; anesthetize skin and track.

SELDINGER — STEP BY STEP

Puncture under real-time ultrasound at ~45°, tracking the tip, until dark flash.
Drop the angle, stabilize, occlude the hub, thread the J-wire to ~15 cm. Never force it.
Never let go of the wire. Remove the needle over it.
Confirm the wire in the vein in transverse and longitudinal planes before dilating.
Nick the skin ~0.5 cm beside the wire, then dilate only the first third to half.
Depth: right IJ ~13 cm · left IJ ~15 · right SC 13–15 · left SC 15–17 · femoral 20.
Withdraw the wire out of the distal (brown) port — check the whole wire is out and on the tray. ◆ CATHETER IN — WIRE OUT
Aspirate then flush every lumen; non-return cap on each.
Secure: two sutures + Biopatch + Tegaderm.
Confirm: CXR for IJ or subclavian — tip at the cavoatrial junction, no pneumothorax.

EQUIPMENT

The right catheter: triple-lumen 7 Fr, 15–20 cm for drugs/monitoring; 8.5 Fr introducer sheath (Cordis/MAC) for volume resuscitation — or the combination AVA 3Xi device, see the Resuscitation Line; 12 Fr dialysis catheter where needed. The set includes 18 g introducer needle + syringe, J-tip guidewire, dilator.
Ultrasound + high-frequency linear probe, sterile probe cover and gel.
Full barrier: gown, gloves, cap, mask, large drape. Dressing tray, 600 mL bowl, 150 mL gallipot.
Skin prep: chlorhexidine 2% in 70% alcohol, or povidone-iodine.
Sharps and syringes: disposable 10/11 scalpel; 2× 10 mL + 1× 5 mL Luer-lock syringes; 18 g blunt, 21 g, and 25 g needles; lidocaine 1%.
To finish: lay it all out and count before draping.

IN THE KIT — 8 ITEMS · ROOM 7 (RESUS BAY) CABINET · VASCULAR ACCESS

Triple-lumen catheter 7 Fr, 15–20 cm ×1
Sterile probe cover + gel ×1
Scalpel No. 11 blade ×1
Luer-lock syringes — 2 x 10 mL, 1 x 5 mL ×3
Needles — 18 g blunt, 21 g, 25 g ×3
Suture 3-0 non-absorbable + needle driver ×1
Biopatch + Tegaderm 10x12 and 6x7 ×1
Non-return valve caps ×1

ALSO NEEDED — NOT IN THE KIT

Full barrier kit and chlorhexidine 2% in 70% alcohol from the shelf. Ultrasound from the bay.
DRAFT — not yet assembled or signed off. If the line is for volume rather than drugs and ports, use the Resuscitation Line.

FIGURE

Right IJ preferred — anterolateral to the carotid, compressible, straight run to the SVC. Never advance the needle toward the carotid. Same two devices, same drawing, same colors as the Resuscitation Line, with a different emphasis. This card is the triple lumen: three ports for drugs and monitoring, each of them flow-limited. If the line is for volume, use the introducer, not a bigger CVC.

WIRE IN ~15 CM · SKIN NICK 0.5 CM

DEPTH: RIJ 13 · LIJ 15 · R-SC 13–15 · L-SC 15–17 · FEM 20 CM

FLOW: 7 FR TLC ~1.6–3.1 L/H BY LUMEN VS 8.5 FR SHEATH ~7.6 L/H

CAUTION: INR >3.0 OR PLATELETS <20

PITFALLS & PEARLS

Losing the guidewire intravascularly — one hand on the wire at all times, and count it out at the end.

Dilating before two-plane wire confirmation → arterial dilation, the injury that matters.

Threading the wire too deep → ventricular ectopy/arrhythmia — stop near 15 cm.

Relying on a triple-lumen for massive transfusion.