Vascular Access Equipment and Setup

MicHael Moore

Izumi Harukuni

▪ INTRODUCTION

Anesthesia can be administered in multiple ways; however, regardless of the type of anesthesia, it is imperative to obtain vascular access to provide anesthesia care. The purposes of obtaining vascular access during anesthesia are (1) administration of fluid, (2) administration of medications, (3) administration of blood products, (4) blood sampling for laboratory testing, and (5) monitoring of hemodynamic parameters. Different types of vascular access may be required for each of these different activities. This chapter discusses the preparation, technique, and complications of different types of venous and arterial access. In addition, the associated equipment, setup, and troubleshooting for each technique are discussed as well.

▪ PERIPHERAL INTRAVENOUS CATHETER

Definition and Indications

Peripheral intravenous (PIV) catheters are short, thin tubes (catheters) that are inserted into a peripheral vein (intravenous [IV]). Peripheral veins are those veins that are on, or near, the surface of the arms, hands, legs, and feet. The major deep vein in the leg and groin region is the femoral vein (FV), and it is considered part of the central venous system. PIV catheters are commonly used as they are usually easy to insert and associated with minimal complications. About 95% of hospitalized patients have PIV catheters. PIV catheters are usually placed in peripheral and superficial veins in the upper extremities. In some patients, they need to be placed in the lower extremities due to limitations or difficulty in obtaining access in the upper extremities (e.g., bilateral arm surgery may prevent extremity access; all the peripheral veins in the arms have been damaged).

PIV catheters vary in length. According to Poiseuille’s law, the rate of fluid flow that can be delivered through a tube is related to the diameter and the length of the tube, the pressure gradient (from one end of the tube to the other), and the viscosity of the fluid moving through the tube. The effect of the diameter of the tube on fluid rate is exponential to the fourth power. This means that a doubling in the diameter of a tube would result in a 16-fold increase in fluid rate (2⁴ = 16). Therefore, small changes in the diameter of a PIV catheter will result in large changes in how fast fluid can flow through the catheter. The flow rate in a tube is inversely proportional to the length of the tubing. For example, doubling the length of the tubing cuts the flow rate by half. Taken together, fluid runs faster through a larger diameter and shorter length catheter.

By convention, most catheters and needles in health care are sized according to the “Stubs iron wire gauge system,” which was first used to quantify the thickness of metal wire. In this inverse system, the smaller the “gauge,” the larger the diameter. When labeling catheters, the gauge is shortened to G. For example, a 14-gauge (14G) catheter is larger than a 20G catheter (Fig. 34.1). This can be confusing because there is a difference if you are referring to the actual gauge of a catheter or the Stubs gauge of a catheter. The actual gauge of a 14G catheter is approximately 2 mm. The actual gauge of a 20G catheter is 1 mm. When someone asks you for a larger gauge catheter, which should you get, the 14G or the 20G? By convention, when health care providers refer to smaller or larger “gauge,” they are referring to the actual size of the needle or the catheter. When they specify a number with gauge (e.g., 14G), they are referring to the Stubs gauge. Depending on the situation and purpose,
the practitioner will decide on the size of the PIV catheter depending upon the desired potential flow rates required and the viscosity of the fluid to be used. Blood is much more viscous than saline and would run more slowly through the same tubing. If blood products or large volumes of fluids may need to be administered in a case, the anesthesia provider would opt for larger bore (smaller G) catheters.

▪ FIGURE 34.1 Peripheral intravenous catheters. Becton-Dickinson Insyte Autogurad catheter in different sizes. The yellow catheter is 24G, the blue is 22G, the pink is 20G, the green is 18 G, the gray is 16G, and the orange is 14G.

The indication for the placement of PIV catheters include

Administration of fluids
Administration of medications
Blood transfusion
Blood sampling for laboratory testing

Contraindications for PIV catheters depend upon the site where the IV line will be placed. Common contraindications include

Massive edema
Burns or injury
Insertion site distal to the potential vascular injury (i.e., access in lower extremities when the patient sustained abdominal or thoracic trauma)
Local infection
Existing arteriovenous fistula
Previous radical axillary dissection

PIV Catheter Equipment

All of the necessary materials and equipment should be available, prepared, and assembled at the bedside prior to placement (Fig. 34.2). Basic equipment includes the following:

▪ FIGURE 34.2 Setup for peripheral intravenous catheter placement.

Appropriate size IV catheters (14-24G), at least two or three in each size. The full range of catheters should be available in the anesthesia cart; however, in most circumstances, it is not necessary to bring the full range of sizes to the bedside during a catheter insertion. The providers will have chosen a particular size they would like to insert. That size, and a couple of smaller catheters, should be ready at the bedside. The smaller catheters are ready in case the provider cannot locate a vein that can accommodate the desired size catheter. Two or three sizes of each of the appropriate catheters should be available in case more than one attempt at cannulation is necessary or a catheter is defective or inadvertently becomes unsterile.
Nonlatex tourniquet
Alcohol or chlorhexidine swab
Sterile or nonsterile gauze
Transparent dressing
Adhesive tape
IV fluid bag with IV infusion set (flushed with fluid) or saline lock (short tubing flushed with saline and saline syringe). Note that there are different types of IV sets that are used for different purposes. See Associated Equipment section below for additional information.
3-mL syringe with a small needle (25G or 30G) and 1% lidocaine if local anesthesia at the insertion site is desired.
In rare cases, an ultrasound or other device may be necessary to assist in peripheral vein location.

To prepare the IV infusion set, first, remove the protective cap on the IV fluid bag. Close the flowregulating clamp on the infusion set and insert the uncapped “spike” into the receptacle on the fluid bag. When “spiking” the bag, care should be taken that the spike on the infusion set remains sterile and does not touch anything other than the inner portion of the receptacle on the fluid bag. Once spiked, hold the fluid bag and drip chamber in an upright position and fill the drip chamber with fluid up to half of the chamber by squeezing the drip chamber a few times. Then, hang the bag on an IV pole and slowly open the regulating clamp to flush the entire tubing with fluid. While flushing, tap the tubing, stopcocks, and ports to remove small air bubbles trapped in these places. It is imperative to de-air the tubing when preparing the IV set for pediatric patients or adults with an intracardiac shunt (i.e., patent foramen ovale, atrial or ventricular septal defect) as even a small amount of air entering systemic circulation may cause an air embolism to vital organs.

Technique for Placing PIV Catheters

Choosing the site and appropriate superficial vein is the first and most important step in placing PIV catheters. Superficial veins in upper extremities are the first choice unless there are contraindications. Generally, the most distal peripheral sites are chosen as the first attempt. This allows the practitioner to move to a more proximal site if the initial attempt fails (cannulating a vein distal to a recent prior attempt that drains the same vein can lead to fluid and medications leaking out of the prior cannulation site). In situations requiring large-bore IV access, such as trauma or cases in which the provider is anticipating significant blood loss, the median cubital vein is often preferred. These veins are usually large and stable. Unfortunately, infiltration (fluid or medications leaking out of the vein) can be harder to detect. In the circumstances where the veins of the upper extremities are not accessible, the saphenous vein of the lower leg or the veins of the lower leg and feet are the next choices. In difficult cases with poor peripheral venous access, the use of transillumination or an ultrasound-guided technique may be necessary.

As with any other invasive procedures, universal precautions should be applied in placing PIV catheters (see Chapter 24). Because infection rates from PIV catheters are very low, full sterile technique is not necessary; however, the site is still prepped with alcohol and care is taken to maintain the sterility of the catheter and needle. Nonsterile gloves must be worn, and eye/face protection is recommended. A gown should be considered in special circumstances.

PIV Catheter Procedure

Tightly apply a tourniquet to the extremity above the site (Fig. 34.3).
Identify the vein by visualization and/or palpation.
Cleanse the site with alcohol or chlorhexidine using an expanding circular motion.
In awake patients, consider infiltrating local anesthesia (i.e., 1% lidocaine with a 27 or 30 gauge needle) in the subcutaneous tissue at the insertion site, being careful not to enter the vein.
Unpack the needle catheter and inspect for any defect.
Insert the catheter (you will observe blood in the flow back in the needle hub chamber) and then advance the needle catheter a short distance into the vein (2-3 mm). Slide the catheter off the needle into the vein.
Release the tourniquet and retract the stylet needle (any sharp material should be discarded in the appropriate sharp container, including safety needles). Blood in catheter hub should be observed (Fig. 34.4).
Connect the IV set tubing or saline flush and ensure the correct placement of the IV catheter (observe free drip of fluid in the drip
chamber or flush without resistance or signs of infiltration).
Secure the catheter with a clear adhesive dressing (e.g., Tegaderm). The clear dressing allows for future inspection of the insertion site (Fig. 34.5) (some practitioners prefer to place a piece of tape over the catheter hub before applying the adhesive dressing).
Secure the IV tubing with tape over the skin. After applying the tape, check the security of the tubing, the connection to the catheter hub, and if fluid is infusing properly.
Adjust the flow rate with a regulating clamp.

▪ FIGURE 34.3 Peripheral intravenous catheter placement: Preparation. The tourniquet is placed proximal to the venipuncture site.

▪ FIGURE 34.4 Peripheral intravenous catheter placement: Completing insertion. Once the catheter is in the vein, release the tourniquet. The blood in the hub of the catheter confirms that the catheter is in the correct position.

Removing PIV Catheters

When a PIV catheter is no longer required, it is malfunctioning (infiltrating or occluding), or any complication is identified, the catheter should be removed.

Stop fluid infusion by occluding the regulating clamp.
Remove the tape and Tegaderm.
Place gauze over the IV site and remove the catheter while applying gentle pressure to the insertion site to stop any bleeding. You may need to apply pressure for 3-5 minutes until bleeding stops. Then, secure the gauze over the site with tape.

Complications of PIV Catheters

Complications related to PIV catheters include the following:

Bleeding from the vein may result in bruises or a hematoma.
Local infection at the insertion site
Phlebitis/thrombophlebitis: inflammation or clotting (thrombosis) of the vein. Infiltration: leakage of fluid or medication into the subcutaneous tissue. Depending on the pH and other properties of the fluid or medication that has infiltrated into the subcutaneous tissue, infiltration may cause inflammation or even tissue necrosis. If a large volume of fluid infiltrates, it may result in compartment syndrome (severe swelling in the extremity, causing compression of blood vessels and potentially cutting off the blood supply to the extremity or tissues).

▪ FIGURE 34.5 Peripheral intravenous catheter placement: Saline flush. The catheter is secure with Tegaderm and the tubing is attached. The blood is now flushed with saline.

Troubleshooting PIV Catheters

Regardless by whom and where PIV catheters are placed, monitoring for proper functioning and any signs of complications should be performed on a regular basis.

Patient response: If the patient does not respond as expected to a medication administered through a PIV catheter, this may be the first sign that the IV is obstructed/kinked or has become disconnected or dislodged or is infiltrating (the medication is going into the subcutaneous tissue and not the vein).
Inspect the IV bag to make sure that it is not empty.
Inspect the insertion site for signs of infection or infiltration.
Inspect the fluid flow rate by observing the drip chamber (flow rates are frequently adjusted during cases and the provider may
forget to return the flow rate to a desired level after making an adjustment). Also, checking that the IV fluid is flowing normally is reassuring that the IV line has not become disconnected or infiltrated.
Check the drip chamber to make sure it is half full and air cannot get into the infusion tubing.
It is also wise to keep IV lines labeled and untangled to prevent the injection of medications or infusions into the wrong IV. Administration ports should be readily accessible.

▪ CENTRAL VENOUS CATHETER

Definition and Indications

“Central lines” or central venous catheters (CVCs) are invasive catheters placed directly into the patient’s central venous circulation. There are a variety of locations, methods of placement, and types of catheters available for use depending on the clinical circumstance. The choice of location and type of line can have a dramatic impact on proper patient care. Prior to setup, confirm the desired line type and location with the placing provider.

Ideal placement of a central line leaves the catheter tip at a location in the superior vena cava, approximately 3-5 cm above the right atrium (RA), or the cavoatrial junction. This is always confirmed by chest x-ray some time after insertion. This location allows administration of medications with negligible circulation times so as to speed their onset. Based on their presence in the central circulation, central lines are a convenient location for blood sampling (discussed elsewhere in this chapter). With all blood returning to the heart via the inferior and superior vena cavae, the unique location of central lines also allows sampling of mixed venous blood for determination of SCVO₂, or central venous oxygen saturation. While the uses of this laboratory value are beyond the scope of this chapter, it is important to be aware of this if assisting in blood sampling (see Chapter 9).

The most common site for placement of a central line remains the internal jugular vein (IJV) in the neck. From the right side of the neck, the cavoatrial junction lies at a depth of approximately 16-18 cm from the right and 19-21 cm from the left side of the neck of adults. This difference is important to note as certain catheters may not have sufficient length for proper placement in the vein if using the left rather than the right side. Importantly, subclavian insertion locations affect the length of the catheter insertion similarly. Using a subclavian central line approach, the cavoatrial junction lies at a depth of approximately 13 cm from the right and approximately 16 cm from the left side of the chest wall (see below for proper placement location on the chest). A nice trick to estimate proper depth can be done by placing a catheter or a piece of string on the patient’s chest from the insertion site to approximately 2-3 cm below the sternomandibular junction and then measuring the length.

While it is possible to place these catheters using physical landmarks, current recommendations are that internal jugular lines be placed using ultrasound guidance. The use of ultrasound in the placement of the central lines has been found to decrease catheter-related complications and time of insertion in some studies.

Central Venous Anatomy

There are multiple locations for central line placement. This chapter provides brief anatomic descriptions of the three most common approaches.

Internal Jugular Anatomy

The IJV is the primary draining vein from the head and leaves the skull at the level of the jugular foramen. It follows into the neck, entering the carotid sheath along with the common carotid artery, vagus nerve, and deep cervical lymphatics (Fig. 34.6). The vein traverses below and medial to the sternocleidomastoid (SCM) muscle, to enter the anatomic triangle bound by the two muscle bodies of the SCM and the clavicle (an important fact for placing central lines). The IJV then joins with the subclavian vein (SCV) to form the innominate vein near the medial edge of the anterior scalene muscle. The innominate vein then follows into the superior vena cava entering the heart.

Subclavian Vein Anatomy

Primarily draining the upper extremities, the SCV is a continuation of the axillary vein. Importantly, it is attached by fibrous tissue to the posterior aspect of the clavicle for approximately 3-4 cm. These attachments do not allow the vein to collapse even in severely hypovolemic patients, making this technique beneficial in such situations. After passing medial to the clavicle, the SCV joins the IJV to form the innominate
vein at the level of the sternoclavicular junction, then passing into the heart as the superior vena cava (Fig. 34.7). It is important to note that the subclavian artery, brachial plexus, phrenic nerve, and internal mammary artery lie just posterior to different regions of the SCV and are separated by the anterior scalene muscle, making damage to these structures a potential complication. Just inferior to the SCV lie the pulmonary apex and pleura, creating a higher potential for pneumothorax with this technique.

▪ FIGURE 34.6 Internal jugular vein anatomy. (With permission from Moore KL, Dalley AF. Clinical Oriented Anatomy. 4th ed. Baltimore, MD: Lippincott Williams & Wilkins; 1999.)

Femoral Anatomy

The FV anatomy is quite simple, which makes accessing this vein easier than many others. As a continuation of the popliteal vein from the lower extremity, the FV enters the femoral sheath in the thigh and continues to the level of the inguinal ligament (Fig. 34.8). Passing underneath this ligament, the FV becomes the external iliac vein, which then travels along the psoas muscle to join with the contralateral external iliac vein, forming the inferior vena cava. The femoral approach takes place in the inguinal region at the level of the femoral sheath. It is important to note that the femoral artery and nerve lie just lateral to the FV in this region, allowing for potential damage to these structures with a femoral access technique. The term NAVeL is a useful mnemonic for remembering the relative femoral anatomy. From lateral to medial —Nerve, Artery, Vein, empty, Lymphatics (Fig. 34.8).

CVC Types

Triple-Lumen Catheter (Fig. 34.9)

Size:	7-French catheter with three lumens (proximal white and blue 18G, distal brown 16G)
Length:	15, 20, and 30 cm
Benefits:	Provides ability to infuse multiple medications simultaneously and monitor the central venous pressure (CVP) Provides access to ports for blood sampling
Negatives:	Does not allow rapid infusion of IV fluids

CVC Introducer (Fig. 34.10)

Size: 8-10	French single-lumen catheter typically used as a sheath for hands-free triple-lumen or pulmonary artery catheter (PAC) insertion. It has an infusion side port.
Length:	10 cm
Benefits:	Provides ability to rapidly infuse large amounts of IV fluids or blood products through the infusion side port. The main valved channel can be used to insert a PAC or hands-free catheter.
Negatives:	Larger dilator with increased risk of injury to the cannulated vessel, especially if inadvertent intraarterial cannulation. By itself, it only provides one port for infusion. Insertion of a secondary catheter (hands-free triple-lumen or PAC) into the main introducer lumen decreases the flow rates that can be delivered through the infusion port.

▪ FIGURE 34.7 Subclavian vein anatomy. (With permission from Moore KL, Dalley AF. Clinical Oriented Anatomy. 4th ed. Baltimore, MD: Lippincott Williams & Wilkins; 1999.)

Hands-Free CVC (Fig. 34.11)

Single- or multilumen catheters are inserted through a CVC introducer and locked in place.

Size:	Vary, typically a 7 French double or triple lumen is used.
Length:	15-30 cm
Benefits:	Allows addition of a multilumen catheter to an introducer without additional skin and vessel puncture. Can be removed, while leaving the introducer in place (reduces the risk of CVC rupture).
Negatives:	When inserted into a CVC introducer lumen, it decreases the flow rates that can be delivered through the infusion port. The lock is not tight enough and has a tendency to be pulled out with tension.

Peripherally Inserted Central Catheters

These are longer, thin catheters typically placed by IV therapy teams in the hospital when long-term IV access is required or the patient has difficult venous access. As the name implies, they are placed peripherally, typically in the antecubital, basilic, or cephalic veins.

Size:	2-6 French (adult and pediatrics)
Length:	Vary by individual (typically 35-45 cm)
Benefits:	Provides long-term venous access without additional punctures Provides access to central circulation without risks of CVC placement
Negatives:	Length and size limit flow rates (cannot be used for rapid infusion). Catheters are prone to clots and kinking.

▪ FIGURE 34.8 Deep femoral vein anatomy. (With permission from Moore KL, Dalley AF. Clinical Oriented Anatomy. 4th ed. Baltimore, MD: Lippincott Williams & Wilkins; 1999.)

Tunneled CVC Ports

These are surgically placed, most often for infusion of chemotherapy and other caustic medications for long-term use. The infusion port is usually placed under the skin on the chest wall and can be accessed by placing a needle through the skin.

CVC Indications

Delivery of vasoactive medications
Monitoring of intravascular volume
Access for frequent blood draws
Access for PAC
Inability to obtain peripheral venous access
Access for special CVC for potential aspiration of a venous gas embolus
Access for insertion of cardiac pacemaker wires or catheters
Access for long-term chemotherapy or parenteral nutrition
Access for dialysis or plasmapheresis
Infusion of medications that are irritating to peripheral veins

▪ FIGURE 34.9 Triple-lumen central venous catheter.

CVC Equipment

Much of the equipment required for central venous access is contained in specialized kits. Contents of CVC kits vary slightly according to the type of catheter included in the kit. In addition, many manufacturers allow institutions to customize the contents of the kits. A description of a generic kit is included below.

Generic CVC Kit (Fig. 34.12)

CVC or CVC introducer
0.032″ diameter threading wire (straight of J-tip), usually contained within a special sheath
7-French dilator
Scalpel
18G thin-walled needle
22G “finder” needle
16G or 18G catheter-over needle
10- to 12-mL syringe (may be a special syringe that allows placement of the wire through the plunger)
Suture (possibly straight or curved)
Needle driver
Caps for infusion port
Gauze and sterile dressing material
Manometry tubing (may or may not be included in kit)
Large sterile drapes (may or may not be included in kit)
Prep sticks and solution (may or may not be included in kit)
Local anesthetic (1% lidocaine), 25G needle, and a 5-mL syringe (equipment for local anesthetic infiltration may or may not be included in the kit)

▪ FIGURE 34.10 Sheath introducer.

▪ FIGURE 34.11 Hands-Off double-lumen central venous catheter.

▪ FIGURE 34.12 Central venous catheter insertion kit.

Additional equipment for CVC insertion that is usually not included in the kit:

Linear-array ultrasound with nonsterile ultrasound gel (nonsterile gel may be used for a “prescan” performed prior to the actual procedure). Sterile ultrasound gel is required for the actual procedure.
Sterile gown, mask, gloves
Sterile towels and sterile gauze pads
Pressure transducer setup (if needed)
Mobile table for setup of equipment
Sterile saline flushes
Sterile sleeve for the ultrasound probe
Sterile ultrasound gel
Additional sterile caps

Technique for CVC Insertion

The first steps are to assemble and prepare the necessary equipment for CVC placement. These steps are described below:

Position the patient in 15 degrees of Trendelenberg for SVC or IJV placement (increases the size of the veins). Confirm with the provider if the Trendelenberg position is desired.
Turn on the ultrasound machine and place in position for easy viewing by provider.
Place a mobile table on the side of the provider’s dominant hand for ease of access.
In sterile fashion, open a central line kit, making sure not to touch the contents. Often, the providers will organize the contents of the kit how they prefer once it is opened. In other institutions, the anesthesia technician will don sterile gloves and organize the kit contents.
Place two sterile saline flushes and sterile ultrasound sleeve and gel onto the sterile field.
Some providers prefer to “prescan” the anatomy with the ultrasound before prepping the patient. If so, turn on the ultrasound, place a small strip of gel on the probe and hand to provider.
Once the “prescan” is finished, wipe gel off area and ensure the region is clean and clear of any debris.
If placing in the IJV, turn the patient’s head slightly to the contralateral side. It may also be necessary to remove the patient’s pillow if it is tilting the patient’s head too far forward or is in the way of the neck. If the patient is intubated, the circuit tubing should be moved so that it is out of the way and secure. In all of these steps, care should be taken to avoid dislodging the endotracheal tube.
Using sterile technique, prep the region for at least 30 seconds. For IJV: prep from bottom of the ear to the clavicle and from the trachea to as far lateral as possible (Fig. 34.13). For SCV: prep from 1 to 2 inches above the clavicle to just above the nipple and from the anterior shoulder to the sternum. For FV: prep from just below the hip to approximately 6 inches below the inguinal crease and from medial groin to the lateral thigh.
Assist the provider with gowning and gloving. Tie the gown in the back. Do not touch the provider’s arms, hands, or chest. Make sure the provider is wearing a mask and loose ties are not hanging down.
Assist with draping, ensuring to only touch the underside of the drape when it is passed to you. Gently pull the drape until completely opened and the body covered (Fig. 34.14).
When the provider is ready, place a small strip of nonsterile ultrasound gel on the probe. The provider will place his or her hand into the sterile sleeve and will grab the probe from you. As he or she passes the end of the sleeve to you, grab the very end and pull along the length of the cable, making sure no uncovered portion of the cable touches the sterile
field (Fig. 34.15). Refer to Chapter 38 for the details on the operation of the ultrasound machine and transducer. The provider may ask for color Doppler during the procedure to confirm the location of vascular structures.
See below regarding the specifics of cannulating the vein and placing the catheter.
Once the vein has been entered and the guide wire is in place, the provider may ask you to take a picture with the ultrasound machine, showing the wire inside the vessel (Fig. 34.16). In many institutions, the picture is printed and placed in the patient’s chart. Ask the provider if a picture will be required and what to do with the print. In some institutions, the provider will want a personal copy of the print for anesthesia billing.
During insertion, the providers’ attention may be focused on the line placement itself. Periodically, review the patient’s status on the monitors and notify the provider of any significant changes in blood pressure, oxygen saturation, machine alarms, heart rhythms, etc. Be prepared to assist with drug administration (vasopressors or anesthetics) or adjustment of anesthetic agents if the provider requires it.
After the procedure is completed, carefully remove the drapes, making sure not to pull the line out and to avoid extubating the patient.
Connect the CVP transducer tubing to one of the flushed ports on the central line (preferably one of the 18G lumens), open all stopcocks, and zero the CVP transducer. Review the waveform and pressure reading (Fig. 34.17).

▪ FIGURE 34.13 Preparation of internal jugular vein: The skin is prepped with tinted chlorhexidine swab from just below the right ear and chin to the right nipple crossing the midline.

▪ FIGURE 34.14 Full-body drape. Patient’s entire body should be covered with a drape.

▪ FIGURE 34.15 Ultrasound transducer is covered in sterile sheath for use in the sterile field.

▪ FIGURE 34.16 This photograph is the still shot of the ultrasound machine screen that demonstrated the presence of the wire in the internal jugular vein. The photograph is taken and placed in patient’s chart for the documentation. This is required for the billing of ultrasound-guided central venous catheterization.

Provider Technique for Placing a CVC

The details of the placement of the central line are intended to give the anesthesia technician a basic understanding of the procedure. This information will help you to be able to assist the provider as needed, particularly if in your institution, the anesthesia technician gowns and

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