Like the thoracocentesis chapter, the purpose of this summary is to unite the information which is otherwise contained in numerous widely spread-out sources. The main audience would probably be the CICM supervisor of training who would need something akin to a reference manual in order to be able to assess the trainee who needs their WCA form filled out. Alternatively, the trainee doing the WCA might benefit from the bibliography at the end of this chapter (but probably not from the chapter itself). Past paper SAQs rarely touch on this, but Question 15 from the second paper of 2015 had asked about the potential complications of CVC insertion.
What one might describe as "required reading" for this topic consists of the following resources, themselves concise literature reviews:
These are 25 and 14 pages, respectively. Of the two documents, the ANZICS Guideline is probably better referenced, but the NSW Health policy is more detailed. Additional resources could include the paywalled treasure chest of UpToDate ("Overview of Central Venous Access"). A free (and excellent) resource which offers excellent detail about the actual technique of insertion is the Central Venous Access document by Rigby et al (undated), from Queen's University in Canada. As far as peer reviewed literature goes, nobody describes the technique better than Bannon et al (2011). Good articles describing PICC insertion are more difficult to track down; Dawson et al (2011) seems to be the most comprehensive.
The ANZICS guideline defines a central line in terms of tip position; "the device must terminate in one of the great vessels ... or in or near the heart to qualify as a central line".
Greater vessels, for the purpose of this definition, are also listed by ANZICS:
Basically, the definition is based on rates of blood flow, which is a function of vessel caliber as determined by the Hagen-Poiseuille equation. Paul Marino's The ICU Book contains Table 2.1 (Ch. 2, 3rd edition, p.18) which lists the blood flow rates through various central veins, albeit without any reference as to where he got these numbers from (presumably, he measured it himself). This table's values are reproduced below:
|Superior vena cava||1800-2000 ml/min|
|Inferior vena cava||1200-2000 ml/min|
|Femoral vein||700-1100 ml/min|
|Internal jugular||500-1400 ml/min|
|Subclavian vein||350-800 ml/min|
There are only a few strong reasons for the insertion of a central venous access device:
Extended indications also include:
Generic contraindications to CVC insertion at any site include:
At various sites, other contraindications can be invented, but they would all fall into the categories of "some bone broken or deformed near the site" or "the site itself is infected". For example, a previously fractured clavicle or severe kyphosis with forward rotation of the shoulders us a relative contraindication to subclavian line insertion. The possibilities are too numerous to list for all possible sites.
The NSW Health policy lists a series of factors which should be "considered" before inserting a CVAD, without offering much guidance on how one should react to them. These factors included:
The same policy also has some selection criteria for when to use one CVAD insertion site over another. To these, a few more suggestions have been added. The whole thing would benefit from a tabulated format where advantages and disadvantages of each site are listed.
What's best? The college declares "a preference for the subclavian vein in most patients", quoting Chittick et al (2010) who suggested this site to be the least likely to get infected and cause a reportable CLABSI. This was on the basis of conflicting evidence; not all the studies agree that the choice of site matters and in fact Deshpande et al (2005) found no difference between sites, apparently because highly experienced operators were inserting the lines. Presumably their aseptic technique was more microbicidal and the number of passes through the skin was lower.
The decision to insert a line on the left or right depends on a few considerations:
The general principles as outlined in the local policy:
Patients who should be considered for an expensive minocycline/rifampicin coated line are identified by the ANZICS guideline as follows:
All CVC packages should have some information regarding the number of lumens, priming volume and theoretical maximum flow rate:
An appropriate consent procedure would need to include the following important matters:
This information was collected from the QLD Department of Health website, where a comprehensive Central Vascular Access Device Insertion Consent Form is available.
Additionally, basic pre-conditions for consent must be demonstrated:
In accepting consent from a patient, we operate under the presumption of competence: i.e. patient is over 18 and is “duly qualified: having sufficient, capacity, ability or authority” to give consent. This is tested by the following criteria:
The NSW Health policy recommends a safe space which has specific characteristics.
You need to have access to:
These characteristics are shared by ED resuscitation areas, ICU rooms, operating theatres, as well as some anaesthetic bays, endoscopy suites, angiography and interventional radiology suites, and potentially other locations around the hospital. A reader has pointed out that whatever "electrical safety support" was supposed to be, it has disappeared from the NSW Health document and the ANZICS paperwork, suggesting that we either no longer care about these risks, or we are no longer equipped to discuss them.
Basically, the patient should be supine for just about every CVC insertion, except PICC. Femoral line insertion can be performed in a semirecumbent position, but also benefits from maximal flatness. In any case, the major guiding principle is to make the central vein in the region of interest the most dependent vein in the body, so that it dilates and makes puncture easier. In an intravascularly depleted patient, the veins will be collapsed unless it is possible to lay them head-down for CVC insertion. This is supposedly less likely in the subclavian vein, which is apparently "suspended" by soft tissue and is therefore less likely to collapse.
The practice of putting people in a Trendelenburg position has a dual purpose, of helping prevent air embolus. If the spontaneously breathing patient takes a deep sudden breath during an IJ venous puncture, they could potentially suck enough air into their central veins to fill the right ventricle. Air flow though a 14G needle can be approximately 100ml per second, according to Teichgräber et al (2004) who presented a case of CVC-associated air embolism to NEJM. Only approximately 100ml is required to fill the RV outflow tract and kill you.
How far head-down do you tilt them? The correct answer is probably "enough to get the veins to dilate, but not so much that they fall off the bed". The ideal position is a compromise between respiratory function, comfort, intracranial pressure and the sinister upward creep of neck fat and massive breasts. Bazaral et al (1981) tilted patients by 14 and found that this increased the crossectional area of the IJ by about 50%, which they said was similar to what you can expect from a Valsalva manoeuvre.
In addition to these concerns, each site has its own anatomical peculiarities which can be exploited to dilate or bring to surface the central veins in relation to surrounding structures.
To make IJ cannulation easier, Bannon et al (2011) recommend a neutral head position, or only as much head rotation as is required to give access to the neck (i.e. don't have the patient trying to bite their own shoulder). Turning the head away from the puncture actually impedes the procedure because it puts the vein directly under the sternocleidomastoid (making an anterior approach especially difficult). Sulek et al (1995) found CT evidence that a contralateral rotation beyond 40° also brings the carotid artery anteriorly, making it more likely to get in the way of the needle.
Ipsilateral arm traction: Anecdotes and non-peer-reviewed sources recommend pulling on the ipsilateral arm to lower the shoulder and make it easier to get under the clavicle without having to angle the needle posteriorly. However, Raju et al (2016) found that this position actually increases the rate of catheter malposition.
Towel under the shoulders: A major decision in positioning for a subclavian line is whether or not to retract the shoulders (eg. by shoving a rolled up towel between the scapulae). Bannon et al (2011) recommend a neutral position of the head and shoulders, quoting radiological evidence that in fact retraction of the shoulders tends to squish the vein between the first rib and clavicle, which will probably make cannulation more difficult. Having said this, notable authors swear by this technique. Bova et al (1996) found a statistically significant improvement in the rates of successful (within three passes) subclavian cannulation with the shoulders retracted which suggests that the difficulty of radiologically proven venous compression is overcome by some sort of other positive factors.
Which position is correct? Nobody can say. Bova et al used a single house officer to cannulate all of their patients, who may have had some considerable experience with one technique and not the other. Raju et al had a selection of experienced anaesthetists, and had so few complications in their small sample that it is difficult to discuss the superiority of one technique over the other.
Hair at the insertion site will interfere with your line insertion. Hair will prevent proper asepsis, trap blood and clot chunks, and then act as a barrier to applying your adhesive dressing. This hair should be removed using clippers as opposed to a razor. Tanner et al (2010) performed a meta-analysis and discovered that shaving increases the risk of operative site infections (the risk approximately doubles).
At minimum, you should have:
The NSW Health policy recommends all patients must have some ECG monitoring. Ones which have a reduced level of consciousness should have a blood pressure monitor and pulse oximetry at minimum.
ECG monitoring is essential because most techniques will at some stage result in the guidewire entering the heart and causing some irritation of the endocardium. Usually, this manifests as ectopics - for example, if in the ventricle, then these will be ventricular ectopics. These arrhythmias are in fact usually consequence-free, but Stuart et al (1990) caution regarding "a distinct possibility of a malignant arrhythmiabeing precipitated by a guidewire".
In addition to the NSW health guideline recommendation, the author would like to add a pressure transducer, which - it goes without saying- belongs in the room when you are going to be inserting a central line. Even if you do not plan to actually use the CVP, the trace and pressure are important means of confirming that you are in the correct vessel.
Local guidelines follow NICE and recommend that "ultrasound should always be used if available and the operator trained in the use" etc. This essentially says that if you are untrained in the use of ultrasound, it will not add any element of safety to your technique. Bannon et al (2011) add that "ultrasound does not obviate the need for anatomic knowledge" because you still need to know which way to safely aim your needle and which anatomical structures you are seeing on ultrasound.
Ultrasound guidance adds the following meaningful benefits to an already safe technique:
An exhausting long list of suggested equipment is listed in the local guidelines. Ideally the equipment should consist of the following minimum:
Here's one which was prepared with an almost ridiculous attention to neatness, as if for the purpose of some sort of equipment photoshoot.
The CVC packs may come with a Raulerson syringe. This thing is under patent held by Dr J.D. Raulerson (1989). In essence, the syringe has a hollow plunger which contains a valve preventing the aspiration of air into the patient. This hollow plunger can be used to introduce the guidewire without disconnecting the syringe from the needle. Though not everybody (anybody?) uses this technique, it could come in handy, for example in helping advance a guidewire by flushing ahead with saline (Pastewski et al, 2006). Most normal people, when faced with this proposition, would raise an eyebrow, as theoretically there is nothing stopping you from hydrodissecting a nice false passage for your guidewire using this method.
The NSW Health policy recommends a two-minute hand scrub. All sorts of local hand-wash policies are available, but for those who want to read more the WHO probably supplies the definitive international document for the rationale behind surgical scrub technique (Widmer et al, 2010).
The operator should dress up surgically:
The assistant should at least wear a surgical mask, a hat and eye protection.
The NSW Health policy has an entire appendix dedicated to choice of antiseptic solution. Bottom line, they recommend some sort of alcohol-rich chlorhexidine wash.
Apparently they found some sort of advantage in ditching povidone-based solutions. The recommended agent ended up being 2% chlorhexidine in 70-80% alcohol (ANZICS would be happy with a mere 0.5%). The recommendation to wait until they dry is again made here, even though it seems to have more to do with the risk of a diathermy-associated alcohol fire.
The NSW Health policy recommends "sterile drape/s fully covering the patient and their bed (unless this is impractical)". A lazy man might argue that it is always impractical to provide that much drape cover.
Here are some drape options for different sites:
Basic things recommended by ANZICS and UpToDate:
Generally, both experienced operators and inexperienced novices tend to benefit from some sort of order. This means lining the equipment up in a manner which represents the order of use. First the needle, guidewire, scalpel, dilator, CVC, flush, bungs and caps, then suture materials and instruments and finally the dressing. A trainee undergoing assessment who performs this ritualised "preparation of the altar" will score more highly by giving the impression of orderly calm.
On the other hand, the trainee whose equipment is strewn haphazardly across their sterile field will give the impression of being disorganised, no matter how technically competent they are. Moreover, a random pile of equipment gives rise to rooting behaviour mid-procedure, which generates errors. While looking for the guidewire in your pig sty of a sterile trolley, you might lose the needle position and need to re-puncture, which would be some combination of unsafe and inelegant.
The most detailed peer-reviewed (and freely available) publication regarding actual technique of central line insertion is probably this 2011 article by Bannon et al, the goal of which is made conspicuous by being published in Risk Management and Healthcare Policy.
The key landmarks are the borders of Sedillot's triangle, named after Charles Sédillot (1804–1883). Bannon et al recommend a somewhat lower approach than that which is commonly practiced by experienced ultrasound operators - 1/3rd of the way from the clavicle to the mastoid. These days most people recommend a halfway point. The closer to the clavicle you get, the more the lateral safety distance separating the carotid and the jugular vein; but also the closer you get to the apex of the lung. Ergo, the high approach has become popular with the ultrasound-savvy crowd, where carotid puncture becomes less of an issue (i.e. you can see it).
Three possible approaches exist:
Safety manoeuvres which are recommended include:
The infraclavicular approach is practiced by most sane people. It was first described by Dudrick et al (1968) in an effort to secure long-term access for TPN. The key landmarks are the junction of the lateral two thirds and the medial third of the clavicle.
Safety manoeuvres include:
Femoral vein CVCs canb be inserted using palpation alone, but ultrasound-guided methods are gaining popularity. Tke key landmarks are the inguinal ligament and the midpoint of the femoral arterial pulse. This has significant relevance to the CICM Fellowship exam; Question 3 from the first paper of 2005 asked candidates to "outline the anatomical structures relevant to the insertion of a femoral venous catheter."
Safety manoeuvres include:
This is an area of greater diversity, and there are more possible insertion sites peripherally which will all end up with the tip in the central vessels. However varied, there are still some standards to follow. Dawson et al (2011) describes the ideal area for PICC puncture as the site where the best ultrasound image of the basilic vein can be seen, which is approximately midway up the arm (approximately 12cm medial to the medial epicondyle of the humerus). Any closer to the axilla and you enter an area with a dangerous amount of microbial life and moisture; any closer to the elbow and you expose the catheter to flexion and possible migration/dislodgement/fracture. Local guidelines for PICC insertion appear to concur with Dawson at least to some extent, as they recommend a site of puncture somewhere above the cubital fossa.
A "pass" is described by the CEC as "each complete insertion of the needle that is intended to cannulate the central vein". Essentially, an otherwise suitably qualified but CVC-untrained person should only have a maximum of three of these passes. Why three?
Sven Ivar Seldinger published on this in 1953, bringing order into the previously lawless Mad Max-like wasteland of vascular catheter insertion (they were just shoving totally random tubing into people, like animals). Seldinger used a "flexible round-ended metal leader" to safely exchange an artery-puncturing needle for a flexible polyethylene catheter. "This technique is simpler than appears on paper and after a little practice should present no difficulties", he wrote. It is now used to introduce just about any sort of hollow object into just about any other hollow object.
In honor of the fact that Seldinger appears to have done his own illustrations for publication, they are reproduced here with all respect (and no permission whatsoever).
To assist insertion, the lumen of a CVC needle hub is tapered (which allows easier insertion of the guidewire) whereas many other needles will have a blunt cylindrical crossection of their hub, all the way to the needle.
A promotional propaganda article from Diagnostic and Interventional Cardiology (Fornell, 2011) discusses angiography guidewire technology in some detail. Perhaps more detail than is expected from CICM trainees in the middle of their program (and let's face it, cardiologists require much more performance from their guidewires than we do). The much more relevant 2015 article by Wolfram Schummer (2015) describes the mechanical properties of Seldinger guidewires we typically use for CVC insertion. Judging by the author's Figure 1, these properties were generally disappointing.
Basically, the following characteristics are expected of an ideal Seldinger guidewire:
These characteristics are met by the usual CVC guidewire. Flexibility is conveyed by the spiral coil construction of the outer wire; stiffness is conveyed by the core wire which does not go all the way to the tip. The tip is J-shaped and composed entirely of the coil, which makes it flexible and atraumatic. The distal end of the guidewire contains the core wire and is stiff all the way to its tip; this makes it easy to threat the line over it. It also makes it easy to perforate the vessel wall if you reverse the guidewire and shove the non-J-tipped stiff end into the needle. This is the wrong way to do it.
In summary, important things about handling the guidewire are:
Most health services have some sort of dedicated policy which specifically demands that the whole guidewire be visualised after insertion. This is because of problems which happened. Bad things clearly followed. Patients have re-presented to the ED weeks following central line insertion with J-wires eroding out of their groins.
So: important not to do that.
Apart from carelessly losing control of the guidewire, it is also possible to sever it:
Usually, the CVAD kit comes with a plastic taper-tipped dilator.
A dilator is required to create a tract which the (usually, soft) CVC cannot create by itself. This is supposed to be a subcutaneous tract. The dilator should never enter more than a few millimetres into the actual vein. Thus, it is important to remember that is is not necessary to shove it into the patient to the hilt. For instance, when inserting a right subclavian or left IJ line, the dilator is often long enough and stiff enough to reach the opposite wall of the greater vessels, creating a tear in a deep mediastinal structure. Gupta et al (2011) present a case report of a (fortunately non-lifethreatening) haematoma from an overvigorous deep dilation.
There are several simple bedside methods which you can use to determine whether you are in a vein or artery.
Needless to say, if you don't flush them they will clot.
All lumens should be capped, because:
The NSW Health policy recommends you use "swabable capless valves" to cap your lumens. These are colloquially known as "bungs". The manufacturer reports that they can withstand a backpressure in excess of 45 psi, which the patient is unlikely to ever generate using their thorax alone (as that would come to approximately 2327 mmHg, or approximately 31,600 cm H2O). As the CEC implies, they can be swabbed, and this favours a relatively clean handling technique. The instruction is to swab them before and after they are accessed.
Interestingly, the volume of a syringle matters. It is significantly more likely for you to fracture the CVC when flushing a blocked lumen with a small syringe, even though this seems counterintuitive. Hayward et al (2011) were able to demonstrate this in the context of injecting various solid lesions in need of hydrodissection.
The main issue to consider is that the CVAD should not be secured by tape alone. Suture or a sutureless "catheter clamp" should be used to secure the device. Re-positioning the device will require you to patientl undo all the fixation and reapply it all again after you have finished, in a way that prevents malposition.
An ideal dressing has the following characteristics:
If two catheters are close together (eg. where an arterial line and central line have both been placed into the same groin) you may use the same dressing.
As far as deciding between sutures and "catheter clamps", there is no specific evidence to guide us. Frey et al (2008) were able to demonstrate that sutureless devices are probably better - at least for PICCs. ANZICS remain unconvinced whether CVCs would benefit.
Both NSW health policy and ANZICS recommend that the CVAD dressings should be changed every 7 days unless soiled, wet or loose. If there is a gauze piece under the dressing soaking up blood from the oozing insertion site, one needs to change it every 2 days.
Having inserted the central line, one should perhaps develop interest in where the tip is positioned. There are two competing needs here. For optimal dilution of infused substances the tip should be closest to the right ventricle; but for optimal safety it should be as far away from it as possible. The NSW Health policy suggests that it is "reasonable" to expect your tip:
The "pericardial reflection" mentioned here presumably refers to the serous pericardium, as opposed to the fibrous pericardium which is seamlessly continuous with the fibrous coats of the greater vessels. A line tip positioned below this reflection is generally viewed as dangerous because a perforation of the wall at this level will give rise to cardiac tamponade and death. Whereas a perforation of the wall above the reflection will merely give rise to a haemomediastinum, which is somehow viewed as a more benign complication.
Where is this pericardial reflection, and how can we determine its position? The gold standard is autopsy. Albrech et al (2004) performed many of these to delineate the limits of the pericardium, and found that it generally ended about 0.8cm below the carina. Unfortunately this technique is poorly suited for routine clinical use. Thankfully Stonelake & Bodenham (2006) were able to validate the carina as a convenient radiological landmark for the non-cadaveric setting.
Radiologically, the most useful landmark is the carina. Bannon et al (2011) mentions that the carina is (almost) always about 1.5cm inferior to the origin of the superior vena cava, and the right main bronchus is almost always about 2-3cm superior to the cavoatrial junction. Stonelake and Bodenham suggested that though some of the lower SVC lies within the border of the pericardial reflection, this "may represent a necessary compromise for left-sided CVCs to ensure they lie parallel to the vessel wall". Right sided lines are already reasonably straight and their tips should be in the upper SVC around the junction of the innominate veins, where blood flow is still excellent but where there is zero risk of cardiac tamponade. The innominate veins themselves are a gray zone. Most people would agree that the blood flow there is satisfactory to avoid thrombosis, but nobody would want to infuse anything particularly noxious into those vessels, nor for a prolonged period of time
Ergo, you should aim for the carina. If your catheter ends up within 2cm or so of the carina, it is unlikely to be in a disastrous place.
Most manuals and policy documents report that the tip of the catheter should not abut the SVC wall, and that the catheter should be parallel to the midline of the SVC wherever possible. This is because of the risk of erosion though the SVC wall, especially if horrible substances like TPN are being given through it. Some authors even go as far as to give a precise "angle of safety" to aim for.
That angle is 40°. This figure arose from the study by Gravenstein et al (1991), who eroded some central line tips through a "vessel wall" simulated from polyethylene film of 12.7μm thickness, pulsated against the line tip at 80bpm. This might seem like a highly unrealistic model but in fact the very next year Duntley et al (1992) were able to scrape up enough literature for a case series of 61 patients with catheter tip erosions, in whom the majority had catheter tips abutting the SVC wall at an angle greater than 45°.
This is of course not a super-urgent problem, as the line is not going to erode instantly- you have some time to reposition it. However, while in this position the distal lumen cannot have anything corrosive hypertonic vasoactive or high-volume going though it, nor can the CVP be measured - which means the central line is unusuable for most of the conventional indications of central line insertion.
This is usually a problem associated with left-sided lines. As the line exits the left innominate vein, it has the opportunity to poke the SVC wall before continuing downward towards the lower SVC. Unless it is not long enough, in which it will never continue downwards, remaining up against the SVC wall, poking it vigorously each time the patient coughs. The consequences are predictably hideous. One may find oneself draining a massive pleural effusion composed almost entirely of propofol, for example. Duntley et al report a mortality rate of 12% (and that's just the ones they reported).
It is possible to estimate the depth of insertion by the use of the Peres equations. Peres et al (1990) prospectively explored the relationship between patient height and catheter position, arriving at a series of empirically derived height-based formulae. Essentially, they all rely on dividing the patients height (in cm) by 10, and then applying some sort of modifier (for instance, for left external jugular catheters the expected depth = height/10 + 4 cm). Thus, for a right IJ line the required depth (using the central approach) ends up approximately 16cm in the average 160cm adult female and perhaps 17-18cm in the tall male.
Now, these equations have undergone extensive modification since 1990. For instance, a variant can be seen in the excellent resource by Phillipe Le Fevre which modifies the formulate with (-2cm) for right SCV, (-1cm) for right subclavian and (+2) for left-sided lines. This follows the results of a study by Czepizak et al (1995), who tested the predictive qualities of Peres' equations and found that in 95% of cases the equations accurately predicted the required line depth provided these minor modifications were made. Here they are, illustrated on the surface of this early Flavian marble.
The problems with developing and using these empirical equations are manifold, and mainly come down to three main facts:
There are other limitations to equation-based depth estimates. For instance, how do they perform in people with severe scoliosis? What is the guideline for their use in people who have unusually long necks? What of patients with acromegaly, pituitary gigantism, achondroplastic dwarves? Not to speak of the paediatric population. In summary, the equations are occasionally useful in the normal Homo sapiens group, insofar as their anatomy remains "classical", and are a useful way of saving yourself some time repositioning and re-suturing the line, not to mention the patient being disadvantaged by additional needles and a second Xray.
It is also possible to measure along the surface of your patient to decide how deep the line should go. For example, the surface landmark corresponding to the carina is supposed to be the manubriosternal joint, otherwise known as the angle of Louis. One should therefore aim to have one's tip somewhere around there. For example, Kim et al (2011) used the junction of the second costal cartilage with the manubrium and sternum as the surface point to aim for.
They draped the patient and then laid the line out on the draped skin, with the tip at this surface landmark. The line was then inserted to the depth predicted by this method. The authors reported that the tip was within 2cm of the carina radiologically in 95% of the inserted lines. Vinay and Tejesh (2016) found this method to be superior in accuracy to height-based formulae.
Again something which might benefit from a big table:
|Pneumothorax / haemothorax||
|Endotracheal cuff puncture||
The ANZICS Guideline has a whole section on routine central line maintenance which covers several important aspects:
Daily review of the CVAD insertion site involves looking for:
In summary, every day you need to answer the questions, "is it infected" and "does the patient still need it?"
For PICC lines, there is also the need to think seriously about thrombosis. The NSW Health policy recommends that we "compare the mid-upper limb circumference" with previous measurements whenever a concern regarding swelling gets raised.
At what stage should the CVC be removed? There are several possible reasons you might want to decannulate somebody.
The NSW Health policy recommends a prescriptive technique for CVAD removal. In summary:
These can be grouped into the categories of "device dysfunction" and "vessel dysfunction"
"Rewiring" refers to threading a guidewire though an old line, removing it (leaving the guidewire in situ)and then introducing a new central line over the guidewire. Generally speaking, this is frowned upon. ANZICS recommend that this desperate act be considered only in the following circumstances:
The increased risk of infection is surprisingly low. Cook et al (1997) - the study used by ANZICS to justify their position - looked at 19 RCTs totaling 918 patients and 1913 catheters, and found that the relative risk of CLABSI is around 1.76, as compared to a new puncture. Having said this, the removed catheter tip should be cultured, and if it was colonised the new required catheter should also be removed.
A variation of this dodgy technique is the recycling of a PA catheter introducer sheath, where the removed PA catheter is replaced with a central line. The NSW Health policy doesn't even mention this, as it is an esoteric thing for most environments. Again, as in the case of guidewire exchange, this should only be done if the sheath has been in situ for less than 72 hours.
Locally, the CEC has published a document which outlines a training framework for CVC insertion. Their recommendations can be summarised in the form of a diagram (stolen from their own document):
The CEC document linked above has a helpful logbook which can be printed and used as a record.
Bundles of care should be used to manage quality assurance related to central line insertion. (Blot et al, 2014) found that these tend to create a significant improvement in the rates of complications.
Infection rates are recorded in the ANZICS CORE CLABSI Registry. This is a central register of all inserted lines, and CLABSIes are reported to this central body for the purpose of data collection and audit. The CLABSI forms tend to also collect some peripheral data, such as the tip osition and any other complications. More ANZICS CLABSI stuff can be found on their main page for this.