pt in Trendelenberg position, fill the wells with saline and flush ports, inject local anesthesia, Penetrate the skin with larger needle with syringe, aspirating as you advance (aim at the ipsilateral nipple), once the vein has been penetrated(dark red, non pulsatile blood), unscrew the syringe and pass the guide wire into the vein (make sure to cap the needle orifice with finger to prevent air embolism), withdraw needle and never let go of guide wire, place dilator over guide wire , use scalpel to make a small incision around the guide wire/dilator, using a twisting motion, push the dilator over the guide wire deeper into the skin, remove dilator and apply pressure to control bleeding, pass the cannula over the guide wire (brown port), pass the TLC into the site to the double line mark on the catheter, aspirate blood from the brown port and then flush with normal saline, place cap on the end, pinch off the lumen, suture TLC hub to skin using one hand tying method, place tegaderm over the suture and TLC hub, order CXR to check placement