Central venous access

Last updated: November 11, 2022

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Placement of a catheter in a large, central vein provides reliable venous access in patients who are critically ill, have poor venous access, and/or require administration of vesicants, irritant solutions, or large volumes of fluid. It also allows for specialist interventions such as advanced hemodynamic monitoring, transvenous pacing, and hemodialysis. The type of catheter used and anatomical location of placement are based on the patient's condition or injury and comorbidities. Large-gauge, single-lumen catheters are used for the rapid administration of fluid or blood products. Smaller gauge, multiple-lumen catheters are used for prolonged fluid and medication administration. The internal jugular vein is frequently chosen for central line placement because it is easy to access and is associated with fewer procedural adverse events than other sites. Insertion is most commonly performed using the Seldinger technique and usually occurs under ultrasound guidance. Complications include arterial puncture, pneumothorax, bloodstream infections, and venous thrombosis.

Properties of CVLs

  • Slower flow rates than peripheral venous catheters of the same diameter because they are longer
  • High flow rate can be achieved with large-gauge central venous catheters (e.g., sheath introducer, dialysis catheters).

The flow rate is subject to Poiseuille law: The flow rate is 16 times slower if a lumen's diameter is halved, but flow rate doubles if the catheter's length is halved!

CVL insertion sites

Comparison of CVLs by insertion site [1][2]
Anatomic location Advantages Disadvantages
Internal jugular line (IJ line)
  • Enters the neck via the left or right IJV
  • Terminates at the SVC-RA junction
  • Uncomfortable for the patient
  • Higher risk of infection than subclavian line
Subclavian line
  • Lowest infection rate
  • Most comfortable for the patient
Femoral line
  • Easier access during ACLS
  • Good insertion landmarks

Duration of use [3][4]

  • Short-term CVLs: usually nontunneled CVLs
    • Triple-lumen CVL: 3 channels; allows simultaneous administration of multiple solutions at different rates
    • Double-lumen CVL: 2 channels; typically large gauge that allows high rates of fluid exchange, e.g., for hemodialysis or plasmapheresis
    • Single-lumen CVL: 1 channel; allows administration of a single solution at a given rate
      • Small gauge: decreases the risk of vessel thrombosis
      • Sheath introducer (large gauge): used for rapid or high-volume fluid administration, or to aid insertion of other lines (e.g., Swan-Ganz catheter)
  • Long-term CVLs
    • Tunneled CVL: skin and vein entry points are separated by a tunnel in the subcutaneous tissue
    • Surgically implantable catheter: proximal terminus is a subcutaneous reservoir that is accessed percutaneously
      • Indications: long-term administration of medications or fluids
      • Advantages: lower rate of CLABSI, can remain in place for years

Special catheters [3][4]

  • Hemodialysis catheters
  • Peripherally inserted central catheter (PICC)
    • Long catheter that is inserted via a peripheral vein and terminates in a large central vein.
    • Advantages: lower procedural risk than other CVLs
    • Disadvantages: high risk of thrombosis, small gauge limits administration rate

We list the most important contraindications. The selection is not exhaustive.

IJ line insertion [1][6]

This approach uses a thin wall needle (referred to as “needle” from here on) and the Seldinger technique.

  1. Center the probe above the IJV.
  2. Place the needle beneath the center of the probe at a 45° angle to the skin.
  3. Apply negative pressure to the syringe plunger and advance the needle until blood flashback occurs.
  4. Hold the needle firmly and remove the syringe.
  5. Feed 15–20 cm of wire through the needle. [6]
  6. Remove the needle while holding the wire in place.
  7. Make a small skin incision over the wire.
  8. Advance the vascular dilator 5–7 cm into the vein.
  9. Remove the dilator and advance the catheter ∼ 16 cm (right IJV) or ∼ 20 cm (left IJV) over the wire. [1][6][8]
  10. Remove the wire, aspirate blood from all ports, and flush each port with saline.
  11. Secure the catheter to the skin and apply a sterile dressing.

Hold the guidewire at all times when performing steps according to the Seldinger technique. [1]

Common pitfalls in internal jugular vein central line placement [1][6][7][9][10]
Challenge Prevention Management
Unable to view internal jugular vein
  • Use an alternative site.
Carotid artery puncture [6][7]
  • Use real-time ultrasound for line placement.
  • Identify the location with the greatest separation between the IJV and carotid artery.
  • Consult vascular surgery immediately. [7]
  • Needle puncture only: Remove the needle and hold pressure. [6]
  • Catheter placed in the carotid artery: Leave in place pending surgical consultation. [6][7]
Ventricular dysrhythmia [1]
  • Ensure that the cardiac monitor is visible and audible to identify ectopy early.
  • Do not advance the wire beyond 15–20 cm.
  • Withdraw the wire until rhythm returns to baseline.
  • In most cases, the procedure can continue.
  • Persistent dysrhythmias: Remove the wire and begin ACLS as needed. [11]
Distal catheter in the atrium [1][6][8][12]
  • Do not exceed the recommended/calculated depth for catheter insertion [1][8]
  • Obtain CXR to verify the final location of the catheter.
  • Withdraw the catheter an appropriate distance using sterile technique and resecure.
  • Verify the new position with CXR.
Resistance to advancing the wire [1][13]
  • Do not use force to overcome resistance.
  • Rotate the wire and/or needle.
  • Decrease the angle of needle entry.
  • If unable to pass the wire, remove the wire and needle as a single unit.
Guidewire embolism
  • Hold the guidewire with nondominant hand at all times during catheter and introducer exchanges required by the Seldinger technique
  • Avoid withdrawing the guidewire through the TWN
  • Consult interventional radiology for retrieval

The distal end of the catheter should be cranial to the tracheal bifurcation on CXR. [6][10]

Whenever possible, insert CVLs under ultrasound guidance to reduce procedure time and risk. [7][14][15]

Obtain a CXR following placement of a CVL to confirm proper positioning of the catheter and identify mechanical complications (e.g., pneumothorax)

We list the most important complications. The selection is not exhaustive.

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  10. Schulman PM, Gerstein NS, Merkel MJ, Braner DA, Tegtmeyer K. Ultrasound-Guided Cannulation of the Subclavian Vein. N Engl J Med. 2018; 379 (1): p.e1. doi: 10.1056/nejmvcm1406114 . | Open in Read by QxMD
  11. Zhang Z, Brusasco C, Anile A, et al. Clinical practice guidelines for the management of central venous catheter for critically ill patients. J Emerg Crit Care Med. 2018; 2 : p.53-53. doi: 10.21037/jeccm.2018.05.05 . | Open in Read by QxMD
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  15. Demetrashvili Z, Kenchadze G, Pipia I, Ekaladze E, Kamkamidze G. Management of Appendiceal Mass and Abscess. An 11-Year Experience. Int Surg. 2015; 100 (6): p.1021-1025. doi: 10.9738/intsurg-d-14-00179.1 . | Open in Read by QxMD

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