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 |
|Internal jugular line (IJ line)|| || |
|Subclavian line|| |
|Femoral line|| || |
Duration of use 
Short-term CVLs: usually
- 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., )
- 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 
- Can be a (long-term use) or (short-term use)
- Usually a large gauge double-lumen CVL
- Peripherally inserted central catheter (PICC)
- Absolute: allergy to an antibiotic impregnated within the catheter 
- Relative 
We list the most important contraindications. The selection is not exhaustive.
IJ line insertion 
This approach uses a(referred to as “needle” from here on) and the .
- Center the probe above the .
- Place the needle beneath the center of the probe at a 45° angle to the skin.
- Apply negative pressure to the syringe plunger and advance the needle until occurs.
- Hold the needle firmly and remove the syringe.
- Feed 15–20 cm of wire through the needle. 
- Remove the needle while holding the wire in place.
- Make a small skin incision over the wire.
- Advance the vascular dilator 5–7 cm into the vein.
- Remove the dilator and advance the catheter ∼ 16 cm (right ) or ∼ 20 cm (left ) over the wire. 
- Remove the wire, aspirate blood from all ports, and flush each port with saline.
- 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. 
|Common pitfalls in internal jugular vein central line placement |
|Unable to view internal jugular vein|| || |
|Carotid artery puncture |
|Ventricular dysrhythmia || |
|Distal catheter in the atrium || |
|Resistance to advancing the wire || || |
|Guidewire embolism|| |
- Complications of indwelling catheters
- Complications of CVC insertion
Whenever possible, insert CVLs under ultrasound guidance to reduce procedure time and risk. 
We list the most important complications. The selection is not exhaustive.