Central Venous Access
The Art of the Central Line
Introduction
Central venous access is required in 8% of hospitalized pts and >5 million central
venous catheters are placed each year. This statistic shows the importance of
learning this skill while in residency. A “Central line” implies that direct access to
the central venous system (Superior/Inferior Vena Cava) has been obtained. This
paper is meant to serve as a summary of all the data on central venous access and as
a quick reference before central venous access is attempted (via summary page).
The focus of this paper will predominantly be on the jugular access site as this is our
preferred approach.
Catheter Insertion Site
The 3 large veins that are typically cannulated are the Internal Jugular, Subclavian,
and Femoral. The preferred site currently by major organizations and critical care
physicians is the Internal Jugular Vein. This is due to easy accessibility, ease of ultrasound guidance in this area, lower failure rate with novice operators and overall low
complication rates, and they are the preferred site for temporary hemo-dialysis.
There have been studies comparing Subclavian versus IJ access. There appears to be
lower infection rates in the subclavian, but these results have not been validated, as
these were observational studies. The randomized trial that compared IJ to
subclavian port access for cancer therapy found no sig differences in infection
rates or mechanical complications. A well established, accepted detail is infection
rates are highest in femoral access, then IJ ~ subclavian (in descending order). If
femoral catheters have to be used, they should be removed as soon as possible
to reduce catheter-associated complications. This means if a femoral line was
placed in the E.R., it should be removed once in the ICU and replaced with an
IJ. Pulmonary complications such as hemo and pneumothorax appear equivalent
despite historic reports of higher rates with the subclavian approach, both being
observed to be ~1%. However, it is anecdotal that subclavian incurs higher
pneumothorax rates. Studies have also showed that IJ access is more preferable in
cachectic pts and in pts with respiratory compromise. When all this data is
reviewed, it is the recommendation that the IJ should be the preferred site
unless the pt is in active CPR and peripheral IV access can’t be established.
With that being said, specific anatomic sites and cannulation approaches have
inherent advantages and disadvantages. Therefore, each physician placing the
central line may have different preferences. Below is a table showing advantages
and disadvantages of the different catheter insertion sites.
Central Venous Access
Approach
Internal Jugular
Advantages
Minimal risk of
pneumothorax (especially
with US guidance)
Head of table access
Procedure-related
bleeding amendable to
direct pressure
Lower failure rates with
novice operators
Excellent target using US
guidance
Subclavian
Easier to maintain
dressing
More comfort
Better landmarks in obese
pts
Accessible when airway is
being established
Femoral
Rapid access with high
success rates
Does not interfere with
CPR
Does not interfere with
intubation
No risk of pneumothorax
Disadvantages
-Not ideal for prolonged
access
-Risk of Carotid artery
puncture
Uncomfortable
-Dressings and catheter
difficult to maintain
-Thoracic duct injury
possible on the left
-Poor landmarks in
obese/edematous pts
-Vein prone to collapse
with hypovolemia
-Difficult to access during
emergencies when airway
control is being
established
-Increased risk of
pneumothorax
-Procedure related
bleeding less amenable to
direct pressure
-Decrease success with
inexperienced operators
-Longer path from skin to
vessel
-Catheter malposition
more common
-Interference with chest
compressions
-Delayed circulation of
drugs during CPR
-Prevents pt moving
-Difficult to keep site
sterile
-Increased risk of illeofemoral thrombosis
Central Venous Access
Access to sites with altered local anatomy, sites with multiple scars from prior
access, and the presence of another central venous catheter or device, such a
as pacer, or ICD, are associated with higher rates of access failure,
malposition, dysrhythmia and other complications and thus are avoided. So if
these things are present, another site needs to be chosen. If a pt has significant
unilateral lung dz, use this side to minimize respiratory decompensation in
the event of a procedure-related pneumothorax. Subclavian should not be
accessed for hemodialysis catheters due to the risk of venous stenosis complicating
subsequent hemodialysis access.
Indications
1. Administration of noxious medications: vasopressors, chemotherapy,
and Total Parenteral Nutrition (TPN) are given by central venous
catheters b/c they can cause phlebitis when given through a peripheral IV
catheter. These medicines are caustic to the vein and almost always lead
to infiltration of a peripheral catheter.
2. Hemodynamic monitoring: Central venous access allows measurement
of the Central venous pressure (CVP) and central venous oxyhemoglobin
saturation (important in the treatment of sepsis and the workup of acute
respiratory failure). In fact, in the new guidelines on Sepsis Management
termed “Surviving Sepsis” (see Wiki for the paper) part of the initial
management is to maintain these patients CVP in the 8-12 mmHg range. A
3. Plasmapharesis, apharesis, hemodialysis, and Renal replacement therapy
(RRT)
4. No or poor peripheral venous access
5. Transvenous cardiac pacing
6. IVC filter placement (Greenfield filter)
Contraindications
1. Anatomic distortion (i.e. prior clavicular fracture, median sternototmy,
neck surgery, or neck irradiation)
2. Other indwelling vascular catheters (i.e. pacemaker, etc)
3. Numerous past access to the site
4. Coagulopathy: this is a RELATIVE contraindication to central venous
catheterization, although significant bleeding is uncommon in the IJ due
to the ability to hold direct pressure. However, IJ access in pts with
coagulopathy places the pt at risk for neck hematoma, which can be lifethreatening due to airway compromise if inadvertent carotid artery
puncture occurs. Here are some ideas to keep in mind:
a. The safety of large bore tunneled cath (we use non-tunneled, see
below) placement has been documented in pts with mild-to-
Central Venous Access
moderate coagulation abnormalities. We use the smaller nontunneled catheters.
b. Thrombocytopenia poses a greater risk compared with a
prolonged INR!
c. A subclavian approach should be avoided in coagulopathy due to
an inability to effectively monitor or compress the venipuncture
site.
With that being said: If the operator is inexperienced, the pt is uncooperative and
wont lay still, or if the US is not available, and there is an underlying coagulopathy,
femoral access should be attempted for emergent access. The femoral line should be
replaced as soon as the coagulopathy is corrected. FFP or platelets can be given
prior to the procedure in patients with severe coagulation abnormalities to reduce
the risk of bleeding complications, but there is little evidence to support this
practice. If this is the case, guidelines should be reviewed for correcting coagulation
abnormalities.
Central Catheters
This is a description of non-tunneled catheters and their specifics. There are other
types including tunneled catheters, PICCs and ports. These should be read about and
understood but are not pertinent in this paper. Non-tunneled catheters are placed
percutaneously with the catheter exiting the skin in the vicinity of the venous
cannulation site. These catheters are much longer than the catheters used to
cannulate peripheral veins and are typically 15-25cm (6-10in) in length. They are
also available with 2 or 3 separate infusion channels. The multilumen catheters are
the most popular b/c they allow multiple infusions through a single venipuncture
site. See the table below for the different types of vascular catheters.
Central Venous Catheter
Single lumen
Double lumen (18 ga, 18
ga)
Triple lumen (18, 18, 16
ga)
Sizes (Gauge or French)
16 ga, 18 ga, or 20 ga
7.5 Fr
Lengths
15cm, 12 cm, 8 cm
15cm, 20cm, 25cm
7 Fr
15cm, 20cm, 25cm
We use triple-lumen catheters. This catheter has an outside diameter of 2.3mm (7
French) and houses one 16-gauge channel and two smaller 18 gauge channels. The
distal opening of each channel is separated by 1 cm to prevent mixing of infusated
solutions. I will break this down more: There are 3 lines in the one line (1 16 ga and
2 18 ga), the end coming out of the patient will have three ports. These three ports
are termed the distal, medial, and proximal ports. These three lines combine into
one larger 7 Fr catheter. On the distal end (the end in the patients jugular vein)
there are three openings: the proximal opening, the medial opening, and the distal
opening. These correspond to the same ports on the proximal end of the catheter.
The end hole (distal) or the distal port (has brown cap on it) is best for drawing
Central Venous Access
blood as its not likely to lay in close proximity to the side wall of the vein. There is a
higher risk of thrombosis and lower infusion rates with multi-lumen
catheters. Infection rates are the same for single, double and triple lumen
catheters. See the diagram on the following page.
Central Venous Access
Figure 1: the middle (242), or distal, port is brown and corresponds to the distal hole (210). The distal
port (242) is the 16-ga channel; the left port (241,medial) and right port (243, proximal) are 18 ga
channels
Preparation
Central Venous Access
1. Internal Jugular Vein Anatomy:
a. The IJ is a continuation of the sigmoid sinus as it exits the jugular
foramen at the skull base. The IJ exits the skull posterior to the
internal carotid artery, but assumes a position anterolateral to the
common carotid artery as it courses beneath the SCM muscle. At
the level of the cricoid cartilage, the IJ is beneath the SCM muscle
and more caudally it is located between the 2 heads of the SCM
muscle at the base of the neck. Its in this region the IJ is 1-1.5cm
from the skin surface. The IJ then joins the brachiocephalic vein
posterior to the medial clavicle. The vein is contained within the
carotid sheath traveling with the carotid artery and vagus nerve
throughout its length. The IJ vein on the right is larger than the left
in the majority of patients. The primary landmarks are the SCM
muscle, which consists of 2 heads: a sternal head and a clavicular
head. Flexing the neck or turning the neck away from the
procedure side can accentuate the SCM muscle. The 2 heads of the
SCM should be palpated. The sternal head is easier to palpate. The
IJ vein emerges just medial to the clavicular head. If the pt’s head
is turned contralaterally to the side of the procedure, this
directly places the carotid artery posterior to the IJ, making
carotid puncture much more likely
2. Informed Consent:
a. Informed consent should be given to each patient. Consent for
vascular access is implied in emergent situations. The
indications, complications, and benefits of the procedure should be
explained. The need for a second procedure (i.e. chest tube) if a
complication should arise should also be conveyed. Also, an
explanation of the procedure being done is courteous.
3. Analgesia and Sedation: This is really dependant on several things:
a. Is the patient intubated? If the patient is already intubated, a
form of sedation will be given already thru an IV (i.e. Propofol,
Ativan, Dexmed.). If this is the case, just be sure the pt is
comfortable under the IV sedative being used. Also, lidocaine to
the area should still be used as the patient still has the ability to
interpret pain.
b. Are they awake? If the pt is awake, a short acting benzodiazepine
(Ativan) can be used to relieve anxiety. If the patient is
uncooperative, an opioid (fentanyl) should be used to obtain
conscious sedation. This requires vital sign monitoring so should
only be done if the patient is in the ER or the ICU.
c. Topical injection: all patients need lidocaine to the area,
regardless if sedated.
4. Positioning: correct patient positioning maximizes the diameter of the IJ
and is associated with increased cannulation success:
Central Venous Access
a. Trendelenburg Position: The Trendelenburg position (head
down) of 10-15 degrees significantly increases IJ diameter
compared with flat positioning. Trendelenburg positioning
also decreases the potential for venous air embolism.
b. Valsalva: The diameter of the compliant vein varies with
respiratory cycle. To increase the diameter of the IJ, just ask
the pt to perform a valsalva. If the pt is not awake, slight
abdominal compression can increase venous distension.
c. Head Position: The position of the pt’s head does 2 things:
influences vein diameter and its relationship to the carotid. Vein
diameter is increased with slight head elevation, while the use of
a shoulder bolster or head rotation past 45 degrees both
decrease vein diameter. The position of the head also influences
the location of the vein relative to the artery. The overlap
progressively increases with rotation of the head contralaterally
from a neutral position. Limiting head rotation minimizes
superimposition of the vessels and decreases the risk of arterial
puncture. Some head rotation will be needed though to adequately
expose the anterior neck.
5. Sterile Technique:
a. Each participant in the room should at least be wearing a hair net
and mask. The proceduralist and their assistant should follow full
sterile technique in gown, glove, mask, and hair. Also, the
ultrasound probe should be placed in a sterile cover and sterile
jelly used.
6. Site Preparation:
a. Wide skin preparation should be used. The prep of choice is
chlorhexidine, which comes standard in all kits. This is the
preferred agent as it has been shown (compared to alcohol and
betadine) to be superior in preventing infections. A wide prep
includes the neck and chest above the nipple line. This allows the
operator to attempt cannulation at an alternative ipsilateral target
(e.g., supraclavicular or infraclavicular subclavian) if the initial
plan fails. If difficult access is anticipated, it is prudent to prepare
both sides. Remember that the sterile covering in the kit has a
small hole in it that will be placed over the sterile site.
7. Equipment: This is a summary of what all will be used and is included in
the kit. Jugular venous catheters are placed using a modified Seldinger
(see below for explanation) technique in a series of defined steps. Prior to
placement, assemble the following equipment:
a. Ultrasound machine
b. Sterile ultrasound transducer gel
c. Sterile ultrasound sheath
d. Sterile gloves, gown, surgical mask, and cap
e. Central line kit
i. Topical anti-septic
Central Venous Access
ii. Local anesthetic
iii. Sterile cover for the patient which has a hole for the sterile
area on the neck and chest
iv. Finder needle/Local needle
v. Introducer needle
vi. Introducer syringe
vii. Guidewire
viii. #11 blade scalpel
ix. Tract Dilator
x. 7 French, triple lumen, 15cm-25cm (length) intravenous
catheter
f. 3 needleless Luer locks: nurse must get these and open them in a
sterile fashion and place on the tray
g. Sterile isotonic saline for flushing: once again, the nurse will place
this into your kit
h. Anti-bacterial covering
i. Transparent dressing
Internal Jugular Vein Cannulation
1. Ultrasound Guidance: the US is literally your best friend. There have
been numerous studies showing there is a decrease in complications,
reduces time to venous cannulation, and increase in successful
cannulation rates when the ultrasound machine is used. Basically, the
ultrasound will be used to center the IJ on the screen and a wheel will be
raised in the area using 1% lidocaine OR the cover on the needle can be
used. This is where the needle will be placed. The IJ (like all veins) is
compressible with the ultrasound. This is the easiest way to differentiate
the IJ from the carotid artery. The probe of the U/S has a small dot on the
side, this dot corresponds to the dot on the screen and this is how we
differentiate left and right on the ultrasound screen. You can tell which
side you are at by gently tapping the lateral aspect of the transducer,
which ever side has a shadow on the screen corresponds to the side
you’ve just tapped on the transducer. The transducer is placed in
transverse orientation over the triangle formed by the two heads of the
SCM. Slowly slide the probe distally, until you find the area of interest,
two dark and oval or round appearing vessels. Use the transducer to
compress the vein to confirm that it is indeed the vein and not the artery.
Position the vein in the center of your image and place the needle to the
midline of the transducer. Estimate or measure the depth of the IJ vein
from the skin surface. You can use the same distance when determining
how far from the transducer the needle should enter the skin when the
angle of insertion is close to 45 degrees. Align the needle with the
longitudinal axis of the vein while advancing it. The needle should be
visualized entering the vein. Ultrasound anatomy of the IJ and it
Central Venous Access
surrounding structures is straightforward to comprehend. This can be
reviewed on the Sono-Site website
(www.sonoguide.com/line_placement.html). This should be viewed prior
to all procedures. Also, you will be required to pass a skills lab showing
competence on ultrasound. See below for an US image.
2. Approach to the IJ: There are 3 standard approaches to the IJ and these
include central, anterior and posterior. We were thought the central
approach and therefore this is what will be described.
a. Central: Initially, the landmarks of the lateral and medial head of
the SCM should be identified and if needed traced onto the skin.
The apex of the triangle formed by the heads of the SCM is ~5 cm
superior to the clavicle and this should be the general area where
the wheel will be raised once the ultrasound is used. This also
approximately marks the needle insertion site for the central
approach: the apex of the triangle. Once the US is used, introduce
the needle lateral to the carotid pulsation felt or seen on the
screen @ an angle of 45 degrees to the skin. Direct the needle
toward the ipsilateral nipple. This path typically travels alongside
or beneath the lateral head of the SCM. If blood is not aspirated
after 2.5 cm, withdraw the needle slowly while maintaining
constant negative pressure and watching for blood return. If
the first needle pass fails, reassess ultrasound anatomy and
make a second pass, this time redirecting the needle in the
direction indicated by the US. The needle should be visualized
entering the vein.
3. Needle Access:
a. General Techniques: The IJ should be cannulated using an
introducer needle with or without the aid of a seeker needle. We
do not generally use the seeker (smaller) needle, instead go
straight to the introducer needle. Once again, recall that isolated
arterial needle puncture is one of the most common complications
of venous access, but is typically uneventful if recognized.
Confirmation that the tip of the needle is within the vein is
essential prior to dilating the subcutaneous tissue and vein. There
is an established learning curve for central venous access
procedures. Experienced operators enjoy greater success rates
with fewer complications, among both experienced an
inexperienced operators, an increased number of introducer
needle passes correlates with increased complication rates, which
are significantly higher after 2-3 unsuccessful passes. If 2
attempts have been made, the needle should be completely
removed and the landmarks reassessed and a new access site
Central Venous Access
Central Venous Access
chosen and the assistance from an upper level resident
should be sought.
b. Access with the Introducer Needle
i. Insert the introducer needle into the skin and apply
continuous negative pressure by pulling back on the
plunger of the syringe. Penetration into the vein will go
unrecognized unless negative pressure is applied, but only
a small amount of continuous negative pressure is needed
(about 1cc of a 10cc syringe) during forward advancement
of the needle.
ii. Always advance and withdraw the needle in the same
vector. Lateral movement of an inserted needle can
lacerate vessels and should not be done. Prior to any
redirection of the needle, it should be withdrawn to the
skin surface.
iii. Anticipate that venous backflow into the introducer needle
will be quick so steady the needle with your other hand to
avoid loosing access when it occurs.
iv. The introducer needle may compress the anterior wall,
puncturing both walls simultaneously without entering
the lumen. Failure to aspirate blood during needle
advancement is common. In this circumstance,
withdraw the needle slowly while maintaining
continuous negative pressure. Up to ½ of jugular
punctures are recognized during needle withdrawal.
v. Once access is achieved, stabilize the hub of the needle and
carefully remove the syringe to avoid dislodging the
introducer needle from the vessel.
vi. Cover the hub of the needle after the syringe is removed to
avoid air entry during jugular access.
c. Venous Confirmation: An intraluminal position of the needle can
be confirmed by observation of the needle entering the vein with
US guided access coupled with a steady flow of dark blood into the
syringe. Bright red blood and high pressure pulsatile bleeding are
important but imperfect clues to arterial puncture, which can
occur, although less frequently, with US access. Moreover, the
absence of these signs is not perfectly reliable for excluding
inadvertent arterial puncture. Dark, nonpulsatile backflow of
blood may be seen with arterial puncture in the face of oxygen
desaturation, hypotension, or needle malposition. If there is any
doubt, the needles location can be confirmed by pressure
transduction (rarely used, but ICU nurse can do for you). If the
carotid artery has inadvertently been punctured, withdraw the
needle and apply pressure over the site for 5-10 minutes. Jugular
venous access can be re-attempted provided anatomic landmarks
Central Venous Access
have not become distorted from hematoma. Inadvertent dilation
and cannulation of the carotid artery with a standard catheter
does not usually pose a significant problem. However, large bore
catheters (like dialysis caths) cause problems and should be left in
place and vascular consultation obtained.
4. Catheter Placement: We place all of our central venous catheters using
the Seldinger technique, which refers to the use of a guidewire placed
into a vessel to provide a conduit for intravascular device placement.
a. Guidewire: Once the jugular vein has been successfully accessed, a
guidewire should be advanced through the needle. We use a flexible Jtip guidewire, favored b/c it negotiates curvatures and minimizes
vessel trauma during passage. The guidewire should always pass
smoothly and easily through the needle without resistance. Methods
to address resistance to guidewire advancement or withdrawal are
discussed below. To place the guidewire:
i. Position the tapered plastic introducer to straighten the
distal J-tip. The orientation of the bevel tip of the
introducer needle and the J-tip of the wire medially can
help facilitate wire placement.
ii. Maintain the length of guidewire under constant
manual control to maintain sterility and avoid its loss
off the operating field.
iii. Advance the guidewire about 15cm on the right IJ and
18cm on the left IJ. Advancing the guidewire deeper
risks intracardiac or IVC wire placement with the
potential for cardiac arrythmia, perforation, and snaring
of other IV devices.
iv. Never forcefully advance the guidewire, as this can kink
and permanently deform the wire and risk vessel injury.
The guidewire should always pass smoothly and easily
through the needle without resistance. Resistance to
guidewire passage can be due to needle dislodgement,
compression of the guidewire against the vessel wall, or
anatomic obstruction. Rotating the needle and/or
guidewire to reorient the bevel or J-tip may relieve
impingement of the guidewire on the posterior vessel
wall.
v. If resistance persists, remove the guidwire and aspirate
blood to confirm intraluminal needle position. Reducing
the angle of the needle against the skin (from 45 to 30
degrees) may facilitate guidewire passage. Once the
guidewire is positioned, hold it firmly in place and
remove the needle.
vi. Resistance during guidewire withdrawal can be
managed by simultaneous removal of the needle and
Central Venous Access
indwelling wire. Continued resistance may indicate
entrapment and warrants diagnostic radiography to
evaluate the wire appearance and position.
Withdrawing a kinked guidewire through the needle
can shear off the wire, allowing it to embolize.
b. Tract Dilation: Central venous catheters are substantially larger
caliber than the needle and guidewire used for venous access. Dilation
of the subcutaneous tissue tract is required for catheter insertion and
is accomplished by threading a single stiff tapered dilator over the
wire to expand the subcutaneous tissue and vein. The skin and fascia
catheter tract should be dilated carefully with gentle pressure. Only
the soft tissue and vein wall need to be dilated. Overzealous efforts
and guidewire kinking risk traumatic vein injury. To place the dilator:
i. Once the guidewire is in place, make a controlled 3 mm
stab incision made in the skin at the entry site with a
#11 blade to prevent dilator from catching.
ii. Thread the stiff tapered dilator over the wire, making
certain the guidewire does not advance and is not
pulled out oat the skin exit site. The guidewire and
dilator should never be advanced as a single unit, to
avoid venous injury. The wire should serve as an
immobile object over which the dilator is passed.
Cephalad retraction of the skin may be needed to
smooth out redundant neck skin to avoid kinking the
wire.
iii. Hold the wire just above the dilator hub, grasp the
dilator just above its tip and push it over the guidewire
with a firm corkscrew motion. Mild resistance is
normal. Excessive resistance may represent an
inadequate skin incision, a malpositioned guidwire, or
guidewire or dilator deformation. Kinking of the
guidewire against the dilator is associated with vessel
trauma and puncture.
iv. As described above, cover the dilator opening to
prevent air entry
v. Advance the dilator only to the anticipated depth of the
IJ, NOT the entire length of the dilator. For the jugular,
the dilator need only be advanced 3-5 cm into the vein
depending upon the thickness of the pts neck.
vi. Withdrawal the dilator while maintaining the guidewire
position within he vessel. Apply direct pressure to the
exit site to maintain hemostasis prior to catheter
insertion.
vii. Steady traction of the wire during soft tissue dilation
helps prevent wire kinking. Rotating the dilator during
advancement often facilitates tract dilation. If resistance
Central Venous Access
is met, it may be related to a kink in the wire, which can
be remedied by advancing the wire deeper or
withdrawing the kink into the dilator. But, overzealous
efforts risks traumatic vein injury.
c. Positioning the Catheter: After the tissues and vein have been
dilated, the catheter is place over the wire and positioned. Thread the
guidewire back through the end hold of the catheter until it emerges
form the distal (brown=middle) port and advance the catheter over
the wire into the vessel. The guidewire is now removed completely
from the vein and the patient. If any resistance is met with forward
advancement, withdraw the catheter and re-dilate the tract. Insert the
catheter to 16-18cm on the right IJ and 20cm for the left IJ. Placing the
catheter too deeply is associated with serious sequlae including
cardiac tamponade, arrythmias, and central vein perforation.
d. Catheter Flushing and Fixation: aspirating blood and subsequently
flushing each port with sterile saline should confirm proper function
of the catheter. The nurse will place 3 Luer locks into the sterile tray,
these should be placed initially. Then saline should be aspirated from
the tray. This syringe with saline should be attached to each individual
Luer lock and aspiration of blood should occur from each port. Once
blood is aspirated, the saline and blood are flushed back into the
patient.
The catheter can be sutured using 2-0 or 3-0 nylon or silk sutures.
There is a catheter anchor attached to the catheter, there is a medial
and lateral hole on this anchor. This is where the suture needle should
pass and subsequently be secured to the skin.
Confirmation of Jugular Catheter Position
This is accomplished via chest radiography. Following placement, a post procedure
CXR is performed to confirm catheter position and exclude peumothorax. The distal
tip of the catheter should lie in the lower SVC. The carina and right tracheobronchial angle represent reliable landmarks for the pericardial reflection, which
represents the lower SVC. Therefore, catheters should be positioned at or above the
carina. If a jugular catheter tip is positioned too deeply it can be repositioned at the
bedside using sterile technique. Remove the sutures, withdraw the catheter, and resuture the catheter into place. If a catheter is not in far enough or in the
contralateral IJ or subclavian, it will need to be replaced over a guidewire under
sterile conditions. The portion of a catheter left out of the body is unsterile and
should never be advanced into the patient, not even if it is under a sterile dressing.
Complications and Management
There are a few complications associated with central venous catheter (CVC)
placement. They are reviewed here and how to prevent/mange them.
Central Venous Access
1. Infection and thrombosis. These are the late complications of central venous
access. There are numerous literature references to this if this occurs. The point I
want to emphasize here is to very frequently monitor the site of insertion for these
complications and correlate that to the clinical picture you are seeing in the patient.
For example, lets say you have a 37 y.o. male who aspirated and went into ARDS
requiring intubation and central line placement. On day 7 of hospital admission he
starts spiking fevers, the insertion site of the central line is erythematous with slight
purulence, this is likely your source. This can be prevented though by daily
inspection of the area.
-Prevention: In a large, prospective cohort study, the following five
steps reduced CVC-related bloodstream infections when instituted together. They
are termed the Pronovost Checklist:
 Hand hygiene – An alcohol sanitizer or antimicrobial soap
should be used immediately prior to donning sterile gloves.
 Chlorhexidine skin antisepsis – A chlorhexidine solution
should be applied by back and forth rubbing for at least 30
seconds. The solution should be allowed to air dry for at
least two minutes and should not be wiped or blotted.
Chlorhexidine appears preferable to a povidone-iodine
solution.
 Maximal barrier precautions – All operators should wear a
mask, cap, sterile gown, and sterile gloves. In addition, a
sterile full-body drape should be placed on the patient.
 Avoid insertion into the femoral vein – Insertion of a CVC
into the subclavian vein is associated with the lowest risk of
infection, followed by the internal jugular vein. In one trial,
289 patient had lines placed in the subclavian site or the
femoral site. There were fewer CVC-related infections
among patients who had a CVC inserted in their subclavian
vein (5 versus 22 percent).
 Remove unnecessary CVCs – A daily review of CVC
necessity should be performed, with prompt removal of
unnecessary CVCs.
There are also a few topics that are being studied but are not Standard of
Care (SOC):
 Antibiotic impregnated CVCs – A meta-analysis of 11
randomized, controlled trials (2603 catheters) found that
CVCs impregnated with chlorhexidien-silver sulfadiazine
were less likely to cause bloodstream infection (odds ratio
0.56, 95% CI, 0.37-0.84). However, this finding has not been
universal.
 Nursing supervision – In a prospective cohort study, the
patient's nurse used a check list defining best-practice to
monitor the procedure, and was empowered to stop the
Central Venous Access

procedure if best-practice was violated. Over a six-month
period, the CVC-related bloodstream infection rate
decreased from 11 to zero infections per 1000 catheter
days. We will delegate and individual in the room to do this
for us.
Vigilant catheter care – A prospective audit of postinsertion catheter care was conducted over a 28-day period
(721 catheter-days). There were 323 breaches in catheter
care and four catheter-related bloodstream infections (5.5
infections per 1000 catheter-days). The major breaches
included dressings that were not intact (158 breaches per
1000 catheter-days) and incorrectly placed caps (156
breaches per 1000 catheter-days). This study suggests that
there is substantial opportunity to better standardize and
improve the maintenance of CVCs. Such care should also
target earlier recognition of potentially infected catheter
sites.
2. Arrhythmia: Ventricular dysrhythmias and bundle branch block are well
recognized complications during central venous access procedures. Periprocedure
arrhythmias are universally the result of guidewire or catheter placement into the
right heart. This will be recognized on the monitor as an arrythmia (usually PVC’s).
-Prevention: Limiting the depth of guidewire insertion to less than 16
cm avoids this complication. Catheter migration up to 3 cm is common with
patient movement and repositioning may cause delayed symptoms.
3. Vascular injury: Arterial puncture is noted in 3 to 15 percent of central
venous access procedures [4]. Immediate recognition and management of arterial
puncture usually prevents subsequent complications.
-Treatment: Once an arterial stick is suspected, the needle is
immediately withdrawn and direct but nonocclusive pressure applied to the
site continuously for 15 minutes to prevent hematoma formation.
Unrecognized arterial cannulation with subsequent dilation and catheter
placement is associated with life-threatening hemorrhage and neurologic
complications. If you dilate and place a catheter into the carotid, do not
remove the line. Just call the surgeon of your preference and talk it out.
Likely, they will tell you to remove it and hold pressure. Late recognition of
arterial cannulation increases the risk of hemorrhagic complications that
may require surgical intervention. Measuring intraluminal pressure with a
transducer prior to dilation aids in recognizing arterial puncture if location is
unclear.
-Prevention: use the ultrasound and do not rotate the neck so much
you “stack” the IJ on the carotid.
4. Pneumothorax: Free aspiration of air into the syringe may occur with
pleural puncture but is often the result of incomplete seal of the syringe and needle.
Central Venous Access
Suspected pleural puncture should prompt close attention for signs or symptoms of
cardiopulmonary distress due to pneumothorax. Pleural puncture can quickly
evolve into tension pneumothorax with hemodynamic collapse, especially in
patients receiving positive pressure ventilation.
-Treatment: if this occurs and is confirmed on CXR, get the chest tube
cart, touch base with the surgeon of your preference, and place a chest tube.
The IR team also places chest tubes but the likelihood of there help is slim.
-Prevention: Do not move to inferior when placing your line. Stay at
the apex of the SCM triangle and do not advance the needle past your IJ while
using the ultrasound. These have never been validated and instead are
experience from the placement of these lines. Also, bear in mind that the IJ is
shallow so you should not have the needle in to the hub!! Another good
practice is to not switch sides in an emergency situation. This is due to the
idea that if you cause one pneumo, that’s better than causing 2 pneumos!
Therefore, avoid contralateral supradiaphragmatic access attempts in close
succession due to the potential for bilateral pneumothoraces.
5. Venous air embolism: Central venous access procedures create a risk for
venous air embolism. Venous air embolism is a serious and poorly recognized
complication that can occur at the time of CVC insertion, while the catheter is in
place, or at the time of catheter removal. Air is easily entrained into the vascular
space when a needle or catheter is left open to the atmosphere. Fatal doses of air
measuring as little as 20 mL can be aspirated in seconds through a large bore
catheter. Upright positioning, hypovolemia, spontaneous inhalation during
instrumentation, and inattention to catheter seals increase the risk for
entraining air. Affected patients can suffer cardiovascular and pulmonary
symptoms including tachyarrhythmias, chest pain, cardiovascular collapse, dyspnea,
coughing, hypoxemia, and respiratory distress. Symptoms contemporaneous with
central line insertion or manipulation are highly suspicious for venous air embolism.
-Treatment: Left lateral decubitus and Trendelenburg positioning to trap
the air in the right ventricular apex is often recommended but has not been
rigorously studied. Supportive measures including fluid resuscitation and
adrenergic agents should be used as needed. One hundred percent inspired
oxygen speeds air resorption.
-Preventing air embolism: Venous air embolism can occur at the time of
CVC insertion, while the catheter is in place, or at the time of catheter removal.
Trendelenburg positioning, Valsalva maneuver, prompt needle/catheter
occlusion, and tight intravenous connections help to avoid this complication
during CVC placement. Prior to CVC removal, patients should be placed in the
supine position. The CVC should be removed during exhalation, when
intrathoracic pressure is greater than atmospheric pressure. Firm pressure
should be applied for at least one minute following removal.
Factors Associated with Fewer Mechanical Complications
Central Venous Access
Mechanical complications are defined as bleeding, blood vessel injury, and
pneumothorax. Four factors are associated with fewer complications: increased
operator experience, fewer insertion attempts, ultrasound guidance and confirming
placement.
Operator experience — It is unknown how many CVCs should be inserted
by an operator each year to maintain his or her skills. However, experience is clearly
important. In one prospective cohort study, operators who had previously inserted
more than 50 CVCs were more likely to be successful at inserting subsequent CVCs,
with fewer complications.
Limiting attempts — The number of attempts is also related to the
likelihood of a mechanical complication. In a prospective cohort study, the incidence
of mechanical complications was sixfold higher when insertion was attempted more
than three times, compared with successful insertion on the first attempt. It is,
therefore, reasonable for an operator to seek assistance if a CVC cannot be
successfully inserted after three attempts.
Ultrasound guidance — Real-time two-dimensional ultrasound guidance is
superior to blind, landmark-guided techniques, particularly when used during CVC
insertion into the internal jugular vein. This was best demonstrated by a
metaanalysis of 18 studies (1646 patients) that compared CVC placement guided by
landmarks versus two-dimensional ultrasound. Ultrasound guidance markedly
reduced insertion failures in both adults (adjusted relative risk 0.14, 95% CI 0.060.33) and infants (adjusted relative risk 0.15, 95% CI 0.03-0.64) when the CVC was
inserted in the internal jugular vein. In addition, the risk of complications was
reduced approximately twofold. The benefit of ultrasound to guide subclavian and
femoral vein placement was uncertain. Despite the apparent benefit of using twodimensional ultrasound guidance for IJ insertion, routine use of Doppler to identify
blood flow does not appear to be beneficial for subclavian line insertion.
Confirm position — A newly placed CVC is frequently used before it has
been confirmed by a chest radiograph that it is correctly positioned. This is most
common in the operating room and in emergent situations. Failure to confirm the
position can be problematic since clinician judgment does not consistently predict
catheter malposition or other mechanical complications, especially with less
experienced operators. A promising technique has been developed that uses a right
atrial electrocardiogram (ECG) to confirm that a CVC has been accurately inserted. A
randomized trial that compared CVC insertion using this technique with CVC
insertion without it found that use of the technique improved the rate at which CVCs
were correctly positioned (96 versus 76 percent).
Central Venous Access
Complications of central venous catheterization
Immediate
Bleeding
Arterial puncture
Arrhythmia
Air embolism
Thoracic duct injury (with left SC or left IJ approach)
Catheter malposition
Pneumothorax or hemothorax
Delayed
Infection
Venous thrombosis, pulmonary emboli
Catheter migration
Catheter embolization
Myocardial perforation
Nerve injury
References:
The ICU Book. 3rd Edition. Paul L. Marino
Pocket ICU. 1st Edition. Frendl, Gyorgy; Urman, Richard
UpToDate: Overview of Central Venous Access, Placement of Jugular Venous
Catheters