Version May 2024
INTRODUCTION — Temporary single and multilumen central venous catheters are important acute and emergency access devices that establish dependable venous access for monitoring, invasive procedures, pharmacologic therapy, fluid and blood resuscitation, and blood exchange therapies in acute and critical illness.
An overview of central venous access for emergency and urgent situations is presented with special attention to site selection, preparation, insertion techniques, and pitfalls.
A detailed review of jugular, subclavian, and femoral catheter placement is reviewed separately. (See "Placement of jugular venous catheters" and "Placement of subclavian venous catheters" and "Placement of femoral venous catheters".)
ACUTE CENTRAL VENOUS ACCESS — Acute central venous access involves use of nontunneled central venous devices (eg, multilumen catheter, large-bore introducer sheath, temporary nontunneled hemodialysis/pheresis catheter) for acute administration of pharmacologic agents, fluids, or blood exchange. The duration of use of these devices is generally limited to two weeks or less. (See "Central venous access: Device and site selection in adults", section on 'Nontunneled catheters' and "Central venous access: Device and site selection in adults", section on 'Short-term'.)
Temporary central venous catheters are inserted directly into the internal jugular vein, subclavian vein, or common femoral vein, with the catheter tip intended to lie in the superior or inferior vena cava. Access is obtained via percutaneous puncture and Seldinger technique, often with ultrasound guidance. Acute central venous access is commonly completed as a bedside procedure.
Urgent or emergency indications — Acute central venous devices are often required in urgent or emergency situations for [1-4]:
●Reliable intravenous access for blood sampling and fluid, blood, or drug administration.
●Administration of therapies at higher risk of peripheral vein thrombophlebitis or extravasation injury (eg, vasopressors, hyperosmolar solutions)
●Hemodynamic monitoring including central venous pressure, venous oxyhemoglobin saturation (ScvO2), and pulmonary artery catheter insertion and measures.
●Central venous access to facilitate insertion of emergency transvenous pacing lead.
●Acute high-volume blood exchange for extracorporeal therapy such as hemodialysis and plasmapheresis.
Relative contraindications — Contraindications to central venous catheterization are relative and depend upon the urgency and alternatives for venous access. While moderate-to-severe coagulopathy is a relative contraindication to central venous access, major bleeding is uncommon, and the need for emergency or urgent venous access may require cannulation despite coagulopathy. The low rate of bleeding complications (<1 percent) even with large-bore catheter placement in this circumstance is well documented.
In general, central venous access at sites that are easy to monitor for bleeding are preferred in patients with significant coagulopathy. Alternatives to the subclavian site are preferred when available because the subclavian site is more difficult to both monitor for bleeding and provide local compression to the puncture site if bleeding or inadvertent arterial puncture occurs. (See "Central venous access: Device and site selection in adults", section on 'Site comparisons'.)
SITE SELECTION — In acute or emergency situations, internal jugular access (especially right sided) has the lowest rate of catheter malposition and may be the optimal site for situations that require correct catheter tip positioning for immediate use, such as emergency drug administration or transvenous pacing [5] (table 1). The supraclavicular approach to the subclavian vein is another reasonable option [6].
Rapid intravenous access is essential during cardiopulmonary resuscitation (CPR). Insertion of a central venous catheter into the subclavian or internal jugular vein allows rapid delivery of medications to the heart during a low-flow state [7,8]. However, whereas subclavian insertion may interfere with chest compressions and internal jugular insertion may hinder intubation efforts, insertion into the femoral vein does not disrupt CPR. In a small trial of patients receiving CPR, real-time ultrasound-guided femoral catheterization was faster and more likely to be successful than alternative approaches [9].
For nonemergency but urgent access needs, the most appropriate site for central venous cannulation can be more individualized. Specific access sites (jugular, subclavian, femoral) and approaches have inherent advantages and disadvantages, which are reviewed elsewhere (table 1). (See "Central venous access: Device and site selection in adults", section on 'Benefits/risk for specific sites'.)
Available approaches for specific access sites are reviewed separately.
●Jugular venous catheters (see "Placement of jugular venous catheters", section on 'Specific approaches')
●Subclavian venous catheters (see "Placement of subclavian venous catheters", section on 'Approaches to the subclavian vein')
●Femoral venous catheters (see "Placement of femoral venous catheters", section on 'Femoral vein cannulation')
The anatomic site chosen for central catheter placement influences the risk for and type of complications [10]. Risks associated with catheters may be minimized with experienced clinician insertion of catheters, use of ultrasound guidance, appropriate sterile technique, and trained nursing staff catheter care [11]. We endorse adherence to sterile technique even for emergency procedures. If patient circumstances prevent appropriate precautions during insertion, the catheter should be replaced as soon as possible to reduce the risk of catheter-related infection. (See "Central venous access: Device and site selection in adults" and "Routine care and maintenance of intravenous devices", section on 'Catheter dwell time and replacement'.)
GENERAL TECHNIQUE — The placement of nontunneled central venous catheters follows a series of standard steps that adhere to common safety principles and are common to all vascular access procedures. The Seldinger guidewire method is the preferred approach [12]. This method gains access to the central vein via an introducer needle through which a matched guidewire is threaded to maintain venous access after needle withdrawal. The catheter is advanced into position over the intravascular guidewire, which is subsequently removed from the catheter. Details for the specific anatomic locations (jugular, subclavian, femoral) are discussed separately. (See "Placement of jugular venous catheters" and "Placement of subclavian venous catheters" and "Placement of femoral venous catheters".)
The steps for insertion of acute nontunneled central venous catheters are as follows:
●Obtain the equipment and devices needed for catheter placement (picture 1 and table 2).
●Prepare (consent, sedation) and position the patient.
●Identify pertinent surface landmarks with special attention to access to the intended puncture site.
●Confirm the location and patency of the target vein and relationship to surface landmarks with ultrasound, as available.
●Pause for a procedural time-out to verify the procedure, site, and technique with team members.
●Whenever available, use sterile technique to prepare the skin and drape the patient.
●Flush the sterile venous catheter lumens with sterile saline. Arrange and position central venous access supplies.
●Re-identify pertinent anatomic landmarks, even if ultrasound will be used. Reconfirm the vein target with ultrasound.
●Infiltrate the skin with local anesthetic (eg, 1 to 2% lidocaine, or an alternative agent).
●Use real-time ultrasound imaging to cannulate the vein via standard introducer needle, micropuncture needle (picture 2), or angiocatheter.
●After confirming venous blood return, insert the guidewire into the vein through the access needle or angiocatheter. (See 'Insert and advance the guidewire' below.)
•Maintain awareness of guidewire depth during insertion. The guidewire should be inserted just beyond the anticipated catheter depth, which is approximately 20 cm for adults and is often marked by two hash marks on the guidewire, while avoiding intracardiac advancement that may trigger arrhythmias.
•Confirm intravenous guidewire placement via ultrasound.
•Remove the needle or angiocatheter while controlling the guidewire.
●Use a #11 scalpel blade to make a single stab skin incision at the puncture site adjacent to the guidewire entrance and along the same trajectory.
●Advance the tissue dilator over the guidewire to the approximate depth of the vein, then remove the tissue dilator while maintaining guidewire position. (See 'Dilate the track' below.)
●Advance the venous catheter onto the guidewire while maintaining control of the guidewire at the skin entry site. Once the catheter is advanced over the guidewire to the level of the skin entry site, the guidewire is next backed out of the vein through the catheter until it emerges from the distal access port. This step allows continuous manual control of the guidewire to avoid inadvertent catheter insertion without guidewire removal, which is the common mistake leading to a retained guidewire. (See 'Insert catheter and remove guidewire' below.)
●Grasp and stabilize the guidewire as it exits the distal access port and advance the catheter over the guidewire into the vein.
●With the catheter in place, remove the guidewire, taking care to stabilize the catheter to maintain intravascular placement. Place the removed guidewire in a visible location on the sterile field as a confirmation step for guidewire removal. This also maintains guidewire sterility in case the guidewire is again needed to troubleshoot catheter malposition.
•Aspirate blood from each access hub and flush with sterile saline to ensure a functioning catheter. (See 'Catheter depth' below.)
●Secure the catheter into place with skin sutures and dress the site using sterile technique. (See 'Catheter fixation' below and 'Dressings' below.)
●In emergency situations, the central venous access may be used immediately. Confirmation of catheter tip position is often performed via chest radiography (for jugular and subclavian approaches only), as needed. (See 'Confirm catheter positioning' below.)
Prepare the patient — Nontunneled percutaneous central catheters are usually placed at the bedside. The equipment needed for central venous catheterization is provided in the table (table 2). Note that antimicrobial prophylaxis prior to percutaneous central venous catheter placement is not standard practice [13].
●Informed consent – Informed consent should be obtained for any central venous catheter, if possible; however, consent for vascular access is often implied with consent for emergency or critical illness treatment. Nevertheless, whenever possible, the procedure plan, including indications, benefits, and potential complications of the procedure (eg, pneumothorax), should be discussed with the patient and/or legal guardian. The potential need to perform a secondary procedure, such as chest tube placement to evacuate a pneumothorax, should also be conveyed. (See "Informed procedural consent".)
●Patient monitoring – All patients should be monitored during central venous access procedures, including continuous cardiac rhythm and pulse oximetry. Supplemental oxygen should be immediately available, and, for some patients, it may be prudent to administer oxygen by nasal cannula prior to covering the patient's head with drapes.
●Patient positioning – Once the access sites and approach are chosen, the patient is positioned to optimize patient and clinician comfort and cardiopulmonary stability. While preparing and draping the patient, a supine position is adequate. The bed or table should be placed at a height that allows the operator to remain comfortable throughout the procedure. The patient is positioned to maximize the diameter of the vein during the vascular access procedure, which depends upon the site selected. Although Trendelenburg position facilitates venous filling for jugular and subclavian access and may reduce the risk of venous air embolism [14-18], critically ill patients and patients with obesity may not tolerate this position. Evaluate patient tolerance for supine or Trendelenburg positioning prior to the procedure. Femoral vein dimension is improved with head-up reverse Trendelenburg positioning [19].
●Sterile technique – To reduce infectious complications, all central venous access procedures, including emergency procedures, should be performed with aseptic technique. This includes surgical antiseptic hand wash, long-sleeved sterile gown, surgical mask, gloves, head covering, and sterile drapes large enough to cover the entire patient, unless otherwise contraindicated due to patient situation [2,20-25]. (See "Overview of control measures for prevention of surgical site infection in adults", section on 'Infection control'.)
While emergency access needs are often voiced as justification to forego facets of sterile technique, the authors highlight that appropriate equipment stocking (eg, prepackaged sterile supplies, comprehensive prefabricated kits, procedure carts) allows rapid use of appropriate sterile technique to support emergency access without delay. Well-intended plans to remove or replace "resuscitation lines" following patient stabilization are not always completed in a timely fashion and contribute to catheter-associated infections.
•Site preparation – Hair should be clipped from the access site prior to skin preparation when time allows. Clipping is preferred to shaving [26]. When jugular or subclavian access is planned, preparing the skin of the neck and chest bilaterally facilitates access to alternative sites if the planned venous site cannot be cannulated.
•Skin antisepsis – Use of antiseptic solution for skin disinfection at the catheter insertion site reduces the risk of infection. A chlorhexidine-alcohol skin antiseptic solution should be applied to the access site and allowed to dry prior to draping the patient [27]. Chlorhexidine-based solutions (>0.5% chlorhexidine preparation with alcohol) are superior to aqueous and alcohol-based povidone-iodine in reducing the risk for catheter colonization and catheter-related bloodstream infection [27-29]. If there is a contraindication to chlorhexidine, alternatives such as tincture of iodine, an iodophor, or 70% alcohol can be used [30].
●Analgesia and sedation – Patient movement may preclude successful cannulation, and, in a conscious patient, every effort should be taken to ensure patient comfort and cooperation. This is accomplished using local anesthesia and sedation, if needed. Subcutaneous infiltration of local anesthetics (eg, 1 to 2% lidocaine, or an alternative agent) (table 3) provides appropriate anesthesia for most access procedures. Avoid injecting air into the subcutaneous tissues, as it will interfere with ultrasound transmission. (see "Subcutaneous infiltration of local anesthetics")
For patients who are awake and anxious, minimal sedation can be achieved with a low-dose, short-acting opioid or benzodiazepine to help the patient relax. Deeper sedation may be needed in uncooperative adults. (See "Procedural sedation in adults in the emergency department: General considerations, preparation, monitoring, and mitigating complications".)
Localize the vein — Familiarity with ultrasound-guided access is a critical aspect for the clinician performing central venous catheterization. When it is available and practical to use, we recommend ultrasound to guide vein localization during emergency or urgent central venous access. When ultrasound is not available or practical, central venous access relies on superficial anatomy (ie, landmark techniques) to guide access.
With ultrasound — Before cannulation, ultrasound performed by the clinician helps to confirm venous patency and identify anatomic variations to aid in selecting the most appropriate site of access. This is particularly useful in patients who have a history of prior instrumentation or deep vein thrombosis in the region of the proposed access site [31]. (See "Basic principles of ultrasound-guided venous access".)
Imaging during needle placement (ie, dynamic or real-time ultrasound) reduces time to venous cannulation and first needle pass success. The principles of ultrasound and techniques to identify venous structures for venous access are discussed in detail elsewhere.
While ultrasound guidance aims to integrate knowledge of pertinent anatomy with individualized detail to optimize the procedure, the use of ultrasound may also provide a false sense of security, especially to inexperienced clinicians. Thus, it is important to maintain attention to superficial landmarks to guide needle insertion site and depth of needle penetration to avoid mechanical complications, even with ultrasound guidance.
Without ultrasound — When ultrasound is not available or practical, central venous access requires technique relying on knowledge of anatomy (ie, landmark techniques) to guide access. The three major venous access points have consistent and recognizable relationships with superficial structures to aid in insertion. The needle entry site and trajectory depend on the target vessel and anatomic approach.
●(See "Placement of femoral venous catheters", section on 'Femoral vein anatomy'.)
●(See "Placement of subclavian venous catheters", section on 'Subclavian vein anatomy'.)
●(See "Placement of jugular venous catheters", section on 'Jugular vein anatomy'.)
In these cases, a small caliber (21 to 22 gauge) exploratory "seeker" needle, 3.5 cm in length, can be used to locate the target vein (picture 3). This minimizes injury in case of inadvertent arterial puncture. Use of the seeker needle is more common for internal jugular cannulation but can also facilitate subclavian and femoral venous access [32-34].
During attempted vein localization, continuous negative pressure is applied on the syringe plunger during both needle advancement and withdrawal. Vessel penetration will go unrecognized unless negative pressure is applied. Always advance and withdraw the needle along the same vector. Lateral movement of an inserted needle can lacerate vessels and should never be done. Withdraw the needle to level of the skin surface prior to redirection.
The steady flow of dark blood into the syringe confirms venous puncture. Following needle localization, take note of the trajectory and depth of the vein for subsequent venipuncture by the introducer needle, which should be directed along the same path. Alternatively, remove the syringe and leave the seeker needle in place to anchor the vessel and provide a guide for cannulation by the introducer needle [35]. Advance the introducer needle alongside (or in the same path as) the preceding seeker needle while applying negative pressure to the syringe.
Insert the introducer needle — Insert the introducer needle into the skin at the intended insertion site and apply continuous negative pressure on the syringe plunger. Penetration into the vein will go unrecognized unless negative pressure is applied, but only a small amount of continuous negative pressure is needed (approximately 1 cc of a 10 cc syringe) during forward advancement of the needle.
Traditionally, the needle bevel is inserted and directed in the anterior orientation known as "bevel up"; however, orienting the bevel of the needle posteriorly (bevel down) may decrease the risk needle tip penetration of the posterior vein wall, known as past-pointing [36].
Catheter-over-needle assemblies may also be used for initial venipuncture. These devices consist of an 18-gauge plastic catheter mounted on a 20-gauge needle. The needle tip is exposed and extends 2 mm distal to the catheter tip. To use the catheter-over-needle unit, attach it to a syringe and advance it into the target vessel as outlined above. Following blood aspiration, advance the needle another 2 to 3 mm to ensure intraluminal positioning of the catheter tip. Advance the catheter over the needle and into the vessel. The indwelling catheter (but not the needle) accommodates a standard guidewire. The catheter-over-needle technique is preferred by some operators but was associated with a lower rate of first-pass needle and guidewire insertion success compared with use of an introducer needle in one randomized trial [37].
With either needle type, the advancing introducer needle may compress but not puncture the compliant vein wall. This is often recognized as tenting of the vein during ultrasound-guided procedures in the absence of venous return in the syringe. The needle may ultimately compress the vessel and puncture the apposed anterior and posterior walls without entering the lumen. Failure to aspirate blood during needle advancement is common. As such, slowly withdraw the needle while maintaining continuous negative pressure and monitoring for blood aspiration. Half of internal jugular vein punctures are recognized during needle withdrawal rather than insertion, and this can occur at any site [38].
Steady unimpeded blood return confirms intraluminal placement. Stabilize the hub of the needle and carefully remove the syringe to avoid dislodgement from the vessel. Be suspicious of arterial puncture if bright red or pulsatile blood is seen. Cover the needle hub between manipulations to avoid air entry. Encourage patients to hum or perform Valsalva maneuvers to augment central venous pressure.
A learning curve exists for central venous access procedures. Experienced operators enjoy greater success rates with fewer complications [39]. Among experienced and inexperienced operators, the number of needle passes correlates with the complication rate, rising significantly following two to three unsuccessful passes [40-42]. After two or three unsuccessful needle passes, remove the needle completely and reassess the surface landmarks, use ultrasound, or consider obtaining assistance from a more experienced operator, if available [32,40,43].
Confirm venous location — During needle insertion, confirm an intraluminal position by the steady flow of dark blood into the syringe. Bright red or high-pressure pulsatile blood are important but imperfect clues to arterial puncture [44].
Isolated arterial needle puncture is one of the most common complications of venous access but is typically uneventful, if recognized early [45]. Conversely, dilation and cannulation of an artery with a large-bore catheter can be associated with severe complications including hemorrhage and vessel thrombosis.
Be aware that distinguishing arterial access from venous access based on the color of the blood or blood flow is imperfect [44]. Dark nonpulsatile blood generally confirms venous access, but arterial desaturation, hypotension, or needle malposition may mask arterial cannulation, particularly during emergency access. If there is any doubt about needle position, confirm venous location by directly transducing the needle or by replacing the needle over the guidewire (without intervening tissue dilation) with a 6 cm, 18-gauge single-lumen transduction catheter or angiocatheter (algorithm 1) [40,44,46,47]. Connection to a pressure line and transducer enables inspection of pressure and waveform tracings on the monitor. Alternatively, a simple length of vertical saline-filled intravenous tubing can be used to confirm venous pressure with respiratory variation. A blood gas drawn from the site and compared with a distant arterial sample is an alternative, albeit more time-consuming, means of discrimination.
Insert and advance the guidewire — Once the introducer needle is in place, the guidewire is inserted. For central venous access, a flexible J-tip guidewire is favored to easily negotiate vessel curves and avoid vessel trauma during passage (picture 4). Prior to guidewire placement, orient the needle bevel to facilitate guidewire passage into the superior vena cava (SVC) or inferior vena cava (IVC) to avoid catheter malposition [48]. The advancing guidewire will veer in the direction of the needle bevel. A medial bevel orientation optimizes jugular and supraclavicular subclavian cannulation, while caudal bevel orientation should be used for subclavian cannulation by the infraclavicular approach to guide the wire into the superior vena cava.
To introduce the guidewire into the needle hub, position the tapered plastic sleeve to straighten the distal J-tip (picture 5). Advance the guidewire with the J-tip oriented toward the SVC. The concept is similar to bevel direction for needle insertion. Directing the J-tip caudally reduces the risk of subclavian catheter malposition [49,50].
The guidewire should pass smoothly and easily thorough the needle, dilator, or catheter with minimal resistance. Do not use undue force, which can permanently kink an obstructed guidewire. Resistance to guidewire passage may be due to needle dislodgement from the target vessel, compression of the guidewire tip against the vessel wall, or anatomic obstruction. When resistance occurs, repeat aspiration of blood to confirm intraluminal needle position. Consider lowering the needle angle to lie along the plane of the vessel. Rotate the needle and/or guidewire to reorient the bevel or J-tip to relieve impingement of the guidewire on the posterior vessel wall. Avoid kinking of the guidewire by advancing it steadily with gentle force. Never forcefully advance the guidewire, as this will kink and permanently deform the wire and risks vessel injury.
An important principle of guidewire management is that the guidewire should pass easily into and out of the indwelling needle, dilator, or catheter. Resistance during guidewire withdrawal or extraction through any companion device may signify a kinked or severely deformed indwelling guidewire. Never forcibly withdrawal a kinked guidewire in this situation, as this risks shearing the wire with subsequent embolization [51]. Instead, the guidewire and companion device should be withdrawn as a single unit. Under most circumstances, extraction of a deformed guidewire will not cause significant vein injury during removal in this manner. Any resistance to simultaneous removal of the guidewire and companion device may indicate guidewire entrapment and warrants diagnostic radiography to confirm device position as the next step.
Keep the guidewire under constant manual control to avoid loss and maintain sterility. Commercial venous access kits commonly include guidewires measuring over 50 cm in length. However, the guidewire should only be inserted to reach the appropriate anatomic target. One study demonstrated that the cava-atrial junction averaged just 16 cm from the right internal jugular vein access site, 18.4 cm from the right subclavian vein, 19.1 cm from the left internal jugular vein, and 21.2 cm from the left subclavian vein [52]. Advancing the guidewire substantially further risks intracardiac or IVC placement with the potential for cardiac arrhythmia, perforation, and snaring of intravascular devices [53]. Guidewires (and catheters) rarely require positioning more than 18 cm deep [52,54]. The length of guidewire remaining outside the patient must be manually controlled to avoid contamination.
Dilate the track — Central venous catheters are larger caliber than the needle and guidewire used for venous access. Dilation of the subcutaneous soft-tissue track is required for catheter insertion. Make a controlled 3 mm deep stab incision in the skin and fascia at the entry site with a number 11 scalpel. Thread the stiff tapered dilator over the wire and position it 3 to 4 cm above the skin incision.
Thread the free end of the guidewire until the tip emerges from the dilator's back end and manually stabilize it prior to advancing the dilator. Control the guidewire to avoid dislodgement and embolization during manipulations. Grasp the dilator 2 cm above the skin entry point and advance it over the immobilized guidewire with a firm corkscrew motion (picture 6). Mild resistance is normal. Excessive resistance may represent an inadequate skin incision, a malpositioned guidewire, or guidewire deformation. Advancement of a kinked guidewire during dilation can cause vessel trauma and puncture [55].
Advance the dilator only to the anticipated depth of the vessel, which approximates the needle depth at the point of blood return. Insertion of the entire length of the dilator is rarely needed, and many access kits include tissue dilators that are longer than the accompanying introducer needle. Remember that the tissue dilator is not intended to dilate the target vein. Forceful insertion of the dilator farther than needed risks guidewire distortion and vascular injury.
Next, withdraw the dilator while maintaining guidewire position within the vessel. Apply direct pressure at the puncture site to maintain hemostasis prior to the next step of catheter insertion.
The placement of a venous sheath (ie, Cordis, a large-bore, nontunneled device with a sideport used for fluid administration or placement of a pulmonary artery catheter or a pacemaker wire) uses a combined sheath/dilator assembly. Insertion requires a minor variation in the standard technique. Once the guidewire is in place and a skin incision is made, the tissue dilator and sheath are advanced over the guidewire together as a unit without the need for an intervening tissue dilator step.
Insert catheter and remove guidewire — To place the catheter, thread the catheter onto the wire through the distal tip lumen (picture 7). Similar to the former dilator step, advance the guidewire back through the catheter until it emerges from the distal port. After the wire is secured at its exit from the distal port, advance the catheter over the wire into the vein, maintaining strict control of the external guidewire (picture 8).
This step emphasizes continuous manual control of the guidewire to avoid inadvertent catheter insertion without guidewire removal, which is a common mistake leading to a retained guidewire.
Occasional resistance to catheter advancement occurs due to the guidewire flexing under pressure of the stiff dilator advancing through the interface of deep tissue planes. This can often be overcome by simultaneously advancing the catheter and wire as a single unit for 2 to 3 cm while maintaining direct continuity with the wire as it exits the distal port.
The guidewire is next withdrawn and removed while maintaining the newly inserted vascular catheter in place. Two steps to assure guidewire removal during the procedure are recommended: verbalizing that the guidewire has been removed at the time of withdrawal and placement of the removed guidewire on a specific and consistent location of the sterile field.
To complete placement of a venous sheath (ie, Cordis), following insertion of the assembly, remove the dilator and guidewire together, leaving the indwelling sheath in position. Once the sheath is in place, the side port is aspirated and irrigated to check function, and the sheath is secured to the skin at its exit site.
Catheter depth — The distal tip of subclavian and jugular catheters should lie in the lower SVC [40,54]. Ideal insertion distance varies by patient size and anatomic site. Initial insertion depth for most adults should be 16 to 18 cm for right-sided internal jugular catheters, 20 cm for left-sided internal jugular and subclavian vein catheters, and 15 to 30 cm for femoral venous catheters [32]. During urgent or emergency central venous access, to minimize intracardiac placement, do not insert catheters more than 18 cm from any torso site [52,54].
Aspirate blood from all catheter lumens to confirm intravascular positioning and to avoid tissue extravasation of drugs from the proximal port due to inadequately inserted catheters [32,56]. Flush each port following aspiration (picture 9).
Catheter fixation — Suture the catheter securely to the skin to prevent inadvertent dislodgement (picture 10). Place a 2-0 silk suture through the skin and tie it loosely (air knot) to avoid pressure necrosis of the skin anchor. Next secure the suture to the catheter hub. Use the additional clamp anchor at the skin insertion site if more than 2 cm of catheter remains exposed. Secure each anchor point with two separate sutures. (See "Routine care and maintenance of intravenous devices", section on 'Dressing and securement'.)
Dressings — A sterile dressing is placed overlying the exit site of the catheter as determined by local hospital practice or policy. The selection of dressing and whether medicated dressings help prevent infection is reviewed separately. (See "Routine care and maintenance of intravenous devices", section on 'Dressing and securement'.)
Confirm catheter positioning — In emergency situations, central venous catheters may be used immediately following insertion, assuming there is no concern for procedure-related complications and there is verification of venous insertion based on blood aspiration and easy catheter flushing. Catheters generally function well with the tip situated in any major vein.
In nonemergency situations, a postprocedure chest radiograph is recommended to confirm catheter course and tip position prior to the use of jugular and subclavian catheters; femoral catheters do not require radiologic confirmation of position prior to use. Routine radiography to confirm apparently uncomplicated right internal jugular catheter placement has been questioned [57-59]. Alternatives to radiography to confirm catheter tip position include ultrasound and transesophageal echocardiography, which are particularly useful in critical care settings and in the operating room [60-62].
If a catheter is misplaced into an incorrect vein, it should be repositioned as soon as possible, but it may still be used for fluid administration under emergency circumstances.
The optimal positioning of the catheter tip depends on the specific access site:
●(See "Placement of jugular venous catheters", section on 'Confirmation of jugular catheter position'.)
●(See "Placement of femoral venous catheters", section on 'Confirmation of femoral catheter position'.)
COMPLICATIONS — The complications related to central venous access (table 4) are discussed separately. (See "Central venous catheters: Overview of complications and prevention in adults".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Venous access".)
SUMMARY AND RECOMMENDATIONS
●Indications for acute/emergency central venous access – Central venous catheters (multilumen, single lumen, venous sheath) provide dependable acute and emergency intravenous access to manage acute illness by the administration of fluids and medications, hemodynamic monitoring, and extracorporeal therapy (eg, hemodialysis, plasmapheresis). (See 'Urgent or emergency indications' above.)
●Contraindications to acute/emergency central venous access – Moderate-to-severe coagulopathy is a relative contraindication to central venous access. In general, however, the need for emergency or urgent venous access may require venous cannulation despite coagulopathy. Bleeding complications in this circumstance are uncommon. A subclavian vein approach is preferably avoided if an alternative access is available. (See 'Relative contraindications' above.)
●Techniques – Central venous catheterization is performed through a series of well-defined steps, the details of which are important for safe catheter insertion. Venous sheaths are placed in a similar manner. (See 'General technique' above.)
•All central venous access procedures, including emergency procedures, should be performed with aseptic techniques. (See 'Prepare the patient' above.)
•Ultrasound guidance is recommended for placement of all central venous access devices, but ultrasound may not be available or practical to guide emergency or urgent central venous access in all situations, in which case anatomic landmark techniques are relied upon for safe central venous access. (See 'Localize the vein' above.)
•Aspiration of dark, nonpulsatile blood generally confirms venous access but is an imperfect sign of venous cannulation. If there is any doubt about needle position, confirm the location by transducing the vessel pressure prior to catheter insertion (algorithm 1). (See 'Confirm venous location' above.)
•The initial catheter insertion depth for most adults should be 16 to 18 cm for right-sided jugular and subclavian catheters and 20 cm for left-sided jugular and subclavian catheters. (See 'Catheter depth' above.)
•Central venous catheters placed for emergency situations may be used immediately following insertion, assuming there is no concern for procedure-related complications and verification of venous insertion based on blood aspiration and easy catheter flushing. (See 'Confirm catheter positioning' above.)
•In nonemergency situations, a postprocedure chest radiograph is recommended to confirm placement of jugular and subclavian catheters prior to use; femoral catheters do not require radiologic confirmation of position prior to use. (See 'Confirm catheter positioning' above.)
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