Indications
| Indication | Clinical Context |
|---|---|
| Hemodynamic monitoring (CVP, ScvO2) | Septic shock, major surgery, cardiac monitoring |
| Vasopressor/irritant drug infusion | Vasopressors, concentrated potassium, TPN, chemotherapy — peripheral IVs unsuitable |
| Inadequate peripheral venous access | Chronic IV drug use, prior chemotherapy, obesity, frequent blood draws |
| Rapid large-volume resuscitation | Trauma, massive transfusion protocol (introducer sheath) |
| Hemodialysis (temporary) | See tunneled catheter guide for long-term; non-cuffed for urgent HD |
| Transvenous pacing wire or PA catheter | Need for large central access in monitored patients |
Contraindications
- Thrombosis of target vessel — assess with ultrasound before attempted access.
- Overlying infection or hematoma at access site.
- Known coagulopathy: INR >2.5 or platelets <50,000 — correct before elective placement; emergent access may override.
- Ipsilateral mastectomy with axillary node dissection — avoid subclavian/IJV on that side.
- Superior vena cava syndrome — consider femoral or direct SVC approach (with procedural team discussion).
Relevant Anatomy
Right Internal Jugular Vein (IJV)
The right IJV lies lateral to the carotid artery at the midcervical level and provides the most direct route to the SVC. Avoid the carotid artery (medial) and, on the left side, the thoracic duct. Optimal patient position: 15–20° Trendelenburg to distend the vein and reduce air embolism risk, head turned slightly to the contralateral side.
Subclavian Vein
The subclavian vein passes beneath the clavicle over the first rib and joins the IJV at the brachiocephalic (innominate) vein. The infraclavicular approach is most common. Do not puncture below the first rib — the lung apex sits immediately inferior and posterior, and an errant needle trajectory risks pneumothorax. The subclavian site carries the lowest infection rate of the three standard sites but the highest pneumothorax risk; ultrasound guidance substantially mitigates this.
Femoral Vein
The femoral vein lies medial to the femoral artery in the femoral triangle, below the inguinal ligament. It carries the highest infection risk of the standard sites and is least preferred for indwelling lines; use when upper-body access is impossible. Ultrasound guidance is the standard of care.
Catheter Tip Position
The optimal tip position is the SVC-RA junction (cavo-atrial junction, CAJ) — lower SVC to CAJ as confirmed on fluoroscopy or post-placement CXR. A tip positioned in the right atrium increases arrhythmia and cardiac perforation risk. A tip terminating in the subclavian or innominate vein is too proximal and increases thrombosis and catheter malfunction risk.
Pre-Procedure Checklist
Site Assessment
- Ultrasound survey of target vein before draping — confirm patency, compressibility, and absence of thrombus
- Document bilateral survey if subclavian access is considered
- Identify arterial anatomy relative to target vein at planned puncture site
Labs
- Platelet count and INR/PT; correct severe coagulopathy before elective placement
- Target platelets >50,000 and INR <2.5 for elective cases; emergent access may require accepting elevated risk with manual pressure backup
Consent
Discuss: arterial puncture (~1–2% IJV; higher with landmark technique), pneumothorax (~1–3% subclavian), hematoma, catheter malposition, infection (CLABSI 1–5 per 1,000 catheter-days), venous thrombosis, and air embolism.
Procedure Overview
The following is a high-level summary. Full real-time ultrasound technique, fluoroscopy-guided tip positioning, difficult access strategies, and tip malposition correction protocols are available in RadCall Pro.
- Patient positioning — Trendelenburg 15–20° for IJV/subclavian (distends vein, reduces air embolism risk); supine for femoral.
- Sterile preparation — maximal sterile barrier (gown, gloves, full drape, cap, mask); chlorhexidine-alcohol skin prep; allow to dry completely before needle entry.
- Ultrasound vein survey — confirm vein patency and diameter, identify artery position relative to vein; mark optimal puncture site.
- Local anesthesia — 1% lidocaine at skin entry and deeper tissues in line with planned needle trajectory.
- Venous puncture — real-time ultrasound guidance (in-plane or out-of-plane technique); aspirate dark, non-pulsatile venous blood; advance guidewire under fluoroscopy or ultrasound; confirm wire in vein (not artery — compare pulsation with contralateral carotid on fluoroscopy; consider pressure transduction if arterial placement uncertain).
- Tract dilation — single-step or sequential dilation over wire; hold firm pressure at skin entry while wire is secured; never lose control of the wire.
- Catheter advancement — advance catheter over wire to appropriate depth; withdraw wire; aspirate blood from each lumen to confirm patency; flush and cap all lumens.
- Tip verification — fluoroscopy preferred intra-procedurally for real-time tip localization; post-placement CXR confirms tip at CAJ; a catheter that is kinked, coiled, or in the wrong vessel requires repositioning before use.
- Securing catheter — suture to skin; apply sterile occlusive dressing with chlorhexidine-impregnated disk; document tip position and procedure details in procedure note.
Complications
| Complication | Rate | Management |
|---|---|---|
| Arterial puncture | ~1–2% (IJV); higher with landmark technique | If only needle in artery — withdraw and apply manual pressure for 10–15 min; if dilator or catheter placed in artery — do NOT remove without vascular surgery consultation; surgical repair typically required to avoid uncontrolled hemorrhage |
| Pneumothorax | 1–3% (subclavian), <1% (IJV) | CXR immediately post-procedure; small/asymptomatic — observation; large or symptomatic — chest tube (see chest tube guide) |
| Air embolism | Rare | Trendelenburg position and controlled breathing during wire/catheter exchanges reduce risk; if suspected — left lateral decubitus (Durant maneuver), 100% O2, aspiration via catheter if in-situ, urgent resuscitation |
| Catheter malposition | Up to 5–10% (variable by site) | Tip in wrong vessel or too high/low; reposition under fluoroscopy before use; do not administer vasoactive or hyperosmolar agents through a malpositioned catheter |
| Hematoma | 1–2% | Manual compression; if expanding or arterial source suspected — vascular surgery involvement; CT for large or hemodynamically significant hematomas |
| CLABSI | 1–5 per 1,000 catheter-days | Strict aseptic insertion technique and daily necessity review are primary prevention; treatment with antibiotics ± line removal per ID guidance; do not routinely change catheters over wire to treat suspected CLABSI |
| Venous thrombosis | ~3–5% per catheter | Anticoagulate if symptomatic; avoid femoral site when possible; routine surveillance ultrasound not indicated for asymptomatic patients |
Post-Procedure Care
- Confirm tip position on fluoroscopy or CXR before using the catheter for infusion of vasoactive or irritant agents.
- Daily assessment of CLABSI risk — remove line as soon as the clinical indication resolves.
- Dressing change: chlorhexidine-impregnated disk + transparent occlusive dressing every 7 days or when soiled/non-occlusive.
When to Escalate
- Arterial injury with dilator or catheter in artery — call vascular surgery immediately before any manipulation; do not remove the device; hold device in place to tamponade hemorrhage until surgical repair is available.
- Tension pneumothorax — emergency needle decompression (2nd intercostal space, midclavicular line) followed by chest tube; do not wait for CXR confirmation if clinical diagnosis is clear.
- Wire lost or catheter embolism — fluoroscopic localization; percutaneous snare retrieval under IR guidance.
- Persistent CLABSI despite antibiotics — line removal and source control; ID consultation; consider septic thrombophlebitis if fever persists after line removal.
References
- Lalu MM et al. Ultrasound-guided subclavian vein catheterization. JAMA. 2015;313(5):522.
- Parienti JJ et al. Intravascular complications of central venous catheterization by insertion site. N Engl J Med. 2015;373(13):1220–1229.
- Marschall J et al. SHEA/IDSA practice recommendation: strategies to prevent CLABSI. Infect Control Hosp Epidemiol. 2014.
- Frykholm P et al. Clinical guidelines on central venous catheterisation. Acta Anaesthesiol Scand. 2014.
- McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. 2003;348(12):1123–1133.