What is the most common fail point for central line (central venous catheter) insertion?

Most Common Fail Points for Central Line Insertion

The most common fail point for central venous catheter (CVC) insertion is difficult venous access, which occurs frequently and is more likely with previous multiple attempts, insertion site scars, and long-term access. 1

Anatomical and Technical Fail Points

Venous Access Difficulties

• Anatomical variations: A relevant proportion of patients have anatomical variations in the internal jugular, subclavian, and femoral veins that cannot be identified using landmark techniques 1
• Venous thrombosis: Especially common in oncologic and critically ill patients, making CVC placement impossible or dangerous 1
• Previous multiple attempts: Significantly increases difficulty of access 1
• Insertion site scars: Create challenges for subsequent access 1

Procedural Complications

• Operator inexperience: Operators with <25 previous insertions have significantly higher complication rates (25.2% vs 13.6%) 2
• Inadequate supervision: Higher levels of supervision are significantly associated with decreased complications (10.7% vs 23.8%) 2
• Site selection: Subclavian vein access results in significantly more overall complications (29.2% vs 17.7%) compared to other sites 2
• Guidewire advancement issues: Guidewires are prone to kinking, particularly during advancement of dilators 1

Specific Complications During Insertion

Vascular Complications

• Arterial puncture: Occurs in 16.2 per 1000 catheters placed 3
  • Significantly more frequent when ultrasound is not used (7.2% vs 2.1%) 2
  • More common at the subclavian site (8% vs 1.6%) 2
• Arterial cannulation: Occurs in 2.8 per 1000 catheters placed 3

Technical Failures

• Placement failure: Occurs in 20.4 per 1000 catheters placed 3
• Pneumothorax: Occurs in 4.4 per 1000 catheters placed 3
• Catheter misplacement: More common with left-sided approaches due to anatomical differences 4

Prevention Strategies

Ultrasound Guidance

• Ultrasound use significantly reduces arterial puncture (risk ratio 0.20; 13.5 vs 68.8 events/1000 catheters) 3
• Ultrasound use significantly reduces pneumothorax (risk ratio 0.25; 2.4 vs 9.9 events/1000 catheters) 3

Site Selection and Operator Experience

• The internal jugular vein should be the primary target vessel 2
• Trainees with <25 previous catheter insertions should be supervised at all times 2
• If difficulty is predicted, insertions should be performed under X-ray control 1

Equipment Considerations

• Use high-resolution ultrasound with color Doppler to study flow 1
• Have a 'difficult access' trolley available with additional instruments, including:
  • X-ray contrast
  • Standard (18G) and micro-puncture needles (20-21G)
  • Compatible guidewires (0.018″ and 0.32″)
  • Various guidewire tips (straight, angled, soft tip, full 'J') 1

Special Considerations

Pediatric Patients

• Guidewires are narrower (0.021″ vs 0.032″ in adults) and more prone to kinking 1
• The diameter of a 'J' tip may impede advancement in a narrow vein 1
• Veins are prone to compression by the probe and access needle, risking transfixion 1

Coagulopathic Patients

• More experienced operators should insert the CVC 1
• Choose insertion sites that allow easy compression of vessels 1
• Femoral access may have lower risk in coagulopathic patients 1

By addressing these common fail points through proper technique, appropriate equipment, adequate training, and use of ultrasound guidance, the morbidity and mortality associated with central line insertion can be significantly reduced.