How can the success rate for central line (central venous catheter) insertion be increased?

How to Increase Success Rate for Central Line Insertion

Use real-time ultrasound guidance for all central venous catheter insertions—this is the single most evidence-based intervention to increase success rates and reduce complications. 1

Primary Technique: Real-Time Ultrasound Guidance

Ultrasound guidance is strongly recommended (Grade A) for all CVC insertions regardless of operator experience. 1 The evidence is compelling:

• For internal jugular vein access: Ultrasound increases overall success rate from 87.6% to 97.6% and reduces total complications from 13.5% to 4.0% 1
• Reduces arterial puncture, hematoma formation, number of attempts, and time to successful cannulation 1
• Benefits are consistent across both experienced and inexperienced operators 1

Ultrasound Approach Selection

For experienced operators, use the short-axis/out-of-plane approach for higher first-attempt success rates 1:

• Better visualization of vein-to-artery relationship
• Easier to learn for novice users 1
• Higher success rate with first attempt for IJV and subclavian vein 1

For enhanced safety, consider the long-axis/in-plane approach 1:

• Visualizes entire needle course and tip depth
• Reduces risk of posterior vessel wall penetration 1
• Experienced users can employ oblique axis view (45° angle) to combine advantages 1

Site Selection Strategy

Prioritize the internal jugular vein over subclavian vein for lower complication risk 1:

• IJV carries less risk of insertion-related complications compared to subclavian 1
• The low lateral approach to the IJV (Jernigan's approach) has the lowest risk of mechanical complications 1

Avoid femoral vein access when possible 1:

• Associated with high risk of infection and catheter-related venous thrombosis 1
• Relatively contraindicated for parenteral nutrition (Grade C) 1

Optimal Patient Positioning

Place patient in Trendelenburg position 2:

• Distends the vein and increases cross-sectional area 2
• Improves likelihood of successful cannulation 2

Catheter Tip Positioning

Position the catheter tip in the lower third of the superior vena cava, at the atrio-caval junction, or upper portion of right atrium (Grade A) 1:

• This location has the least incidence of mechanical and thrombotic complications 1
• Check tip position during the procedure, especially with infraclavicular subclavian approach (Grade C) 1
• Obtain post-procedure chest X-ray when tip position not confirmed intra-operatively or when using blind subclavian approach (Grade B) 1

Procedural Verification Steps

Visualize the needle tip AND guidewire in the target vein before vessel dilatation 3:

• Confirms proper placement before advancing catheter 3
• Prevents complications from misplaced access 3

Use ultrasound to detect bilateral lung sliding before and after IJV/subclavian CVC insertion to rule out pneumothorax 3

Consider using ultrasound with rapid infusion of agitated saline to visualize right atrial swirl sign (RASS) for detecting catheter tip misplacement 3

Equipment Optimization

Use high-frequency linear transducer with sterile sheath and sterile gel 3

Consider echogenic needles, plastic needle guides, or ultrasound beam steering when available to increase success rates 3

Infection Prevention Bundle

Combine ultrasound guidance with maximal sterile barrier precautions 3:

• Use standardized procedure checklist 3
• 2% chlorhexidine for skin antisepsis 1
• Proper hand washing and staff education 1
• These measures together reduce infectious complications 3

Training Requirements

Ensure operators complete systematic training before independent practice 3:

• Combination of simulation-based practice and supervised patient insertions 3
• Minimum competency assessment including: anatomical knowledge, no technical errors on checklist, complication recognition, and real-time needle tip tracking with first-attempt success in at least five consecutive simulations 3
• Periodic proficiency reassessment to maintain competency 3

Special Considerations for Pediatric Patients

The evidence in children is more limited and somewhat conflicting 1, 4. However, meta-analysis shows ultrasound-guided CVC placement in pediatric patients significantly increases success rates by 31.8% and decreases mean number of attempts required 5. Despite one older study showing different results 1, the preponderance of evidence supports ultrasound use in children 5.

Common Pitfalls to Avoid

• Do not use static ultrasound alone to mark needle insertion site—always use real-time dynamic guidance 3
• Avoid surgical cutdown—not cost-effective and increases infection risk (Grade A) 1
• Do not place catheter tip too deep into atrium near tricuspid valve—increases mechanical and thrombotic complications 1
• Integrate anatomical landmark knowledge with ultrasound skills—understanding anatomy remains crucial for proper probe positioning and image interpretation 2