What is the procedure for central venous catheter placement?

Central Venous Catheter Placement Procedure

Use real-time ultrasound guidance for all central venous catheter insertions, following a systematic six-step approach that includes pre-procedure vessel assessment, real-time needle guidance, and confirmation of needle, wire, and catheter position. 1, 2

Pre-Procedure Preparation

Equipment Assembly

• Gather sterile drapes, personal protective equipment (hat, mask, sterile gloves, sterile body gown), ultrasound machine with high-frequency linear probe, sterile ultrasound probe cover, sterile gel, and central venous catheter kit 3
• Use a standardized equipment set and follow a checklist or protocol 3

Patient Positioning

• Place the patient in Trendelenburg position (15-30 degrees head-down) to distend the vein and increase cross-sectional area, improving cannulation success 2, 4, 3
• Minimize head rotation during internal jugular vein access to reduce arterial-venous overlap 3

Site Selection Strategy

Preferred Access Sites (in order of recommendation)

1. Internal jugular vein (IJV) - FIRST CHOICE: Lowest complication risk, with ultrasound guidance reducing total complications from 13.5% to 4.0% and increasing success rate from 87.6% to 97.6% 2, 5
2. Subclavian vein: Higher risk of pneumothorax and catheter-related complications, but lower infection risk than femoral 4
3. Femoral vein - AVOID when possible: Associated with high infection risk and catheter-related venous thrombosis 2, 4

Specific IJV Approach

• Use the low lateral approach (Jernigan's approach) for the internal jugular vein, which has the lowest risk of mechanical complications 2

Systematic Six-Step Ultrasound-Guided Approach

Step 1: Assess the Target Vein

• Use ultrasound to identify the target vein, adjacent artery, and surrounding anatomic structures in both short-axis (transverse) and long-axis (longitudinal) views 1, 3
• Check for anatomic variations, which occur in a significant proportion of patients and cannot be detected by landmark techniques alone 1, 3
• Test vein compressibility by applying pressure with the probe to confirm patency and exclude venous thrombosis 1
• Identify the artery as a circular pulsatile structure and the vein as an oval, non-pulsatile, compressible structure 6

Step 2: Establish Sterile Field

• Prep and cover the puncture site with a large sterile drape 1
• Wear full sterile barriers: hat, mask, sterile gloves, and sterile body gown 1
• Cover the ultrasound probe and cable with a sterile cover/shield 1
• Use sterile conductive medium (ultrasound gel) 1

Step 3: Use Real-Time Ultrasound Guidance for Needle Puncture

• Position yourself so the insertion site, needle, and ultrasound screen are in your line of sight during needle insertion 1
• Hold the ultrasound probe with your non-dominant hand while advancing the needle with your dominant hand (single-operator technique) 1
• Choose between two ultrasound approaches:
  • Short-axis/out-of-plane view: Easier to learn, better visualization of vein-artery relationship, higher first-attempt success rate among experienced users 1
  • Long-axis/in-plane view: Allows visualization of entire needle course and tip depth, reducing risk of posterior wall penetration 1
• Constantly identify the needle tip with ultrasound during advancement to the vein 1

Step 4: Confirm Needle Position in the Vein

• Use real-time ultrasound to confirm the needle tip is placed centrally in the vein before advancing the guide wire 1
• Verify in both short-axis and long-axis views 1
• Use color Doppler imaging to further confirm patency and blood flow 1

Step 5: Confirm Wire Position in the Vein

• After wire advancement, confirm correct guide wire position in both short-axis and long-axis ultrasound views 1
• Ensure the wire is not in the artery by verifying venous placement with ultrasound, manometry, or pressure waveform 3

Step 6: Confirm Catheter Position in the Vein

• After catheter placement over the guide wire, visualize correct catheter position in the vein using ultrasound in both short-axis and long-axis views 1
• Position the catheter tip in the lower third of the superior vena cava, at the atrio-caval junction, or upper portion of the right atrium 2, 4
• This location has the least incidence of mechanical and thrombotic complications 2, 4

Post-Procedure Verification

• Obtain a chest X-ray when the tip position is not confirmed intra-operatively or when using the blind subclavian approach 2, 3
• Check for wire retention in the vascular system if the complete guidewire cannot be located in the procedural field 3

Evidence-Based Benefits of Ultrasound Guidance

Ultrasound guidance provides dramatic improvements across all metrics:

• Reduces total complications by 71% (RR 0.29) 1
• Reduces arterial puncture by 72% (RR 0.28) 1
• Reduces hematoma formation by 73% (RR 0.27) 1
• Increases first-attempt success by 57% (RR 1.57) 1
• Decreases number of attempts by 1.19 attempts on average 1
• Decreases time to successful cannulation by 30.52 seconds 1

These benefits are consistent across both experienced and inexperienced operators 2, 5

Common Pitfalls and How to Avoid Them

Critical Errors to Avoid

• Never rely solely on anatomic landmarks without ultrasound guidance, as anatomic variations occur frequently and increase complication risk 3
• Do not place the catheter tip too deep into the atrium near the tricuspid valve, as this increases mechanical and thrombotic complications 2
• Avoid surgical cutdown, as it is not cost-effective and increases infection risk 2

Management of Complications

• If unintended arterial cannulation with a large-bore catheter occurs, leave the catheter in place and immediately consult vascular surgery or interventional radiology 3
• Do not remove a large-bore catheter from an artery without surgical backup available 3

Technical Considerations by Site

For Subclavian Approach

• Use a thin-wall needle (Seldinger) technique rather than catheter-over-needle technique 4, 3
• Be aware of higher risks: pneumothorax, catheter fatigue, "pinch-off syndrome," and potential catheter fracture 4
• The infraclavicular area facilitates easier dressing changes compared to neck exit sites 4

For Internal Jugular Approach

• Either thin-wall needle or catheter-over-needle technique is acceptable based on operator experience 3
• The low lateral approach has the lowest mechanical complication risk 2