What are the best practices for central line (Central Venous Catheter) insertion?

Central Line Insertion: Best Practices

Use real-time ultrasound guidance for all central venous catheter insertions, particularly for the internal jugular vein, combined with maximal sterile barrier precautions and chlorhexidine-based skin preparation to minimize mechanical complications, infections, and mortality. 1

Pre-Procedure Preparation

Equipment and Environment Setup

• Assemble a standardized equipment cart containing all necessary supplies before beginning the procedure 1
• Use a procedural checklist to ensure all steps are followed systematically 1
• Have an assistant present during catheter placement 1
• Perform the procedure in an environment that permits strict aseptic technique 1

Operator Training and Competency

• Complete systematic training that includes simulation-based practice, supervised patient insertions, and expert evaluation before performing independent insertions 2
• Demonstrate competency in real-time needle tip tracking with ultrasound and successful cannulation on first attempt in at least five consecutive simulations 2
• Undergo periodic proficiency assessments to maintain competency 2

Infection Prevention Measures

Hand Hygiene and Barrier Precautions

• Perform hand hygiene using alcohol-based waterless product or soap and water immediately before the procedure 1
• Apply maximal sterile barrier precautions: all operators must wear sterile gown, sterile gloves, cap, and mask covering both mouth and nose 1
• Cover the patient with a full-body sterile drape 1

Skin Preparation

• Use alcoholic chlorhexidine solution containing at least 2% chlorhexidine for skin preparation in adults, infants, and children 1
• Allow the antiseptic solution to dry completely before making the skin puncture 1
• For neonates, base the use of chlorhexidine on clinical judgment and institutional protocol due to potential skin injury risk in infants <1000 grams and <7 days postnatal age 1
• If chlorhexidine is contraindicated, use povidone-iodine or alcohol as alternatives; skin preparation solutions should contain alcohol unless contraindicated 1

Additional Infection Prevention

• Administer daily chlorhexidine preparation baths to ICU patients aged over two months 1
• Do not routinely administer intravenous antibiotic prophylaxis; consider it only on a case-by-case basis for immunocompromised patients and high-risk neonates 1

Site Selection Strategy

Prioritization by Infection and Thrombosis Risk

• Select an upper body insertion site (internal jugular or subclavian) when possible to minimize thrombotic complications compared to femoral site 1
• Avoid the femoral site in ICU settings to minimize infectious complications 1
• Recent evidence shows peripherally inserted central catheters (PICCs) have the lowest CLABSI risk compared to other central line types 1

The femoral site carries significantly higher infection and thrombosis risk, though it may be necessary in specific clinical scenarios such as patients requiring or anticipated to require hemodialysis (where subclavian should be avoided due to stenosis risk) 1. For neonates, tunneled femoral catheters with exit sites outside the diaper area on mid-thigh may provide acceptable safety 1.

Site-Specific Considerations

• Base insertion site selection on clinical need, practitioner judgment, experience, and skill 1
• Select sites that are not contaminated or potentially contaminated (avoid burned or infected skin, inguinal area, areas adjacent to tracheostomy or open surgical wounds) 1

Patient Positioning

• Position the patient in Trendelenburg (head-down) position when performing internal jugular or subclavian access, when clinically appropriate and feasible 1
• This positioning increases venous diameter and cross-sectional area, improving success rates 1
• Minimize head rotation during internal jugular vein access to reduce arterial-venous overlap 3

Note: Trendelenburg positioning may not be feasible in emergency circumstances or with other clinical constraints 1.

Ultrasound-Guided Technique: Six-Step Systematic Approach

Step 1: Identify Anatomy and Vessel Localization

• Use static ultrasound imaging before prepping and draping to identify anatomy, determine vessel localization, and assess patency for internal jugular vein cannulation 1
• Static ultrasound may also be used for subclavian or femoral vein selection 1
• Use both short-axis (transverse) and long-axis (longitudinal) views to visualize the vein and its anatomic relation to the artery 1
• Check for anatomic variations, which occur in a significant proportion of patients and cannot be detected by landmark techniques alone 1
• Use color Doppler imaging and Doppler flow measurements to differentiate venous from arterial vessels 1

Step 2: Confirm Vessel Patency

• Assess for venous thrombosis using two-dimensional ultrasound during preprocedural evaluation 2
• Evaluate target blood vessel size and depth 2
• Identify hypoplastic veins or underfilling due to intravascular hypovolemia 1

Step 3: Real-Time Ultrasound Guidance for Venipuncture

• Use real-time (dynamic) ultrasound guidance with a high-frequency linear transducer for vessel localization and venipuncture when the internal jugular vein is selected 1, 2
• When feasible, use real-time ultrasound for subclavian or femoral vein cannulation 1
• Use a sterile ultrasound probe cover and sterile gel 2
• Either transverse (short-axis, out-of-plane) or longitudinal (long-axis, in-plane) approach may be used based on operator preference 1, 2
• Avoid using static ultrasound alone to mark the needle insertion site; always use real-time guidance 2

Real-time ultrasound for internal jugular vein access reduces mechanical and infectious complications, decreases number of needle passes and time to cannulation, and increases overall success rates 2. For subclavian access, it reduces mechanical complications and needle passes while increasing success rates 2. For femoral access, it reduces arterial punctures and procedure time while increasing success 2.

Step 4: Confirm Needle Position in the Vein

• Visualize the needle tip in the target vein before advancing the guidewire 2
• After inserting the catheter-over-needle or thin-wall needle, confirm venous access 1
• Do not rely on blood color or absence of pulsatile flow alone for confirming venous location 1

Step 5: Confirm Wire Position in the Vein

• When using the thin-wall needle (Seldinger) technique, confirm venous residence of the wire after threading 1
• When using the catheter-over-needle technique, wire confirmation may not be needed if: (1) the catheter enters the vein easily and manometry or pressure-waveform measurement provides unambiguous venous confirmation, AND (2) the wire passes through the catheter into the vein without difficulty 1
• If there is any uncertainty that the catheter or wire resides in the vein, confirm venous residence of the wire before inserting a dilator or large-bore catheter 1
• Visualize the guidewire in the target vein using ultrasound prior to vessel dilatation 2

Step 6: Confirm Catheter Position

• After final catheterization and before use, confirm residence of the catheter in the venous system as soon as clinically appropriate 1
• Confirm the final position of the catheter tip as soon as clinically appropriate 1
• For central venous catheters placed in the operating room, perform a chest radiograph no later than the early postoperative period to confirm catheter tip position 1
• Ultrasound with rapid infusion of agitated saline may be used to visualize a right atrial swirl sign (RASS) for detecting catheter tip misplacement (this is an advanced skill requiring specific training) 2
• Verify that the wire has not been retained in the vascular system by confirming presence of the removed wire in the procedural field 1

Catheter Selection and Insertion Technique

Catheter Size and Type

• Select catheter size (outside diameter) and type based on clinical situation and operator skill/experience 1
• Select the smallest size catheter appropriate for the clinical situation 1

Needle Technique Selection

• For subclavian approach, select a thin-wall needle (Seldinger) technique rather than catheter-over-the-needle (modified Seldinger) technique 1
• For jugular or femoral approach, select either thin-wall needle or catheter-over-the-needle technique based on clinical situation and operator skill/experience 1
• Base the technique decision at least in part on the method used to confirm wire residence in the vein before threading a dilator or large-bore catheter 1
• The catheter-over-the-needle technique may provide more stable venous access if manometry is used for venous confirmation 1

Insertion Attempts

• Base the number of insertion attempts on clinical judgment 1
• Make the decision to place two catheters in a single vein on a case-by-case basis 1

Post-Procedure Verification and Complication Detection

Pneumothorax Screening

• Rule out post-procedure pneumothorax by detecting bilateral lung sliding using a high-frequency linear transducer before and after insertion of internal jugular and subclavian vein catheters 2

Prevention of Air Embolism

• Position patients in Trendelenburg during catheter insertion and removal to prevent air entrainment 4
• Maintain meticulous technique and control of guidewires throughout the procedure 4
• Use ECG monitoring throughout upper body CVC insertions to detect complications including air embolism 4

Air embolism occurs in approximately 0.5% of central line placements and can range from subtle signs to shock and cardiac arrest 4. The risk is highest during insertion, manipulation, or removal when negative intrathoracic pressure from deep inspiration can draw air into the venous system 4.

Common Pitfalls and How to Avoid Them

Relying on Anatomic Landmarks Alone

• Never rely solely on anatomic landmarks without ultrasound guidance, as anatomic variations occur in a significant proportion of patients and substantially increase complication risk 1, 3
• Even when using ultrasound, understanding anatomical landmarks remains crucial for proper probe positioning and image interpretation 1, 3

Inadequate Venous Confirmation

• Always verify venous placement with ultrasound, manometry, or pressure waveform analysis to avoid catastrophic arterial dilation or cannulation 1, 3
• Blood color and pulsatility are unreliable indicators of vessel type 1

Unintended Arterial Cannulation

• If unintended arterial cannulation with a large-bore catheter occurs, leave the catheter in place and immediately consult vascular surgery or interventional radiology 1, 3
• Removing a large-bore catheter from an artery can cause severe hemorrhage, hematoma, pseudoaneurysm, arteriovenous fistula, arterial dissection, neurologic injury including stroke, or severe airway obstruction 1

Wire Retention

• If the complete guidewire cannot be located in the procedural field, order chest radiography immediately to check for wire retention in the vascular system 1, 3

Loss of Landmark Technique Skills

• Combine and integrate knowledge from anatomic landmark techniques with ultrasound-guided techniques to achieve the best skill level 1
• Maintain competency in landmark techniques for situations when ultrasound is unavailable 1