What are the best practices for central line insertion?

Best Practices for Central Line Insertion

Use real-time ultrasound guidance for internal jugular vein cannulation with maximal sterile barrier precautions, chlorhexidine skin preparation, and systematic confirmation of venous placement at each step to minimize life-threatening complications including arterial injury, pneumothorax, and catheter-related bloodstream infections. 1

Pre-Procedure Preparation

Equipment and Environment

• Perform central line insertion in an environment that permits strict aseptic technique 1
• Use a standardized equipment set and follow a checklist or protocol for placement 1
• Have an assistant present during catheter placement 1
• Gather ultrasound machine with high-frequency linear probe, sterile probe cover, sterile gel, and complete central venous catheter kit 2

Infection Prevention Protocol

• Perform hand hygiene using proper hand washing technique 1
• Apply maximal barrier precautions including sterile gowns, sterile gloves, caps, masks covering both mouth and nose, full-body patient drapes, and eye protection 1
• Use chlorhexidine-containing solution with alcohol for skin preparation in adults, infants, and children 1
• For neonates, determine chlorhexidine use based on clinical judgment and institutional protocol 1
• If chlorhexidine is contraindicated, use povidone-iodine or alcohol as alternatives 1

Site Selection and Patient Positioning

Choosing the Insertion Site

• Select an upper body insertion site (internal jugular or subclavian) when possible to minimize thrombotic complications compared to femoral site 1
• Avoid contaminated or potentially contaminated sites including burned or infected skin, inguinal area, or areas adjacent to tracheostomy or open surgical wounds 1
• Base final site selection on clinical need, practitioner judgment, experience, and skill 1

Patient Positioning

• Position the patient in Trendelenburg position when performing central venous access in the neck or chest, when clinically appropriate and feasible 1
• Minimize head rotation during internal jugular vein access to reduce arterial-venous overlap 2

Ultrasound Guidance Protocol

Pre-Procedure Imaging

• Use static ultrasound imaging before prepping and draping for prepuncture identification of anatomy to determine vessel localization and patency when the internal jugular vein is selected 1
• Static ultrasound may also be used for subclavian or femoral vein selection 1
• Check for anatomic variations using ultrasound, which occur in a significant proportion of patients 2
• Use both short-axis and long-axis views of the vessels 2

Real-Time Ultrasound During Insertion

• Use real-time ultrasound guidance for vessel localization and venipuncture when the internal jugular vein is selected for cannulation 1
• When feasible, real-time ultrasound may be used when the subclavian or femoral vein is selected 1
• This approach may not be feasible in emergency circumstances or in the presence of other clinical constraints 1

Needle and Catheter Selection

Catheter Size

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

Technique Selection

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

Verification of Placement at Each Step

Initial Venous Access Confirmation

• After insertion of a catheter that went over the needle or a thin-wall needle, confirm venous access 1
• Do not rely on blood color or absence of pulsatile flow for confirming that the catheter or thin-wall needle resides in the vein 1
• Methods for confirming venous placement include ultrasound, manometry, or pressure-waveform analysis measurement 1
• For neonates, infants, and children, confirmation of venous placement may take place after the wire is threaded 1

Wire Placement Confirmation

• When using the thin-wall needle technique, confirm venous residence of the wire after the wire is threaded 1
• When using the catheter-over-the-needle technique, confirmation that the wire resides in the vein may not be needed when: (1) the catheter enters the vein easily and manometry or pressure-waveform measurement provides unambiguous confirmation of venous location, AND (2) the wire passes through the catheter and enters 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 after the wire is threaded before inserting a dilator or large-bore catheter 1
• Methods for confirming wire placement include ultrasound (identification of the wire in the vein), transesophageal echocardiography (identification of the wire in the superior vena cava or right atrium), continuous electrocardiography (identification of narrow-complex ectopy), or fluoroscopy 1

Final Catheter Position Verification

• 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 the position of the catheter tip 1
• Methods for confirming catheter tip position include chest radiography, fluoroscopy, or point-of-care transthoracic echocardiography or continuous electrocardiography 1

Guidewire Retention Check

• Verify that the wire has not been retained in the vascular system at the end of the procedure by confirming the presence of the removed wire in the procedural field 1
• If the complete guidewire is not found in the procedural field, order chest radiography to determine whether the guidewire has been retained in the patient's vascular system 1

Management of Complications

Arterial Cannulation

• When unintended cannulation of an arterial vessel with a dilator or large-bore catheter occurs, leave the dilator or catheter in place 1, 2
• Immediately consult a general surgeon, vascular surgeon, or interventional radiologist regarding surgical or nonsurgical catheter removal for adults 1, 2
• For neonates, infants, and children, management should be individualized based on vessel size and clinical context 1

Common Pitfalls to Avoid

• Relying solely on anatomic landmarks without ultrasound guidance increases complication risk, especially with anatomic variations 2
• Failing to verify venous placement with ultrasound, manometry, or pressure waveform can lead to arterial dilation or cannulation 2
• Not checking for guidewire retention can result in retained foreign body requiring surgical removal 1
• Multiple insertion attempts should be based on clinical judgment, but excessive attempts increase complication risk 1

Additional Considerations

Antimicrobial Catheters

• For selected patients, use catheters coated with antibiotics, a combination of chlorhexidine and silver sulfadiazine, or silver-platinum-carbon-impregnated catheters based on risk of infection and anticipated duration of catheter use 1
• Do not use catheters containing antimicrobial agents as a substitute for additional infection precautions 1

Multiple Catheters

• The decision to place two catheters in a single vein should be made on a case-by-case basis 1