How do I place a central venous catheter without ultrasound guidance, including indications, patient selection criteria, and the step‑by‑step landmark technique?

Central Venous Catheter Placement Without Ultrasound

While landmark-based central venous catheter placement remains a necessary skill for situations when ultrasound is unavailable, you should understand that ultrasound guidance is now the standard of care and significantly reduces complications—therefore, landmark technique should only be used when ultrasound is truly inaccessible. 1, 2

When Landmark Technique May Be Justified

The Association of Anaesthetists of Great Britain and Ireland explicitly states that understanding the landmark technique is necessary for situations when ultrasound is not available, despite their strong recommendation for routine ultrasound use. 1

Common barriers to ultrasound availability include:

• Limited equipment availability (reported by 28% of intensivists) 1
• Emergency situations where ultrasound is not immediately accessible 1
• Resource-limited settings 1

Understanding the Risks of Landmark Technique

You must counsel patients and document that landmark technique carries significantly higher risks compared to ultrasound guidance:

• Higher rates of arterial puncture at all sites (internal jugular, subclavian, and femoral veins) 2, 3, 4
• Increased mechanical complications including pneumothorax and hemothorax 1, 2, 3
• More needle passes required for successful cannulation 2, 3, 4
• Lower first-pass success rates 2, 3, 4
• Longer procedure times 2, 3
• Inability to detect anatomic variations, which occur in a significant proportion of patients at all central venous sites 1, 2
• Inability to identify venous thrombosis before attempted cannulation 1, 5

Site Selection for Landmark Technique

Internal Jugular Vein (IJV):

• Historically the most common site for landmark technique, with 50% of UK anesthesiologists using surface landmarks and 30% using carotid palpation as their first-choice approach in 2008 1
• Right-sided approach preferred over left to avoid thoracic duct injury and reduce risk of stenosis 5

Subclavian Vein (SV):

• Has the lowest infection risk of all central venous access sites 5
• Carries risk of pneumothorax with landmark technique 1, 2

Femoral Vein (FV):

• Alternative when other sites unavailable 1, 2
• Higher infection risk compared to subclavian 5

Landmark Technique: Step-by-Step Approach

Pre-Procedural Preparation

Patient positioning:

• Place patient in Trendelenburg (head-down) position to increase venous filling for internal jugular vein access 2, 6
• Minimize head rotation during internal jugular access to reduce arterial-venous overlap 6
• Use head-up (reverse Trendelenburg) position for femoral vein access 2
• Position leg in abducted and externally rotated position for femoral access 2

Sterile technique:

• Maintain maximal sterile barriers: hat, mask, sterile gloves, sterile body gown, large sterile drape 6, 3
• Use standardized procedure checklist to reduce infection risk 3

Internal Jugular Vein Landmark Technique

Anatomic landmarks:

• Identify the triangle formed by the two heads of the sternocleidomastoid muscle and the clavicle 1
• Palpate the carotid artery to estimate vein location (vein typically lies lateral to artery) 1

Critical limitation: This approach cannot account for anatomic variations or arterial-venous overlap, which occur frequently 1, 2

Subclavian Vein Landmark Technique

Anatomic approach:

• Identify the junction of the middle and medial third of the clavicle 1
• Needle insertion typically 1 cm below the clavicle 1

Major risk: Pneumothorax occurs more frequently with landmark technique compared to ultrasound guidance 2, 3

Femoral Vein Landmark Technique

Anatomic landmarks:

• Use the mnemonic "NAVEL" (Nerve, Artery, Vein, Empty space, Lymphatics) 2
• Palpate femoral artery; vein lies medial to the artery 2

Limitation: Arterial puncture rates are significantly higher without ultrasound guidance 2, 3

Verification of Venous (Not Arterial) Placement

Never rely on blood color or pulsatile flow alone to confirm venous access—these are unreliable indicators. 5, 3

Verification methods:

• Manometry or pressure waveform analysis to confirm venous pressure 6
• Chest radiography post-procedure to confirm catheter position and rule out pneumothorax 3

Post-Procedure Complication Management

If unintended arterial cannulation with large-bore catheter occurs:

• Leave the catheter in place 2, 6
• Immediately consult vascular surgery or interventional radiology 2, 6

Screen for pneumothorax:

• Obtain chest radiography after internal jugular or subclavian insertion 3
• Consider point-of-care ultrasound to detect bilateral lung sliding if available 3

Critical Pitfalls to Avoid

• Do not use static ultrasound alone to mark the needle insertion site—this does not provide the benefits of real-time guidance 2, 3
• Do not attempt multiple passes blindly—each additional needle pass increases complication risk 2, 3, 4
• Do not ignore new neurological deficits after IJV catheterization—even with apparently successful placement, this may indicate carotid artery injury 7
• Do not attempt to cannulate a vein you suspect may be thrombosed—this risks pulmonary embolism and technical failure 5

Maintaining Competency

Despite the shift to ultrasound-guided technique, landmark skills are deteriorating:

• 13% of intensivists express concern about losing landmark technique skills due to ultrasound use 1
• You must maintain proficiency in both techniques through periodic practice and assessment 3
• Competency should include knowledge of anatomy, recognition of complications, and emergency management skills 3