How should a central venous catheter be placed using an anatomic landmark technique when ultrasound is unavailable, including site selection, sterile precautions, and post‑procedure verification?

Landmark Central Venous Catheter Placement Without Ultrasound

Critical Caveat: Ultrasound Should Be Standard

Landmark-based central venous catheter placement should only be performed when ultrasound is genuinely unavailable, as ultrasound guidance reduces total complications by 71%, arterial puncture by 72%, and increases first-pass success by 57%. 1, 2

The Association of Anaesthetists of Great Britain and Ireland explicitly states that clinicians must maintain landmark skills specifically for situations where ultrasound cannot be used, while simultaneously issuing strong recommendations for routine ultrasound guidance. 1

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When Landmark Technique Is Justified

Acceptable Scenarios

• Equipment unavailability: 28% of intensivists report limited ultrasound equipment access as a barrier. 1
• Emergency situations: When ultrasound devices are not immediately accessible during time-critical resuscitation. 1
• Resource-limited settings: Clinical environments lacking ready ultrasound access. 1

Unacceptable Rationale

• Concerns about "losing landmark skills" (cited by only 13% of intensivists) do not justify routine landmark use when ultrasound is available. 1
• Perception of increased procedural time with ultrasound (22% of respondents) is not evidence-based—ultrasound actually decreases cannulation time by 30.52 seconds. 3

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Site Selection Algorithm

First Choice: Internal Jugular Vein (IJV)

• Preferred landmark site when ultrasound unavailable, as 50% of UK anesthesiologists historically used surface landmarks and 30% used carotid palpation for IJV access. 1
• Lower pneumothorax risk compared to subclavian approach. 1

Second Choice: Femoral Vein (FV)

• Acceptable alternative when IJV or subclavian access is not feasible. 1
• Carries lower risk of life-threatening mechanical complications (no pneumothorax risk). 4

Avoid When Possible: Subclavian Vein (SV)

• Notable pneumothorax risk with landmark technique. 1
• Should be reserved for situations where IJV and femoral sites are contraindicated. 1

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Sterile Precautions (Maximal Barrier Protocol)

Apply full sterile barriers regardless of technique: 5, 6

• Operator: Hat, mask, sterile gloves, sterile body gown
• Field: Large sterile drape covering entire puncture site and surrounding area
• Skin preparation: Chlorhexidine-based antiseptic with adequate contact time

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Anatomical Landmark Technique by Site

Internal Jugular Vein Cannulation

Patient Positioning:

• Place patient in Trendelenburg (head-down) position to increase venous filling. 5, 6
• Minimize head rotation to reduce arterial-venous overlap. 6
• Turn head 30–45 degrees away from insertion side.

Anatomical Landmarks:

• Identify the triangle formed by the two heads of the sternocleidomastoid muscle and the clavicle (the "triangle of safety"). 1
• Palpate the carotid artery; the internal jugular vein typically lies lateral to the artery at the apex of this triangle. 1
• Insert needle at the apex of the triangle, directing it toward the ipsilateral nipple at a 30–45 degree angle to the skin.

Critical Limitation:

• This technique cannot detect anatomic variations (present in a substantial proportion of patients) or arterial-venous overlap, both of which significantly increase arterial injury risk. 1

Subclavian Vein Cannulation

Patient Positioning:

• Trendelenburg position. 5
• Place rolled towel between scapulae to allow shoulder depression.

Anatomical Landmarks:

• Locate the junction of the middle and medial thirds of the clavicle. 1
• Insert needle approximately 1 cm below the clavicle at this point. 1
• Direct needle toward the suprasternal notch, advancing parallel to and just beneath the clavicle.

High-Risk Warning:

• Landmark-guided subclavian access carries notable pneumothorax risk. 1
• Mechanical complications (pneumothorax, hemothorax) occur significantly more often with landmark technique. 1

Femoral Vein Cannulation

Patient Positioning:

• Position leg in abducted and externally rotated position. 5
• Consider head-up (reverse Trendelenburg) position to increase femoral vein lumen. 5

Anatomical Landmarks:

• Use the mnemonic "NAVEL" (lateral to medial): Nerve, Artery, Vein, Empty space, Lymphatics
• Palpate femoral artery pulse below inguinal ligament
• Insert needle 1–2 cm medial to arterial pulsation, 2–3 cm below inguinal ligament
• Direct needle cephalad at 30–45 degree angle

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Procedural Technique (Seldinger Method)

Step-by-Step Approach

1. Needle insertion: Advance needle while maintaining negative pressure on syringe. 7

2. Venous confirmation: Dark, non-pulsatile blood return suggests venous placement (but cannot definitively exclude arterial puncture without manometry or waveform analysis). 6

3. Guidewire advancement: Once blood return confirmed, introduce guidewire through needle into vessel. 7

   • Wire should advance smoothly without resistance
   • Never force the wire

4. Needle removal: Remove needle over wire while maintaining wire position. 7

5. Skin incision: Make small incision at base of guidewire. 7

6. Dilation: Advance dilator over guidewire, then remove. 7

7. Catheter insertion: Railroad central venous catheter over guidewire into vein. 7

8. Guidewire removal: Withdraw guidewire while maintaining catheter position. 7

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Post-Procedure Verification (Mandatory)

Immediate Verification

• Aspirate all lumens: Confirm easy blood return from all ports
• Flush all lumens: Ensure no resistance to flushing

Radiographic Confirmation

• Chest X-ray mandatory for all internal jugular and subclavian line placements to verify:

  • Correct catheter tip position (proximal third of superior vena cava or right atrium) 7
  • Absence of pneumothorax or hemothorax
  • No guidewire retention in vascular system 6

• Do not use catheter for infusions until proper positioning confirmed radiographically

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Management of Complications

Inadvertent Arterial Cannulation

If large-bore catheter or dilator placed in artery:

• Leave the catheter in place 5, 6
• Immediately consult vascular surgery or interventional radiology 5, 6
• Do NOT remove large-bore catheter from artery without surgical backup

If only small-gauge needle in artery:

• Remove needle and apply direct pressure for minimum 10 minutes
• Monitor for expanding hematoma

Pneumothorax

• Obtain stat chest X-ray if respiratory distress, decreased breath sounds, or subcutaneous emphysema develops
• Prepare for chest tube placement if tension physiology present

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Competency Considerations

Training Requirements

• Residents learning only ultrasound-guided technique are not immediately proficient with landmark technique. 8

• Transition from ultrasound to landmark technique results in:

  • Marked decrease in success rate (65% vs 93%) 8
  • Increase in complication rate (33% vs 8%) 8

• Minimum 10 landmark procedures required to achieve acceptable success rate (81%) and complication rate (6%) after ultrasound-only training. 8

Skill Maintenance

• 13% of intensivists express concern about losing landmark proficiency due to predominant ultrasound use. 1
• This concern must be balanced against the 71% reduction in total complications with ultrasound guidance. 2

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Comparative Risk Data: Landmark vs Ultrasound

Landmark technique is associated with:

• 72% higher arterial puncture rate across all sites (IJV, subclavian, femoral) 1, 2
• 73% higher hematoma formation rate 2
• 43% lower first-pass success rate 2
• Mean 1.19 additional attempts required for successful cannulation 2
• Inability to detect pre-existing venous thrombosis before cannulation 1

For subclavian vein specifically:

• Ultrasound reduces arterial puncture risk by 79% (RR 0.21) 4
• Ultrasound reduces hematoma formation by 74% (RR 0.26) 4

For femoral vein specifically:

• Ultrasound increases first-attempt success by 73% (RR 1.73) 4