When and how should a central venous catheter be placed using an anatomic landmark technique without ultrasound guidance?

Central Venous Catheter Placement Without Ultrasound

Landmark-based central venous catheter placement should only be performed when ultrasound is truly unavailable—such as in emergencies, equipment failure, or resource-limited settings—because ultrasound guidance reduces complications by 70% and improves success rates. 1

When Landmark Technique Is Justified

The landmark approach is reserved for specific scenarios where ultrasound cannot be used:

• Emergency situations where ultrasound devices are not immediately accessible 2
• Equipment unavailability, reported by 28% of intensivists as a barrier to routine ultrasound use 2
• Resource-limited settings lacking ultrasound equipment 2
• Extensive subcutaneous emphysema that prevents adequate ultrasound visualization 1

Clinicians must maintain landmark skills for these rare situations, even though ultrasound is now standard of care. 1, 2

Site Selection for Landmark Technique

Internal Jugular Vein (Preferred)

The internal jugular vein should be the primary target vessel when performing landmark-based catheterization because it has lower complication rates compared to subclavian access. 3

Anatomical approach:

• Identify the triangle formed by the two heads of the sternocleidomastoid muscle and the clavicle 2
• Palpate the carotid artery; the internal jugular vein lies lateral to it 2
• In 2008,50% of UK anesthesiologists used surface landmarks and 30% relied on carotid artery palpation for IJV cannulation 2

Subclavian Vein (Higher Risk)

Subclavian access carries significantly higher risk of pneumothorax and should be avoided when possible without ultrasound. 2, 3

Technique:

• Locate the junction of the middle and medial thirds of the clavicle 2
• Insert the needle approximately 1 cm below the clavicle 2
• Subclavian approach resulted in 29.2% overall complications versus 17.7% for other sites 3
• Arterial puncture occurred in 8% of subclavian attempts versus 1.6% at other sites 3

Femoral Vein (Emergency Alternative)

The femoral site is acceptable when internal jugular or subclavian access is not feasible, though it carries higher infection and thrombosis risk. 1, 2

Critical Limitations and Risks

Landmark techniques cannot detect anatomic variations or venous thrombosis, both of which occur frequently and substantially increase complication risk. 1, 2

Complication Rates Without Ultrasound

• Total complications: 13.5% with landmark versus 4.0% with ultrasound for internal jugular access 1
• Arterial puncture: 7.2% without ultrasound versus 2.1% with ultrasound 3
• Overall procedural complications: 19.5% in landmark-based series 3
• Mechanical complications (pneumothorax, hemothorax) occur more frequently with landmark technique 2

Operator Experience Matters Critically

Operators with fewer than 25 previous insertions cause significantly more complications (25.2% versus 13.6% for experienced operators). 3

• Inexperienced operators combined with subclavian approach are significant predictors for increased complications 3
• Close supervision reduces complication rates from 23.8% to 10.7% 3

Procedural Approach When Ultrasound Is Unavailable

Pre-Procedure Assessment

• Verify there are no alternative options for ultrasound availability 1
• Select internal jugular vein as first choice unless contraindicated 3
• Ensure adequate supervision if operator has <25 prior insertions 3

Technique Principles

• Use strict aseptic technique with maximum barrier precautions 1
• Limit attempts: switch to another operator before complications occur rather than persisting 4
• Avoid rapid "searching" movements with the needle 1
• Maintain awareness of needle direction and depth at all times 1

Post-Procedure Verification

Chest radiography is mandatory after landmark-based insertion to confirm tip position and rule out pneumothorax. 1, 5

Common Pitfalls to Avoid

• Do not assume anatomic landmarks are reliable—variations occur in a substantial proportion of patients 1, 2
• Do not persist with multiple attempts—switch operators or sites early 4
• Do not use subclavian approach in patients with potential dialysis needs—it causes central venous stenosis 6
• Do not skip post-procedure chest X-ray—complications may not be immediately apparent 5

The De-Skilling Concern

Thirteen percent of intensivists express concern about losing landmark proficiency due to predominant ultrasound use. 2 This creates a paradox: landmark skills must be maintained for emergencies, yet routine ultrasound use means fewer opportunities to practice landmark techniques. The solution is simulation-based training and periodic skill maintenance, not routine use of an inferior technique. 1