- CVC is a cannula placed in a central vein (e.g. subclavian, internal jugular or femoral)
(1) IV access (especially if difficult peripheral access)
(2) CVP monitoring
(3) ScvO2 monitoring/sampling
(4) Infusions of irritant substances (e.g. vasoactive agents, chemotherapy or TPN administration)
(5) Renal replacement therapy, olasmapheresis and apheresis
(6) Transvenous pacing
Large bore peripheral IV lines, RICC lines, Swan sheaths or IO access is preferred for rapid fluid fluid resusciation
- respiratory failure
- raised ICP (cannot tilt head down)
-> can use femoral approach in all the situations above
- obstructed vein (e.g. thrombus, or tumour)
- overlying skin infection, burn or other disease process
- hemorrhage from target vessel
- uncooperative patient
- multi-lumen catheter
- brown lumen is the distal lumen (used for CVP monitoring)
METHOD OF INSERTION AND/OR USE
- aseptic technique
- ultrasound guided (if possible)
- head down (IJ, SC)
- head up (femoral)
- Seldinger technique
- ensure control of the guidewire
-> course: from jugular foramen -> joins subclavian vein behind sternal extremity of clavicle
-> medial: internal and common carotid, 9th to 12th cranial nerves above common carotid + vagus
-> anterolateral: skin, superficial fascia, platysma, cervical fascia, sternomastoid, sternohyoid, omohyoid
-> posterior: transverse process of the cervical vertebrae, levator scapulae, scalenus medius and anterior, cervical plexus, phrenic nerve, thyrocervical trunk, vertebral vein, 1st part of subclavian artery
-> tributaries: inferior petrosal sinus, facial, pharyngeal, lingual, superior thyroid, middle thyroid, occipital veins
- central approach: find 1cm above the apex of head of SCM and clavicle -> 60 degrees to skin aiming towards ipsilateral nipple (blood should be obtained within 3cm)
- lateral/posterior approach: find 2-3 finger breaths above clavicle along posterior border of SCM, direct needle towards jugular notch (blood should be aspirated within 5cm)
- anterior approach: identify the carotid and mid point of medial SCM border, aim toward ipsilateral nipple
-> superior: midpoint of clavicle
-> anterior: skin, external jugular vein, clavicle
-> medial: fascia, trachea
-> posterior: subclavian artery, first rib, scalenus anterior, phrenic nerve and fascia over pleura
- approaches: supraclaviclar, infraclavicular and lateral
-> NAVEL (nerve – artery – empty space – lymph node (lateral to medial))
-> boundaries of the femoral triangle are adductor longus and sartorius
- approach: slight external rotation of hip, palpate pulse, medial to arterial pulsation
Video demonstration of landmark approach to IJV CVC insertion
- pneumothorax (highest for SCV)
- failure to locate vein
- accidental arterial puncture
- thoracic duct injury
- guide wire embolus
- air embolus
- haemopericardium and tamponade
- catheter blockage
- catheter knots
- infection (no difference in the rate of catheter-related bloodstream infections between the IJ, SC and Femoral sites -> 2.5 infections/ 1000 catheter days)
- catheter fracture
- vascular erosion
- vessel stenosis
- osteomyelitis of clavicle
Formulas for Catheter Insertion Length Based on Patient Height and Approach
(Height in cm)
|In SVC (%)||In RA (%)|
|Right Subclavian (RSCV)||(Height/10) – 2 cm||96||4|
|Left Subclavian (LSCV)||(Height/10) + 2 cm||97||2|
|Right Internal jugular (RIJV)||Height/10||90||10|
|Left Internal jugular (LIJV)||(Height/10) + 4 cm||94||5|
In practice, I tend to estimate the length based on patient height and body habitus and the CVC insertion location.
Confirmation of position
- ultrasound visualisation of needle insertion, guidewire placement and CVC
- pressure measurement
- assess for CVP trace
- inject agitated saline and observe rapid appearance of bubbles on bedside echo
- Do not shave hair at insertion site unless it interferes with dressing adhesive, as it may increase the risk of infection from disruption of the epidermal barrier by skin lacerations.
- Draw up normal saline in a 10-mL syringe and lignocaine in a 5-mL syringe to ensure these two agents are not mixed up during the procedure.
- Use ECG monitoring during insertion of IJV and subclavian lines to detect transient dysrhythmia caused by guidewire irritation of the myocardium.
- CVC insertion is not necessary, or even optimal, for fluid resuscitation. A short wide-bore cannula is better.
- Ultrasound guidance is virtually the standard of care, where available and time permits. However the proceduralist must have adequate training.
- Abdominal compression or valsalva can increase the diameter of the internal jugular vein.
- Before inserting a CVL anticipate the future management of the patient, e.g. avoid IJV if PAC likely to be required, avoid SVC if likely to need fistula formation for hemodialysis, etc.
- Access to the SCV during CVC insertion may be facilitated by caudal traction (5 cm extension) on the ipsilateral upper limb, or by placing a roll under the ipsilateral shoulder.
- The chance of a complication escalates with repeated attempts, especially for SCV CVC insertion.
- Avoid placing a CVC in to shallow a depth — if in too the CVC can be pulled back, if too shallow CVC needs to be replaced by railroading a guidewire
References and Links
- Czepizak CA, O’Callaghan JM, Venus B. Evaluation of formulas for optimal positioning of central venous catheters. Chest. 1995 Jun;107(6):1662-4 PMID: 7781364.
- Kujur R, Rao MS, Mrinal M. How correct is the correct length for central venous catheter insertion. Indian J Crit Care Med. 2009 Jul-Sep;13(3):159-62. PMC2823099. (external validity is questionable!)
- Marik PE, Flemmer M, Harrison W. The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis. Crit Care Med. 2012 Aug;40(8):2479-85. PMID: 22809915.
FOAM and web resources
- SOCMOB — Why should we insert CVCs? (2013)
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.