Overview of Central Venous Access

9/4/2018 Overview of central venous access - UpToDate
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Overview of central venous access
Authors: Alan C Heffner, MD, Mark P Androes, MD

Section Editors: Allan B Wolfson, MD, David L Cull, MD
Deputy Editor: Kathryn A Collins, MD, PhD, FACS
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Mar 2018. | This topic last updated: Oct 24, 2017.
INTRODUCTION — Central venous access is a commonly performed procedure with approximately 8 percent of
hospitalized patients requiring central venous access during the course of their hospital stay. More than five
million central venous catheters are inserted in the United States each year [1,2].
Central venous access is also needed to place pulmonary artery catheters, plasmapheresis and hemodialysis
catheters, as well as to place inferior vena cava filters, introduce wires for transvenous pacing and defibrillator
devices, and for venous interventions. The central venous access site and manner in which access is achieved
depend upon the indication for placement, patient anatomy, and other patient-related factors.
The indications for central venous access, types of central catheters, catheter selection, site selection, and
general issues of preparation and placement will be reviewed here. The role of catheters and devices for
monitoring cardiac parameters, or administering chemotherapy or parenteral nutrition is discussed in separate
topic reviews.
The placement of jugular, subclavian, and femoral catheters; issues specific to these anatomic sites; routine
maintenance and care of catheters and port devices; and complications of central venous catheters and related
devices are discussed elsewhere. (See "Placement of jugular venous catheters" and "Placement of subclavian
venous catheters" and "Placement of femoral venous catheters".)
INDICATIONS
● Common indications for the placement of central catheters include [3-5]:
• Inadequate peripheral venous access
• Administration of noxious medications – Medications such as vasopressors, chemotherapy, and

parenteral nutrition are typically administered by central venous catheters because they can cause vein
inflammation (phlebitis) when given through a peripheral intravenous catheter.
• Hemodynamic monitoring – Central venous access permits measurement of central venous pressure,
venous oxyhemoglobin saturation (ScvO2), and cardiac parameters (via pulmonary artery catheter).
• Extracorporeal therapies – Large bore venous access is required to support high-volume flow required
for many extracorporeal therapies, including hemodialysis, continuous renal replacement therapy, and
plasmapheresis.
● Venous access is also needed to place venous devices and for venous interventions including:
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• Transvenous cardiac pacing
• Inferior vena cava filter placement
• Venous thrombolytic therapy
• Venous stenting
RELATIVE CONTRAINDICATIONS — Contraindications to central venous catheterization are relative and

depend upon the urgency and alternatives for venous access. Cannulation is generally avoided at sites with
anatomic distortion or other indwelling intravascular hardware, such as a pacemaker or hemodialysis catheter.
Vascular injury proximal to the insertion site represents another relative contraindication.
Coagulopathy and/or thrombocytopenia — Moderate-to-severe coagulopathy is a relative contraindication to

central venous catheterization, although major bleeding is uncommon. A systematic review of central line
placement in coagulopathic patients documented a bleeding incidence of 0 to 32 percent, with major bleeding
complicating 0.8 percent. Importantly, the risk of bleeding was not predicted by the severity of the coagulopathy,
and there was no demonstrable benefit of prophylactic blood product administration prior to the procedure [6].
The need for urgent and emergency venous access may require cannulation in spite of coagulopathy, and the
safety of standard nontunneled and large-bore tunneled catheter placement in this circumstance has been
documented [7-11]. The platelet count, international normalized ratio (INR), and partial thromboplastin time (PTT)
thresholds for which central venous catheterization can safely be performed remain unclear. Thrombocytopenia
appears to pose a greater risk compared with prolonged clotting times [12,13]. Retrospective studies suggest
that no preprocedure reversal is warranted for platelet count >20 x 109/L and INR <3.0 [6].
In general, nontunneled catheterization at sites that are easy to monitor for bleeding are preferred in patients with
coagulopathy. The subclavian approach is often avoided due to inability to effectively monitor or compress the
venipuncture site, unless an alternative site is not suitable. Ultrasound guidance decreases the number of
attempts required for successful cannulation and reduces complication rates, including bleeding. Whenever
available, cannulation should be performed by an experienced provider using ultrasound guidance for patients
with coagulopathy [14]. (See 'Use of ultrasound' below.).
In spite of common concern and practice, there is limited evidence supporting routine correction of coagulopathy
prior to central venous cannulation [6,11,15,16]. We advocate consideration of administration of a preprocedure
blood product (eg, platelets, fresh frozen plasma [FFP], plasma frozen within 24 hours [PF24], prothrombin
complex concentrate) for severe coagulopathy (eg, platelet count <20 x 109/L and INR >3.0) when time allows,
and based on the clinical decision that the benefit of preprocedure replacement outweighs the risk. Indications
for correcting coagulopathy in patients undergoing invasive procedures and dosing are discussed in detail
elsewhere. (See "Clinical and laboratory aspects of platelet transfusion therapy", section on 'Preparation for an
invasive procedure' and "Clinical use of plasma components", section on 'Overview of indications'.)
CENTRAL CATHETERS AND DEVICES — Central venous catheters can be inserted percutaneously or
surgically.
Nontunneled — Nontunneled central catheters (figure 1) are placed percutaneously with the catheter exiting the
skin in the vicinity of the venous cannulation site. These catheters are most commonly used for temporary
access to the central circulation. Catheters are available in a variety of lengths (15 to 30 cm) and catheter
materials (eg, polyurethane, silicone). Specialized catheters for longer-term infusion may contain a valve
mechanism to limit backflow of blood for the purpose of preventing infection and catheter thrombosis. Power
injectable catheters for administration of intravenous contrast are also available.
Nontunneled central catheters may be single, double, triple, or quadruple lumen. The different lumens infuse fluid
through holes located on the side of the catheter. The distal hole is more reliable for drawing blood because it is
less likely to be suctioned against the wall of the vein during aspiration. As the number of lumens increase, the
overall diameter of the catheter increases, and the diameter of the individual luminal channels generally
decreases. The use of multilumen catheters reduces the maximum infusion rate of the catheter and increases
the rate of catheter thrombosis. (See "Catheter-related upper extremity venous thrombosis", section on
'Catheter-related factors'.)
Peripherally inserted central catheters (PICCs) are another type of commonly used central access device. These
devices are gaining in popularity due to the relative ease of insertion into the upper arm veins (cephalic or basilic
veins) (figure 2), a lower risk of some complications, and patient tolerance. Single and double lumen PICCs and
valved devices are available. PICCs are less favored in patients with significant renal dysfunction due to the risk
of venous thrombosis or stenosis that could complicate long-term access options for hemodialysis; however, the
incidence of this potential complication is not well established [17,18]. As with centrally-inserted catheters, the
rate of venous thrombosis for PICCs increases with increasing number of lumens and catheter diameter. (See
"Catheter-related upper extremity venous thrombosis", section on 'Catheter-related factors'.)
Antibiotic and antiseptic-impregnated central catheters are available, and may decrease rates of bacterial
colonization and catheter-related infection. (See "Prevention of intravascular catheter-related infections", section
on 'Antimicrobial-impregnated catheters'.)
Introducer sheath — An introducer sheath (eg, Cordis) is a special type of venous access catheter that is
single-lumen, but with a larger bore (8.5 F) and shorter length than standard central catheters. The proximal end
of these devices contains a hemostatic valve through which other devices are introduced into the venous
circulation (eg, pulmonary artery catheter). However, the device can be used alone for rapid fluid infusion due to
the large luminal diameter. (See 'Specialized venous devices' below.)
Implanted — Implanted catheters are meant to be semipermanent with removal reserved if complications occur
or the device is no longer needed (eg, completion of chemotherapy). Two types of implanted central venous
catheters are available: tunneled catheters and totally implantable venous access devices (figure 1). Power
injectable tunneled catheters and port devices are available. PICCs may also be attached to an implanted port
device. They are typically used for shorter duration than most implanted catheters, such as for prolonged
courses of intravenous antibiotics.
Tunneled — Tunneled central venous catheters traverse a subcutaneous tunnel between the catheterized
vein and the skin exit site. The catheter may be round or flat and catheter sizes can range from 2.7 to 12.5 F (eg,
Hickman, Broviac). A cuff (velour, Dacron) is positioned in the subcutaneous tissue adjacent the exit site. In
general, rates of infection associated with tunneled catheters are lower than those reported with the use of
nontunneled central venous catheters [19]. Dialysis and pheresis catheters are specialized large-bore double
lumen catheters designed for the exchange of large volumes of blood at high flow rates. (See "Prevention of
intravascular catheter-related infections", section on 'Determinants of infection risk' and "Central catheters for
acute and chronic hemodialysis access", section on 'Dialysis catheters'.)
Subcutaneous port — Totally implantable venous access devices (TIVADs) have been used widely since
their introduction in the 1980s (eg, Port-a-Cath, BardPort, PowerPort, Infuse-a-Port, Medi-port) [20-23]. The
catheter of these devices is passed from the cannulated vein beneath the skin and attached to a subcutaneous
infusion port or reservoir that is placed into a subcutaneous pocket. PICC devices can also be attached to a
subcutaneous port (eg, Passport).
The port or reservoir is accessed through the skin by needle puncture into the port's self-sealing septum. Single
and dual port devices are available. The main factor limiting infusion rate with these devices is the bore of the
access needle (eg, Huber, 19 [0.053" = 1.33 mm diameter] to 22 gauge [0.045" = 1.2 mm diameter]), which is
nearly always smaller than the internal diameter of the catheter attached to the port. Subcutaneous ports are
commonly used to administer chemotherapy agents because of their low rates of extravasation and infection
[24]. Subcutaneous ports also have the advantage of concealment from view, making this option more
cosmetically appealing. Magnetic resonance compatible devices are available.
Specialized venous devices — Several medical devices require central venous access for placement. These
devices are typically deployed through an introducer sheath. (See 'Nontunneled' above and 'Introducer sheath'
above.)
● Vena cava filters – Vena cava filters are indicated to decrease the risk of fatal pulmonary embolism in
selected patients with deep vein thrombosis. Central venous access is obtained through the internal jugular
or femoral vein and a long sheath facilitates device introduction under fluoroscopy or ultrasound-guidance.
The placement of inferior vena cava filters and their complications are discussed elsewhere. (See
"Placement of vena cava filters and their complications".)
● Pulmonary artery catheters – Pulmonary artery catheters are inserted through a venous sheath and the tip
of the catheter is positioned in the pulmonary artery as a means to monitor on cardiac function (figure 3).
Insertion of pulmonary artery catheters is discussed in detail elsewhere. (See "Pulmonary artery catheters:
Insertion technique in adults".)
● Pacemakers/Defibrillators – The placement of pacemaker/defibrillator leads also requires central venous

access (figure 4). After the vein is accessed, a sheath is introduced through which the pacemaker leads are
introduced and positioned into the heart. The leads are attached to the pacemaker, which is placed into a
subcutaneous pocket similar to other subcutaneous port devices (see 'Subcutaneous port' above). Issues
related to cardiac pacemakers and defibrillators are discussed elsewhere. (See "Temporary cardiac
pacing".)
DEVICE SELECTION — A wide range of central venous catheters and devices are available. Device selection
depends primarily upon the indication for access but patient anatomy and other patient-related factors may also
have a bearing.
The choice between temporary (nontunneled) versus permanent (tunneled, port) placement, depends upon the
indication for central access. Patients who require access for only a short period of time (days) need not be
exposed to the discomfort or risks associated with tunneled devices [25]. Patients requiring long-term access
(weeks, permanent) benefit from tunneled or port devices, which are associated with lower rates of catheter
infection compared with nontunneled catheters. Selected patients may benefit from antibiotic-coated catheters
based upon infectious risk, cost, and anticipated duration of the catheter. (See "Prevention of intravascular
catheter-related infections", section on 'Type of catheter'.)
A single lumen, large-bore introducer sheath facilitates rapid administration of large volumes of fluid during
emergencies. For less emergent fluid resuscitation, a nontunneled central line is preferred over peripherally
inserted central catheters (PICC), which do not provide adequate flow rates due to their small caliber and longer
catheter length.
Multiple lumen catheters are used more often than single lumen catheters, primarily because of the need to
administer multiple pharmaceutical agents. In general, the smallest diameter catheter (fewer lumens) appropriate
for the clinical situation should be used to reduce the risk of venous thrombosis [3].
Compared with port devices, tunneled catheters have some disadvantages. Tunneled catheters may have higher
infection rates related to care of the external catheter. (See "Diagnosis of intravascular catheter-related
infections" and "Prevention of intravascular catheter-related infections".).
In addition, activities such as showering or swimming with tunneled catheters are limited. Because subcutaneous
ports allow more normal activities and cannot be seen (and thus are not an external reminder of the patient's
illness), ports are often preferred when intermittent infusion therapy (eg, chemotherapy) is needed. The
disadvantages of subcutaneous port devices are the need to puncture the port through the skin to access the
device and the small caliber of the catheter, and thus, limited infusion rate. Port devices are not appropriate for
patients who require frequent dosing or continuous infusion of larger fluid volumes such as with total parenteral
nutrition.
SITE SELECTION — Selection of the most appropriate site for central venous cannulation is based upon the
expertise and skill of the operator, patient anatomy (eg, known venous occlusion, presence of lymphedema), the
risks associated with placement (eg, coagulopathy, pulmonary disease), and access needs (eg, patient needs
and duration of catheter use) [26-30]. Although it is tempting to always use the same approach, knowledge of
access techniques at multiple access sites is important to meet varying patient needs [31]. Higher success rates
and lower rates of mechanical complications are clearly related to operator experience [32-35].
Commonly used vein cannulation sites for central venous access include:
● Jugular vein
• External jugular vein
• Internal jugular vein (central, posterior, anterior approaches)
● Subclavian vein (supraclavicular, infraclavicular, axillary approaches)
● Femoral vein
Specific techniques for placement of central venous catheters at these sites are discussed elsewhere. (See
"Placement of jugular venous catheters" and "Placement of subclavian venous catheters" and "Placement of
femoral venous catheters".)
The needle insertion site should be chosen in an area that is not contaminated or will potentially become
contaminated (eg, burned or infected skin, adjacent to tracheostomy or open surgical wound) [3].
Specific anatomic sites and cannulation approaches have inherent advantages and disadvantages (table 1).
Access sites with altered local anatomy (eg, prior clavicle fracture), sites with multiple scars from prior access,
and the presence of another central venous catheter or device (such as a pacemaker or internal defibrillator) are
associated with higher rates of access failure, malposition, dysrhythmia, and other complications, and should be
avoided if alternative sites are available [13,36,37]. If a patient has significant unilateral lung disease, the
hemithorax ipsilateral to the disease should be cannulated (internal jugular, subclavian access) to minimize
respiratory decompensation in the event of a procedure-related pneumothorax. Subclavian venous access for
hemodialysis catheters is avoided due to the risk of venous stenosis complicating subsequent hemodialysis
access [28]. (See "Central catheters for acute and chronic hemodialysis access", section on 'Basic principles'.)
Right subclavian anatomy carries the theoretical advantage of lower pneumothorax risk due to the lower pleural
apex and absence of the thoracic duct. However, this access site is associated with higher rates of catheter
malposition and vessel trauma [38]. However, for implanted port access, a trial did not find a significant
difference in the rate of thrombotic or occlusion events for right-sided versus left-sided access [39].
Subclavian versus internal jugular access — Systematic reviews show minor variations in complications
between the subclavian and internal jugular access sites [1,40-42]. Subclavian access is associated with a lower
risk for infection but a higher rate of insertion failure. The rate of overall mechanical complications appears
similar.
A 2012 meta-analysis suggested that nontunneled subclavian access is associated with lower risk of catheter-
related infection compared with alternative sites [40]. A later multicenter trial focusing on intravascular
complications of nontunneled central catheters in intensive care unit patients found a lower composite risk of
bloodstream infection and symptomatic deep vein thrombosis for subclavian compared with jugular vein
catheterization [43]. A later meta-analysis that included this trial, two other trials, and six observational studies
found no difference in the rate of surgical site infection [42]. For implantable port access for cancer therapy, a trial
comparing the internal jugular with subclavian site also found no significant difference in infection rates [44]. (See
"Prevention of intravascular catheter-related infections", section on 'Anatomic location'.)
In the multicenter trial [43], subclavian access was associated with a higher rate of insertion failure and had a
higher rate of pneumothorax (1.5 versus 0.5 percent), but overall, there was no difference in major (grade ≥3)
mechanical complications between these sites (2.1 versus 1.4 percent; hazard ratio [HR] 0.5, 95% CI 0.3-1.1).
Although not mandated, nearly two-thirds of jugular access procedures were facilitated under ultrasound
guidance, and this was not associated with reduced mechanical complications.
For patients who are cachectic or have respiratory compromise, a jugular approach may be preferred to avoid
pneumothorax. The subclavian site may be preferentially avoided in patients with severe coagulopathy unless
alternative sites are suboptimal. Although arterial puncture may occur more frequently with the jugular approach,
recognition of bleeding and its control are easier at this site. (See 'Coagulopathy and/or thrombocytopenia'
above.)
Femoral access versus other sites — We generally favor nonfemoral access points due to ease of care and
ability to permit ambulation, in the absence of clinical factors such as emergency situations, respiratory distress,
uncooperative patient, absence of another alternative site, and when the operator is sufficiently experienced with
nonfemoral central venous access [3].
Warnings to avoid femoral cannulation have focused on higher risks of infectious and thrombotic complications
compared with torso access sites [34,45,46]. However, a systematic review found no difference in the rate of
nontunneled-catheter-related bloodstream infection when comparing femoral, subclavian, and jugular sites [28].
Contemporary trials examining femoral access sites show decreasing rates of infection that are comparable with
jugular access [43,47]. These rates parallel an overall reduction in catheter-related bloodstream infection, which
is a testament to the impact of improved adherence to aseptic technique and proper catheter management.
Higher body mass index was a factor associated with nontunneled-catheter-related infection at the femoral site in
one trial [48]. In a larger trial, the composite outcome of bloodstream infection and symptomatic deep vein
thrombosis was significantly greater for the femoral compared with the subclavian site (hazard ratio [HR] 3.5,
95% CI 1.5-7.8), but similar to the internal jugular site [43]. Femoral access was associated with the fewest
mechanical complications.
Peripheral versus central vein insertion — Peripherally inserted central catheters (PICCs) have gained
popularity for ease of insertion and lesser procedural risk (eg, hemo- or pneumothorax). Typically, PICCs are
placed by intravenous (IV) nurses and are most commonly used for temporary access needs (expected infusion
>15 days to 30 days) [25], such as outpatient IV antibiotic administration.
Catheter placement is often performed with the assistance of ultrasound to access the peripheral vein. Once
accessed, a catheter is placed over a guidewire and positioned in the central veins. The initial catheter length is
based on estimates using anatomic landmarks. Position is confirmed radiographically.
PICC lines should be avoided or used with great caution in patients with chronic kidney disease or end-stage
renal disease due to the incidence of peripheral and central venous stenosis/thrombosis which complicates
future hemodialysis access [25,49-51]. Perception of decreased risk of catheter-associated bloodstream infection
with PICCs compared with alternative central catheters is not supported in the literature, especially among
hospitalized patients [52,53]. As such, we discourage routine use of PICCs in patients at risk for future
hemodialysis access.
Emergency central access — Achieving rapid intravenous access is essential in the care of critically-ill patients,
including those undergoing cardiopulmonary resuscitation (CPR). Volume resuscitation does not generally
require central access if sufficient peripheral IV access can be obtained (eg, 14 or 16 gauge IV catheters).
Peripheral IV access is preferred due to the higher flow rates that can be achieved through these short, large-
bore catheters. However, peripheral access may be challenging in patients with hypovolemic shock. Under these
circumstances, a single-lumen, large-bore central venous introducer sheath is often used. (See 'Nontunneled'
above.)
Femoral venous access is less likely to disrupt CPR, whereas subclavian or internal jugular insertion may
interfere with chest compressions or intubation efforts. In a small, randomized study of patients receiving CPR,
real-time ultrasound-guided femoral catheterization was faster and more likely to be successful than other
approaches [54]. (See "Placement of femoral venous catheters".)
Internal jugular access (especially right-sided) carries the lowest rate of catheter malposition and may be the
optimal central venous access site in emergency situations when correct positioning is needed for immediate
use, such as for drug administration or transvenous pacing (table 1) [1,28]. The supraclavicular approach is
another option [55]. Instillation of medications via the subclavian or internal jugular veins allows rapid delivery to
the heart [56,57]. (See "Placement of jugular venous catheters" and "Placement of subclavian venous
catheters".)
PREPARATION — Nontunneled percutaneous central catheters are usually placed at the bedside, while
tunneled catheters and port devices can be placed in an interventional suite or operating room using fluoroscopic
guidance. The equipment needed for central venous catheterization is given in the table (table 2).
Informed consent — Informed consent should be obtained for any central venous catheter including those
placed percutaneously or requiring an incision (eg, port). Consent for vascular access is implied for emergency
situations.
The procedure plan, including indications, benefits, and potential complications of the procedure (eg,
pneumothorax) should be discussed with the patient and/or legal guardian. The potential need to perform a
secondary procedure, such as chest tube placement to evacuate a pneumothorax, should also be conveyed.
(See "Informed procedural consent".)
Monitoring — All patients should be monitored during central venous access procedures, including continuous
cardiac rhythm and pulse oximetry. Supplemental oxygen should be immediately available and, for some
patients, it may be prudent to administer oxygen by nasal cannula prior to covering the patient's head with any
drapes.
Positioning — Once the access sites and approach are chosen, the patient is positioned to maximize comfort.
While preparing and draping the patient, a supine position is adequate. The bed or table should be placed at a
height that allows the operator to remain comfortable throughout the procedure. The patient is positioned to
maximize the diameter of the vein during the vascular access procedure, which depends upon the site selected.
Although Trendelenburg position facilitates venous filling for jugular and subclavian access and may reduce the
risk of venous air embolism [58-62], critically ill and obese patients may not tolerate this position. Patients at risk
for respiratory compromise may require anesthesia with a controlled airway to safely place a central catheter or
device. (See "Anesthesia for the obese patient", section on 'Patient positioning'.)
Site preparation — Hair should be clipped from the access site prior to skin preparation. Clipping is preferred to
shaving [63]. A chlorhexidine-alcohol skin antiseptic solution should be applied to the access site and allowed to
dry prior to draping the patient [64]. An additional preparation kit may be required for those that contain only
iodine solutions, as chlorhexidine skin antisepsis is superior at reducing short-term catheter-related infection.
When jugular or subclavian access is planned, preparing the skin of the neck and chest bilaterally facilitates
access to alternative sites in the event the planned venous site cannot be cannulated. (See "Overview of control
measures for prevention of surgical site infection in adults", section on 'Skin antisepsis' and "Prevention of
intravascular catheter-related infections", section on 'Insertion site preparation'.)
Sterile technique — To reduce infectious complications, all central venous access procedures, including
emergency procedures, should be performed in a location that permits the use of aseptic technique with full
barrier precautions, including sterile drapes large enough to cover the entire patient, surgical antiseptic hand
wash, sterile gown, mask, gloves, and cap [3,65,66]. (See "Antimicrobial prophylaxis for prevention of surgical
site infection in adults", section on 'Device placement' and "Prevention of intravascular catheter-related
infections".)
Antimicrobial prophylaxis — Antimicrobial prophylaxis prior to percutaneous central venous catheter

placement is not standard practice. A meta-analysis comparing antibiotics versus no antibiotics for totally
implanted venous access devices also showed no significant difference in infection rate [67].
Analgesia and sedation — Patient movement may preclude successful cannulation and, in a conscious patient,
every effort should be taken to ensure patient comfort and cooperation. This is accomplished using sedation and
local anesthesia (topical, infiltrated). For patients who are awake and anxious, minimal sedation can be achieved
with a low-dose, short-acting benzodiazepine to help the patient relax. Deeper sedation may be needed,
especially in uncooperative children or adults. (See "Procedural sedation in children outside of the operating
room" and "Procedural sedation in adults outside the operating room".)
Topical anesthetics are helpful and effective when time permits, particularly in children. The algorithm provides
guidance regarding selection of an appropriate topical agent in children (algorithm 1). (See "Topical anesthetics
in children".)
Infiltration of the skin overlying the access site is usually accomplished with lidocaine (eg, 1 or 2 percent).
Lidocaine with epinephrine is generally unnecessary but may be useful during the placement of tunneled
catheters to decrease bleeding from the subcutaneous tunnel. (See "Subcutaneous infiltration of local
anesthetics".)
Subcutaneous infiltration of local anesthetics may also be helpful, but overzealous infiltration can distort
landmarks, increase the depth of penetration needed to access the vessel, and can cause vein compression
making needle access more difficult.
Care should be taken not to inject air into the subcutaneous tissues, because it will interfere with the
transmission of ultrasound waves. (See 'Use of ultrasound' below.).
For tunneled catheters or port placement, infiltration of a longer acting local anesthetic (eg, bupivacaine) into the
tract or subcutaneous pocket will help to limit postoperative pain. (See "Management of acute perioperative
pain", section on 'Preventive analgesia'.)
USE OF ULTRASOUND — Prior to the placement of central catheters, ultrasound imaging evaluates venous
patency in patients who have a history of prior instrumentation or deep vein thrombosis in the region of the
proposed access site [68]. (See "Catheter-related upper extremity venous thrombosis", section on 'Duplex
ultrasonography'.)
Preprocedure ultrasound also identifies anatomic variations, which is particularly useful for reducing trauma
associated with line placement in children. In a study of 140 children, anatomic variations occurred in
approximately 7 percent [69].
Familiarity with ultrasound-guided access is a critical aspect for the practitioner performing frequent central
venous catheterization. Static ultrasound can be helpful to localize the vein when using techniques that rely on
knowledge of anatomic landmarks (ie, landmark technique), while dynamic ultrasound is used to guide vein
puncture in real-time. (See "Principles of ultrasound-guided venous access", section on 'Dynamic ultrasound to
guide vein cannulation' and "Principles of ultrasound-guided venous access", section on 'Ultrasound-guided
techniques'.)
Real-time ultrasound imaging during needle placement reduces time to venous cannulation and the risk of
complications for jugular and femoral access. Periprocedure ultrasound also assists with early detection of
arterial and venous guidewire malposition [70,71]. Training and use of ultrasound guidance is recommended, and
is particularly useful in pediatric access and for high-risk patients, including those with coagulopathy. When
ultrasound is not available, central catheters are placed using landmark techniques. The principles of ultrasound
and techniques to identify venous structures for venous access are discussed in detail elsewhere. (See 'General
technique' below.)
Bedside ultrasound is also useful to detect guidewire position and postprocedure pneumothorax [71]. A meta-
analysis pooling the results of 20 studies found a sensitivity of 88 percent and specificity of 99 percent for the
detection of pneumothorax using ultrasonography, compared with 52 and 100 percent for chest radiography. An
important caveat to these studies was that accuracy of diagnosis was dependent upon ultrasound operator skill.
(See 'Confirmation of catheter tip positioning' below and "Thoracic ultrasound: Indications, advantages, and
technique".)
GENERAL TECHNIQUE — The placement of central catheters and other venous devices follows similar
principles. Specific details of central catheter placement for the various anatomic locations (jugular, subclavian,
femoral) and other devices are discussed elsewhere. (See "Placement of jugular venous catheters" and
"Placement of subclavian venous catheters" and "Placement of femoral venous catheters" and 'Other devices'
below.)
Nontunneled central catheters — The general method for placing nontunneled central catheters is as follows:
● Obtain the equipment and devices needed for catheter placement (picture 1 and table 2)
● Prepare (consent, sedation, antibiotics) and position the patient
● Using sterile technique, prepare the skin and drape the patient
● Identify pertinent anatomic landmarks
● Identify the vein with ultrasound when available (preferred)
● Infiltrate the skin with local anesthetic
● Cannulate the vein (needle or angiocatheter) and confirm the intravenous location of the needle
● Insert the guidewire into the vein through the access needle or angiocatheter
● Remove the needle or angiocatheter while controlling the guidewire
● Make a small stab incision in the skin at the puncture site adjacent to the guidewire
● Advance the dilator over the guidewire into the vein, taking care to control the guidewire, then remove the
dilator
● Thread the catheter over the guidewire, taking care to control the guidewire
● Remove the guidewire, taking care to control the catheter
● Sequentially aspirate blood from each access hub and flush with saline to ensure functioning of the catheter
● Suture the catheter into place and dress the site using sterile technique
● Confirm the position of the tip of the catheter
Other devices — The basic principles for placing other central venous devices are similar to those outlined
above; however, a venous sheath is typically placed over the guidewire into the vein first, and the catheter,
device, or pacemaker lead is introduced through it. Once the device is in place, the sheath is removed. A brief
description of the placement of these devices compared with standard percutaneous central catheters is given
below.
Venous sheath placement — The introducer sheath (eg, Cordis) is a combined dilator and sheath assembly
with a side port for intravenous access. Once the guidewire is in place and the vessel is dilated, the dilator and
sheath are advanced over the guidewire together. The dilator and guidewire are then removed, leaving the
sheath in place. Once the sheath is in place, the side port is aspirated and irrigated to check function, and the
sheath is sutured to the skin at its exit site.
Tunneled catheters — Venous access for tunneled catheters is obtained in a manner similar to nontunneled
catheters. The exit site of the catheter on the skin is chosen, which determines the length of catheter that will be
needed for proper catheter tip positioning. For some tunneled catheters, the excess length of catheter provided is
trimmed before the catheter is tunneled; for others, it can be trimmed afterward. Other types of catheters come in
fixed lengths (eg, dialysis catheters) and the position of the exit site is chosen to accommodate the
predetermined length of the catheter. For subclavian and jugular tunneled catheters, the exit site on the chest
wall should be located below the midclavicle in a position that does not interfere with clothing or upper extremity
mobility.
Percutaneous access is performed as outlined above. Once the guidewire is in position, the skin at the guidewire
exit site is incised to accommodate at least the diameter of the catheter. Following administration of local
anesthesia to the catheter exit site and planned subcutaneous tunnel, an incision is made at the planned
catheter exit site. A tunneling device is usually included in the catheter kit, and it is attached to the end-hole of
the catheter. The catheter is advanced subcutaneously from the catheter exit site to the guidewire exit site, and
the tunneler is removed. Care is taken to ensure that the tunnel provides a gentle curve in the catheter from the
catheter exit site to the guidewire site. Acute angulation may lead to poor flow rates and catheter malfunction.
After dilating the vein, the dilator/sheath combination is placed over the wire. The dilator is removed, and the
catheter is advanced through the sheath and the sheath peeled away. The position of the tip of the catheter is
checked and adjusted, as needed. The cuff of the tunneled catheter is ideally located at the exit site of the
catheter, but it may come to rest more cranially.
Subcutaneous ports — For subcutaneous port placement, a pocket is created for the port device after
venous access has been established. Prior to placing the port, the function should be checked by inserting a
needle and irrigating with saline, which should flow freely through the port hub.
Once the guidewire is in place, local anesthetic is administered into the skin and subcutaneous tissue of the
planned pocket. An incision is made through the skin and subcutaneous tissues. With electrocautery, a pocket is
created to accommodate the device by undermining the subcutaneous tissue. The device is placed into the
pocket, and the size of the pocket and orientation of the device is adjusted as needed.
Once the pocket is completed, the catheter is tunneled from the pocket to the guidewire exit site, if needed (eg,
jugular venous access). Care is taken to avoid catheter angulation which will lead to mechanical dysfunction.
After dilating the vein, the dilator/sheath combination is placed over the wire. The dilator is removed and the
catheter is placed through the sheath, and the sheath peeled away. The catheter is positioned and adjusted as
needed. The excess catheter is trimmed and attached to the hub of the port device, which is placed into the
pocket and sutured into place. Placing sutures in at least three points of fixation into fascial tissue is important to
prevent port rotation, which can transpose the access hub away from the skin surface making access impossible.
The subcutaneous tissues and skin are sutured closed. Prior to dressing the wound, the port should be accessed
through the skin, and the port aspirated and irrigated to confirm its proper functioning.
CONFIRMATION OF CATHETER TIP POSITIONING — Confirmation of catheter tip positioning can use one or
more of the following methods: chest radiography, fluoroscopy, ultrasound, transesophageal echocardiography
(typically intraoperative), and endocavitary electrocardiography (EC-ECG) [71-80]. Chest radiography and
fluoroscopy are the most commonly used methods in the United States.
We generally obtain a postprocedure chest radiograph to confirm the course of the catheter and position of the
tip prior to use of jugular and subclavian catheters in nonemergency situations. Femoral catheters do not
generally require radiologic confirmation of position. Some studies have questioned the need for routine
radiography for uncomplicated right internal jugular catheters placed with a single needle pass [74,76,77].
Alternatives to radiography, particularly in critical care settings or in the operative room, include ultrasound and
transesophageal echocardiography. (See 'Use of ultrasound' above and "Intraoperative transesophageal
echocardiography for noncardiac surgery".)
Another alternative, EC-ECG, relies on the recognition of typical P wave patterns during catheter positioning.
Once the catheter has been inserted into the vein, it is connected via a wide-bore needle to an
electrocardiograph monitor lead. On the ECG tracing, a normally shaped P wave identifies the mid-to-upper
superior vena cava, the widest P wave indicates the central catheter tip at the superior vena cava-right atrium
junction, and a biphasic P wave identifies the location of the right atrium. Several reviews in pediatric and
hemodialysis populations have confirmed the utility of this technique [81-84]. In the largest review of over 1000
cases, the technique was successfully applied in 98.3 percent. Preexisting cardiac arrhythmias constituted the
main reason for not being able to use the technique [84].
The optimal positioning of the tip of the catheter depends on the specific access site. In general, catheters
function well with the tip situated in any major vein. However, suboptimal tip position may be related to delayed
complications. If a catheter is malpositioned within the venous system, it may still be used under emergency
circumstances but should be repositioned as soon as feasible. In contrast, inadvertent placement of a catheter
into the arterial system mandates immediate attention [85].
Catheter tip confirmation and positioning, management of malpositioned catheters, and management of
inadvertent arterial puncture are discussed separately for the commonly used access sites. (See "Placement of
jugular venous catheters", section on 'Catheter placement' and "Placement of femoral venous catheters", section
on 'Confirmation of femoral catheter position' and "Placement of subclavian venous catheters", section on
'Confirmation of subclavian catheter position'.)
CATHETER MANAGEMENT — Management of central catheters is aimed at preventing catheter infection and
thrombosis, and handling mechanical complications.
Proper catheter maintenance involves minimizing the duration of temporary catheter access, performing routine
catheter site inspections, periodically changing the catheter site dressing, using aseptic technique when handling
catheters, and changing the catheter, when indicated. Catheter site management and catheter care are
discussed elsewhere. (See "Prevention of intravascular catheter-related infections", section on 'Site care' and
"Prevention of intravascular catheter-related infections", section on 'Catheter care'.)
Catheter lumen thrombosis may be reduced using catheter lock solutions, and when thrombosis occurs
thrombolytic therapy may restore lumen patency. Thrombosis related to mechanical problems often requires
catheter replacement. These issues are discussed elsewhere. (See "Antibiotic lock therapy for treatment of
catheter-related bloodstream infections", section on 'Anticoagulant' and "Catheter-related upper extremity venous
thrombosis", section on 'Thrombosis prevention' and "Catheter-related upper extremity venous thrombosis",
section on 'Catheter management'.)
COMPLICATIONS — The complications related to central venous access (table 3) are discussed separately.
(See "Complications of central venous catheters and their prevention".)
SUMMARY AND RECOMMENDATIONS
● Common indications for central venous access include inadequate intravenous access, medication and fluid
administration, hemodynamic monitoring and extracorporeal therapy (eg, renal replacement therapy,
plasmapheresis). Central venous access is also used to facilitate insertion of vascular devices, including
inferior vena cava filters, pacemakers, and defibrillators, and to perform venous interventions. (See
'Indications' above.)
● Severe coagulopathy is a relative contraindication to central venous catheterization, with thrombocytopenia

posing a greater risk than prolonged clotting time. The subclavian approach is often avoided in patients at
high risk for bleeding due to an inability to effectively monitor or compress the venipuncture site. If central
access is absolutely necessary, the most experienced individual available should perform the procedure.
(See 'Coagulopathy and/or thrombocytopenia' above.)
● Central venous catheters can be inserted through the jugular, subclavian, or femoral veins, or via upper arm
peripheral veins. The type of catheter and site chosen are often determined by the clinical scenario of the
individual patient and provider preference. The optimal site is determined by operator experience, patient
anatomy, and clinical circumstances. (See 'Site selection' above.)
● Prior to the placement of central catheters, we recommend ultrasound imaging to evaluate venous patency
in patients who have a history of vascular instrumentation or prior deep vein thrombosis in the region of the
proposed access site. (See 'Use of ultrasound' above and "Catheter-related upper extremity venous
thrombosis".)
● Real-time ultrasound imaging during vessel puncture reduces time to venous cannulation and the risk of
complications. Thus, ultrasound guidance is recommended when equipment and expertise are available,
and is particularly useful in pediatric venous access and in high-risk patients, such as those with
coagulopathy. (See 'Use of ultrasound' above and "Principles of ultrasound-guided venous access", section
on 'Summary and recommendations'.)
● Central venous catheterization is performed through a series of well-defined steps. Venous sheaths are
placed in a similar manner. (See 'General technique' above.)
● Chest radiography is often used to confirm jugular and subclavian catheter placement prior to use in
nonemergency situations. Femoral catheters do not generally require radiological confirmation of position.
The need to confirm placement in all patients undergoing jugular venous access procedures is controversial.
Periprocedural ultrasound is an alternative aid to avoid catheter malposition and detect pneumothorax. (See
'Confirmation of catheter tip positioning' above.)
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Topic 8194 Version 33.0
GRAPHICS
Types of central venous access
Long-term tunneled central venous catheters often include a cuff (B) located just above
(cephalad) to the skin exit site. The cuff facilitates tissue ingrowth over a two- to three-
week period to anchor the catheter and minimize bacterial migration from the exit site.
Graphic 95494 Version 2.0
Anterior view superficial veins of the upper extremity
The cephalic vein originates at the radial aspect of the wrist traversing the
radial border of the forearm. It receives tributaries from both the ventral and
dorsal surfaces. At the antecubital fossa, it provides a tributary to the median
cubital vein. In the upper arm, it travels in the groove between the pectoralis
major and deltoid muscles. It pierces the coracoclavicular fascia and,
crossing the axillary artery, ends in the axillary vein just below the clavicle.
Sometimes it communicates with the external jugular vein by a branch that
ascends anterior to the clavicle.
The basilic vein originates in the ulnar aspect of the wrist traversing the ulnar
side of the forearm to the antecubital fossa where it is joined by the median
cubital vein. It ascends in the groove between the biceps brachii and
pronator teres, crosses the brachial artery at the elbow, and continues
cephalad along the medial border of the biceps brachii. It perforates the deep
fascia of the upper arm and joins the brachial vein.
Pulmonary artery catheter insertion
This schematic diagram shows the proper orientation of the pulmonary artery
catheter when inserted through the left subclavian vein. The curvature of the
catheter is oriented so that it will facilitate passage of the catheter through the
cardiac chambers and into the pulmonary artery.
ICDs and pacemakers compared
Implantable cardioverter defibrillators (ICDs) work differently than pacemakers

do. Both devices are implanted under the skin and have wires called
"electrodes" leading to the heart. Both devices send electrical signals to the
heart to keep it beating normally. But ICDs can give a much more powerful jolt
to the heart if it starts to beat in a dangerous way. Pacemakers cannot do that.
http://www.nhlbi.nih.gov/health/dci/Diseases/icd/icd_whatis.html.
Advantages and disadvantages of central vein approaches
Approach Advantages Disadvantages
External Superficial vessel that is often visible Not ideal for prolonged venous access
jugular Coagulopathy not prohibitive Poor landmarks in obese patients
Minimal risk of pneumothorax (especially with High rate of malposition
US guidance) Catheter may be difficult to thread
Head-of-table access
Prominent in elderly patients
Rapid venous access
Internal Minimal risk of pneumothorax (especially with Not ideal for prolonged access
jugular US guidance) Risk of carotid artery puncture
Head-of-table access Uncomfortable
Procedure-related bleeding amenable to Dressings and catheter difficult to maintain
direct pressure
Thoracic duct injury possible on left
Lower failure rate with novice operator
Poor landmarks in obese/edematous patients
Excellent target using US guidance
Potential access and maintenance issues with
concomitant tracheostomy
Vein prone to collapse with hypovolemia
Difficult access during emergencies when airway control
being established
Subclavian Easier to maintain dressings Increased risk of pneumothorax

More comfortable for patient Procedure-related bleeding less amenable to direct
Better landmarks in obese patients pressure
Accessible when airway control is being Decreased success rate with inexperience
established Longer path from skin to vessel
Catheter malposition more common (especially right
SCV)
Interference with chest compressions
Femoral Rapid access with high success rate Delayed circulation of drugs during CPR
Does not interfere with CPR Prevents patient mobilization
Does not interfere with intubation Difficult to keep site sterile
No risk of pneumothorax Difficult for PA catheter insertion
Trendelenburg position not necessary during Increased risk of iliofemoral thrombosis
insertion
US: ultrasound; SCV: subclavian vein; CPR: cardiopulmonary resuscitation; PA: pulmonary artery.
With permission from: Factor P, Sznajder JI. Vascular cannulation. In: Principles of Critical Care, Hall JB, Schmidt GA, Wood
LDH (Eds), McGraw-Hill, New York, 1992. Copyright 1992 McGraw-Hill.
Equipment for central venous cannulation
2 percent chlorhexidine skin preparation solution
Sterile gown, gloves, face shield and cap
Sterile gauze pads: 4" x 4"
Sterile drapes
1 percent lidocaine; 5cc
25 Ga. needle with 3cc lock-tip syringe
Seeker needle: 3.5 cm 22 Ga. needle with 5cc slip-tip syringe
Introducer needle: 6 cm 18 Ga. large bore needle with 5cc slip-tip syringe
J-tip guidewire
Transduction catheter: 6 cm 18 Ga. catheter
Transduction tubing
Tissue dilator
Sterile catheter flush solution
Sheath
Catheter or other device (eg, port, pulmonary catheter)
Sterile sleeve for the catheter
2-0 silk sutures
Sterile dressing
Equipment needed for central venous cannulation, in order of use during procedure. For certain procedures (eg,
pulmonary artery catheter placement) additional supplies (drapes, gowns) or additional catheter sets (introducer,
sheath, pulmonary catheter, other venous device) may be needed.
Algorithm for topical anesthetic use* in children
IV: intravenous; LP: lumbar puncture.

* For example: Lidocaine/prilocaine 2.5 percent/2.5 percent (EMLA); Liposomal lidocaine 4 percent (LMX 4 );
Tetracaine gel (40 mg tetracaine per 1 g of gel, Ametop). Tetracaine gel is an ester-type local anesthetic that
is not available in the USA.
• For patients with an emergent need for a procedure or with non-intact skin, infiltrative anesthetic is
suggested. For patients with an allergy to amide anesthetics, refer to UpToDate topics on allergic reactions
to local anesthetics.
Δ Methemoglobinemia is only a contraindication for lidocaine/prilocaine (EMLA). (refer to UpToDate topics on
clinical features, diagnosis, and treatment of methemoglobinemia.
◊ Topical anesthetic should be applied as soon as the need for a procedure is evident. Refer to UpToDate
topics on topical anesthetics in children.
Data from: Zempsky, WT, Cravero, JP, Committee on Pediatric Emergency Medicine, and Section on
Anesthesiology and Pain Medicine. Relief of pain and anxiety in pediatric patients in emergency medical
systems. Pediatrics 2004; 114:1348.
Access needles and guidewire
(Top panel) Seldinger needle (left) with its sharp solid obturator in place, Potts-
Cournand needle (center), with a hollow obturator that allows the operator to
see blood flashback , and an 18-gauge thin-wall needle (right). The needles are
surrounded by an 0.038-inch, 145-cm J-guidewire.
(Bottom panel) A Doppler-guided SmartNeedle.
Reproduced with permission from: Baim DS. Grossman's Cardiac Catheterization,

Angiography, and Intervention, Seventh Edition. Philadelphia: Lippincott Williams &
Wilkins, 2006. Copyright © 2006 Lippincott Williams & Wilkins.
Complications of central venous catheterization
Immediate
Bleeding
Arterial puncture
Arrhythmia
Air embolism
Thoracic duct injury (with left SC or left IJ approach)
Catheter malposition
Pneumothorax or hemothorax
Delayed
Infection
Venous thrombosis, pulmonary emboli
Venous stenosis
Catheter migration
Catheter embolization
Myocardial perforation
Nerve injury
SC: subclavian; IJ: internal jugular.
Contributor Disclosures
Alan C Heffner, MD Speaker's Bureau: Edwards Lifesciences [Hemodynamic monitoring, shock, sepsis
(Hemodynamic monitoring devices)]. Mark P Androes, MD Nothing to disclose Allan B Wolfson, MD Nothing
to disclose David L Cull, MD Nothing to disclose Kathryn A Collins, MD, PhD, FACS Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform to
UpToDate standards of evidence.
Conflict of interest policy

Overview of Central Venous Access - UpToDate

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Overview of Central Venous Access - UpToDate

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9/4/2018 Overview of central venous access - UpToDate

Official reprint from UpToDate®

Authors: Alan C Heffner, MD, Mark P Androes, MD

● Common indications for the placement of central catheters include [3-5]:

• Inadequate peripheral venous access

• Administration of noxious medications – Medications such as vasopressors, chemotherapy, and

• Transvenous cardiac pacing

• Inferior vena cava filter placement

• Venous thrombolytic therapy

RELATIVE CONTRAINDICATIONS — Contraindications to central venous catheterization are relative and

Coagulopathy and/or thrombocytopenia — Moderate-to-severe coagulopathy is a relative contraindication to

● Pacemakers/Defibrillators – The placement of pacemaker/defibrillator leads also requires central venous

• External jugular vein

• Internal jugular vein (central, posterior, anterior approaches)

● Subclavian vein (supraclavicular, infraclavicular, axillary approaches)

Antimicrobial prophylaxis — Antimicrobial prophylaxis prior to percutaneous central venous catheter

approximately 7 percent [69].

● Prepare (consent, sedation, antibiotics) and position the patient

● Identify pertinent anatomic landmarks

● Identify the vein with ultrasound when available (preferred)

● Infiltrate the skin with local anesthetic

● Remove the needle or angiocatheter while controlling the guidewire

● Remove the guidewire, taking care to control the catheter

● Confirm the position of the tip of the catheter

SUMMARY AND RECOMMENDATIONS

● Severe coagulopathy is a relative contraindication to central venous catheterization, with thrombocytopenia

Use of UpToDate is subject to the Subscription and License Agreement.

Topic 8194 Version 33.0

Types of central venous access

Graphic 95494 Version 2.0

Anterior view superficial veins of the upper extremity

Graphic 55596 Version 8.0

Pulmonary artery catheter insertion

Graphic 54333 Version 1.0

ICDs and pacemakers compared

Implantable cardioverter defibrillators (ICDs) work differently than pacemakers

Graphic 67053 Version 8.0

Advantages and disadvantages of central vein approaches

Approach Advantages Disadvantages

Subclavian Easier to maintain dressings Increased risk of pneumothorax

Graphic 71716 Version 6.0

Equipment for central venous cannulation

2 percent chlorhexidine skin preparation solution

Sterile gown, gloves, face shield and cap

Sterile gauze pads: 4" x 4"

1 percent lidocaine; 5cc

25 Ga. needle with 3cc lock-tip syringe

Seeker needle: 3.5 cm 22 Ga. needle with 5cc slip-tip syringe

Transduction catheter: 6 cm 18 Ga. catheter

Sterile catheter flush solution

Catheter or other device (eg, port, pulmonary catheter)

Sterile sleeve for the catheter

2-0 silk sutures

Graphic 54646 Version 4.0

Algorithm for topical anesthetic use* in children

IV: intravenous; LP: lumbar puncture.

Graphic 67047 Version 3.0

Access needles and guidewire

Reproduced with permission from: Baim DS. Grossman's Cardiac Catheterization,

Graphic 82032 Version 2.0

Complications of central venous catheterization

Thoracic duct injury (with left SC or left IJ approach)

Venous thrombosis, pulmonary emboli