Overview
Central venous catheter (CVC) insertion involves the placement of a catheter into a large central vein (internal jugular, subclavian, or femoral) to provide reliable vascular access for administration of medications, fluids, and monitoring of central venous pressure.
CVC is essential for critical care, major surgery, and patients requiring long-term vascular access. It allows for administration of vasoactive medications, total parenteral nutrition, hemodialysis, and central venous pressure monitoring. Mastery of this skill is crucial for anesthesia practice.
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Indications
Central venous pressure monitoring in critically ill patients
Administration of inotropes, vasopressors, and vasodilators
Long-term nutritional support
Renal replacement therapy access
Vascular access for complex procedures
Administration of chemotherapeutic agents
Rapid vascular access in emergencies
Extended antibiotic therapy
Contraindications
Absolute Contraindications
Relative Contraindications
📋 Equipment Checklist
Check off items as you gather them:
Pre-procedure Preparation
Preparation includes patient assessment (coagulation status, anatomy, previous procedures), equipment check (CVC kit, ultrasound, monitoring), informed consent, and understanding the anatomy of the target vessels and surrounding structures.Step-by-Step Procedure
Step 1: Patient Assessment
Assess patient for contraindications, check coagulation status, perform physical examination, and obtain informed consent. Position patient appropriately (Trendelenburg for IJ, flat for subclavian).
⚠️ Common Mistakes to Avoid:
- Inadequate assessment
- Missing contraindications
- Poor positioning
💡 Pro Tip:
Always check coagulation status and perform thorough physical examination before procedure.
Step 2: Equipment Preparation
Prepare CVC kit, check all equipment, set up ultrasound machine, draw up local anesthetic, and ensure sterile technique.
⚠️ Common Mistakes to Avoid:
- Incomplete equipment check
- Wrong catheter size
- Poor sterile technique
💡 Pro Tip:
Use ultrasound guidance for all CVC insertions to improve success rate and reduce complications.
Step 3: Sterile Technique
Perform sterile preparation with antiseptic solution, drape the area widely, and maintain strict aseptic technique throughout the procedure.
⚠️ Common Mistakes to Avoid:
- Inadequate sterile technique
- Poor skin preparation
- Contamination
💡 Pro Tip:
Maintain strict aseptic technique to prevent catheter-related bloodstream infections.
Step 4: Vessel Localization
Use ultrasound to identify target vessel, assess patency, and mark insertion site. Confirm vessel anatomy and absence of thrombosis.
⚠️ Common Mistakes to Avoid:
- Poor ultrasound technique
- Not checking vessel patency
- Wrong vessel identification
💡 Pro Tip:
Always use ultrasound guidance. Identify both artery and vein to avoid arterial puncture.
Step 5: Needle Insertion
Insert needle under ultrasound guidance, confirm venous blood return, and advance guidewire through needle into vessel.
⚠️ Common Mistakes to Avoid:
- Arterial puncture
- Poor needle angle
- Guidewire advancement problems
💡 Pro Tip:
Confirm venous blood (dark, non-pulsatile) before advancing guidewire. Arterial blood is bright red and pulsatile.
Step 6: Catheter Insertion
Dilate tract, insert catheter over guidewire, remove guidewire, and confirm catheter position.
⚠️ Common Mistakes to Avoid:
- Catheter too deep
- Poor catheter securing
- Air embolism
💡 Pro Tip:
Keep the patient in Trendelenburg position during insertion to prevent air embolism.
Step 7: Position Confirmation
Confirm catheter position with chest X-ray, check all lumens for blood return, and secure catheter properly.
⚠️ Common Mistakes to Avoid:
- No chest X-ray
- Poor catheter securing
- Not checking lumens
💡 Pro Tip:
Always obtain chest X-ray to confirm catheter position and rule out pneumothorax.
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Post-procedure Care
Post-procedure care includes confirming catheter position with chest X-ray, monitoring for complications (infection, thrombosis, pneumothorax), securing the catheter, and documenting the procedure details.Complications & Management
| Complication | Incidence | Signs | Management | Prevention |
|---|---|---|---|---|
| Pneumothorax | 1-3% | Chest pain, dyspnea, decreased breath sounds, subcutaneous emphysema | Chest X-ray, oxygen therapy, chest tube if large | Ultrasound guidance, proper technique, avoid deep insertion |
| Arterial puncture | 2-5% | Bright red pulsatile blood, expanding hematoma, distal ischemia | Remove needle, apply pressure, monitor for complications | Ultrasound guidance, confirm venous blood, proper technique |
| Catheter-related infection | 3-8% | Fever, erythema at insertion site, purulent discharge, positive blood cultures | Remove catheter, antibiotics, blood cultures | Strict aseptic technique, proper dressing, early removal |
| Thrombosis | 5-15% | Arm swelling, pain, decreased venous return, catheter dysfunction | Remove catheter, anticoagulation, vascular consultation | Proper catheter size, early removal, prophylactic anticoagulation |
| Air embolism | <1% | Sudden dyspnea, chest pain, cardiovascular collapse, neurological symptoms | Left lateral decubitus position, oxygen, supportive care | Trendelenburg position, occlude hub during insertion |
| Malposition | 3-8% | Catheter dysfunction, arrhythmias, chest pain, abnormal X-ray | Reposition or replace catheter, confirm position | Proper technique, confirm position with X-ray |
Clinical Pearls
Always use ultrasound guidance - it improves success rate and reduces complications.
Confirm venous blood before advancing guidewire - arterial puncture is dangerous.
Keep patient in Trendelenburg position during insertion to prevent air embolism.
Always obtain chest X-ray after insertion to confirm position and rule out pneumothorax.
Document procedure details including approach, complications, and catheter position.
Practice sterile technique religiously - catheter-related infections are serious.
Be prepared for complications - have emergency equipment ready.
Check catheter function regularly - thrombosis can develop quickly.
Use appropriate catheter size - larger catheters increase thrombosis risk.
Remove catheters as soon as possible to reduce infection and thrombosis risk.