• Infusion of drugs irritant to veins
• Long-term IV feeding, antimicrobials, chemotherapy (especially tunnelled catheters)
• Persistently difficult peripheral venous access
• Insertion of Swan-Ganz catheter or intracardiac pacing device
• Use of invasive cardiac output monitoring device that requires CVC

• Sepsis at cannulation site
• Carotid artery aneurysm (precludes use of internal jugular vein on same side)
• Coagulopathy – hypo and hypercoagulation states

Danger of serious morbidity

• If not competent in procedure, organise supervision by a clinician experienced in the procedure

Sterility is essential

• Perform technique in a sterile environment where possible
• e.g. treatment room, critical care or theatre suite
• Perform procedure using full sterile technique
• Use correct equipment
• Ongoing attention to sterility of line and dressings by all users
• Removal of line when no longer required

Use of ultrasound

• Equipment and assistance to place line under 2D imaging ultrasound guidance is present in theatres and critical care

Internal jugular vein

• If in elective situation, use 2-dimensional (2D) imaging ultrasound guidance

Subclavian vein

• Consider dynamic (real-time) 2D ultrasound for subclavian vein CVC insertion
• fewer complications and a higher success rate than landmark techniques
• 2D imaging ultrasound should be available in areas where central line cannulation is carried out on a regular basis

Check your central line equipment pack

Items to consider

• Sterile gloves, hat, mask, gown and full sterile drapes
• Dressing pack with gauze swabs, gallipots
• Scalpel holder with blade size 11
• Skin antiseptic. If not allergic to alcoholic chlorhexidine gluconate use 2% solution
• if allergic (but not to iodine) use alcoholic povidone-iodine solution
• Lidocaine 1% plain in a 5 mL syringe fitted with an orange (25 G) needle
• Sodium chloride 0.9% in a 20 mL syringe
• For catheters which require heparin lock, heparinised sodium chloride 10 units/mL in a 5 mL syringe
• 0 or 1 silk or nylon suture
• For peripherally inserted catheters, tourniquet
• Pressure transducer set
• Sodium chloride 0.9% (500 mL bag)
• Bionector^® (Vygon) hubs for three-way taps
• prevent repeated unscrewing of ports for access to line
• if cleaned with each use, reduce infection
• Sterile clear semi-permeable occlusive dressing, or antimicrobial CVC dressing

• Compare risk of infection against risk of mechanical complications

Patient-specific risks

• Pre-existing catheters
• Anatomical deformity
• Bleeding diathesis
• Some types of positive pressure ventilation

Relative risk of mechanical complications

• Bleeding
• Thrombosis
• Pneumothorax

Risk of infection

• To reduce risk of infection, consider peripherally inserted (arm) catheter

Arm vein

• Infection risk low
• Minimum length of catheter 600mm

External jugular vein

• Infection risk medium
• Minimum length of catheter 200mm

Subclavian vein

• Infection risk medium
• Minimum length of catheter 150mm 

Internal jugular vein

• Infection risk high
• Minimum length of catheter 150mm

Catheter type

Long-term use

• For patients in whom long-term (>3–4 weeks) vascular access is likely, use tunnelled catheter or implantable vascular access device

Lumens

• Unless multiple ports are essential for patient management, use single-lumen catheter

Total parenteral nutrition

• Use single-lumen catheter or designate one port exclusively for this purpose 

High risk of catheter-related bloodstream infection

• For adult inpatients who require short-term (1–3 weeks) central venous catheterisation, use antimicrobial impregnated central venous access device (CVAD)
• if all other aseptic precautions are instituted, further reduces infection

Chlorhexidine allergy

• Do not use chlorhexidine impregnated cannula

Consent

• Explain procedure and reassure patient
• check patient not allergic to skin antiseptic
• Obtain and record consent

Position of patient and site of insertion

• Place patient into correct position for chosen approach
• Check site of introduction

Aseptic technique

• Scrub up using full sterile technique
• don gown, gloves, hat, mask and face and eye protection
• Prepare skin with antiseptic
• Drape operative field

Local anaesthetic

• Attempt aspiration on syringe before injection to ensure needle is not intravascular
• Local anaesthetic may not be necessary in anaesthetised patients

• Check fit and function of equipment

• Whichever vein used, maintain venous pressure above atmospheric by correct position or tourniquet on limb to avoid air embolism

Antecubital fossa – median (basilic) or cephalic veins

• Place patient either supine or in a semi-recumbent position, with arm abducted approximately 60°
• Distend veins by tourniquet
• Turn head to same side to compress neck veins
• Abduct arm
• Partially insert catheter then release tourniquet
• before releasing tourniquet, position proximal end of catheter below level of patient's elbow to avoid air embolus
• advance catheter to predetermined length
• Catheter passage through cephalic vein may be impeded by fascia deep to axillary vein

External jugular vein

• Place patient at 20° head down
• Vein runs from angle of mandible to behind middle of clavicle
• Choose most prominent of the right or left veins
• STOP if no vein visible or palpable
• Turn patient's head to contralateral side
• Insert catheter >200 mm length
• In 50% of patients, catheter cannot be threaded into an intrathoracic vein
• if so, try finger pressure above clavicle, depressing shoulder, or flushing catheter
• use of Seldinger or a spiral J-shaped wire may help
• DO NOT use excessive force

Internal jugular vein

• See Figure 1
• Place patient supine, at 20° head down with head turned to contralateral side
• Preferentially use right jugular vein running behind sternomastoid close to lateral border of carotid artery
• not left to avoid injury to thoracic duct
• Use 2-D imaging ultrasound guidance to identify vein and correct placement of guidewire
• see Figure 2
• Insert cannula
• operators of limited experience can try cannulation with the smaller locator needle/catheter to locate vein first and then use that as guide
• if artery is punctured, compress firmly for ≥5 min

• Aspirate blood on all lumens to check catheter position before injecting fluid
• On connection to pressure transducer, CVP waveform should be visible, not arterial
• Fix catheter with suture at clip site and securing holes at hub for internal jugular lines
• Cover insertion site with a clear sterile dressing 

Chest X-ray

• Look for pneumothorax
• Check tip of a right-sided line is at or above the level of the carina
• confirms tip of catheter lies above pericardial reflection to avoid arrhythmias and perforation
• A left-sided line should ideally lie above the carina but:
• preferable to have the line in the SVC lying parallel to the vein (e.g. in a vertical position) rather than abutting against the wall of the SVC or lying high in the innominate vein

Injury to vital structure

• Pneumo- or haemothorax, arterial puncture
• Damage to thoracic duct or phrenic nerve 

Arterial insertion

• Confirm by placing a small gauge cannula over guide wire and into vessel and transducing pressure before dilation

Tear of vein

• Avoid by inserting dilator no more than a few cm

Kinking of guide wire

• Avoid a perpendicular approach into vein 

Air or guidewire embolus

• Place patient in head-down position during insertion of line
• If not in use ensure all ports closed and clamped
• Do not lose sight of guidewire externally at any time

Cardiac arrhythmias

• Usually stop spontaneously
• If persistent, withdraw catheter into SVC
• If severe, treat

Perforation of myocardium, mediastinum or pericardium

• Ensure free aspiration of each lumen
• Transduce main lumen and check position on X-ray
• If suspected, withdraw catheter and stop infusion

Infection, local or systemic sepsis

• Take great care with aseptic technique

• Change IV giving set as per hospital protocols using aseptic technique
• Use needleless connectors where available
• if possible, do not inject drugs or take blood samples through rubber bungs
• Maintain continuous flow through catheter to prevent clotting
• if clotting occurs, try to clear by injecting 2–5 mL heparinised sodium chloride 0.9% 10 units/mL under pressure

Infection

• Monitor venepuncture site for infection daily
• If an infection occurs, see Management of central catheter-related sepsis in Artificial nutritional support in Surgical guidelines