The indications for central venous catheterization are listed
in Table 33-4. The indication for direct
central venous access in the setting of resuscitation of cardiac
arrest is debated.
The most frequent sites used for central venous access are the
internal jugular, subclavian, and femoral veins (Figures 33-3 and 33-4). The external jugular
vein, a superficial structure, also provides a route to the central
Vascular anatomy of the neck.
Vascular anatomy of the torso and lower extremities.
The clavicles, first ribs, sternum, sternocleidomastoid (SCM), platysma, and
other strap muscles of the neck overlie the internal jugular and
subclavian veins (Figure 33-4). The internal
jugular vein lies lateral to the internal carotid artery inside
the carotid sheath. The internal jugular vein joins the subclavian
vein to form the brachiocephalic vein.
The subclavian vein crosses under the clavicle at the medial
to proximal third of the clavicle. The subclavian artery lies posterior
and superior to the brachiocephalic vein. The thoracic duct joins
the left subclavian vein at its junction with the left internal
jugular vein. The domes of the pleura lie posterior and inferior
to the subclavian veins and medial to the anterior scalene muscles.
The femoral vein is the most accessible central vein below the
waist. It travels in the femoral sheath with the femoral artery,
nerve, and lymphatics deep to the medial third of the inguinal ligament.
A mnemonic for the anatomy of the femoral structures from lateral
to medial is NAVEL: nerve, artery, vein, empty
space, and lymphatics.
Central Venous Access
Before beginning, explain the procedure and obtain informed consent,
if possible. In an emergency situation, implied consent is acceptable.
Next, identify the access site and approach and position the patient.
Prepare all materials before the procedure (Table
Table 33-5 Materials
for Central Venous Catheterization |Favorite Table|Download (.pdf)
Table 33-5 Materials
for Central Venous Catheterization
|Sterile personal protective gear (gloves, gown, mask, hair
|Sterile drape and towels|
|Sterile prep solution (povidone-iodine or chlorhexidine)|
|3 × 10-mL syringes containing sterile
normal saline flush|
|Central venous catheter set containing:|
|1% Lidocaine, small-gauge needle and
|18-Gauge introducer needle|
|#11 Blade scalpel|
|Single- or multi-lumen catheter|
|4×4 gauze pads|
|3-0 or 4-0 silk suture with straight needle
or with needle driver|
|Sterile transparent dressing|
The technique for all approaches is summarized in Table
33-6 and depicted in Figure 33-5.
33-6 Seldinger Technique* for Insertion of Central
Venous Line |Favorite Table|Download (.pdf)
33-6 Seldinger Technique* for Insertion of Central
|1. Gown in standard sterile fashion.||Use sterile gloves and gown. Wear mask and hair covering.|
|2. Identify vessel using either US guidance or landmarks.||—|
|3. Prep and drape patient using standard sterile
procedure.||Prep a wide area so an alternate site can be used if initial
|Prep the entire ipsilateral neck and upper chest when preparing
to insert an internal jugular or subclavian catheter.|
|4. Open the central catheter kit.||—|
|A. Inspect for content in a sterile fashion.|
|B. Place kit close to bedside and operator.|
|C. Maintain sterile conditions.|
|5. Anesthetize area in all conscious patients.||Inject area with 1%–2% lidocaine.|
|Anesthetize the periosteum of the clavicle if using the subclavian approach.|
|Reorient to landmarks after injection.|
|6. Hold the 18-gauge introducer needle on a 10-mL syringe
in the dominant hand and align the needle to the target.||—|
|7. Advance the needle slowly though the skin and subcutaneous
tissue until a flash of dark venous blood appears.||Maintain steady constant aspiration of syringe.|
|8. Stabilize the needle with the nondominant hand.||—|
|9. Check for continued free venous flow with aspiration.||If no flow is noted, withdraw the needle slightly, as the
needle may have breached the posterior vessel wall.|
|10. Remove the syringe attached to the needle and immediately
occlude the catheter with a finger.||This maneuver helps to prevent introducing air in the catheter
and subsequent central system air embolism.|
|11. Insert the guidewire gently through
the needle. Always maintain a firm grip on the wire—do
not let go of the wire for any reason.||The wire should advance with minimal resistance.|
|Do not force the wire for any reason.|
|If the wire does not pass easily, reattach the syringe and
aspirate to confirm continued venous flow.|
|Reposition the needle as needed.|
|Premature ventricular contractions or dysrhythmias during
wire advancement may indicate that the wire is in the right atrium
|12. Remove the needle over the wire when the guidewire is
inserted at least 10 cm into the vessel.||—|
|13. Incise the skin with a #11 blade scalpel at
the entry site to accommodate the venodilator or catheter.||Do not cut the guidewire.|
|14. Advance the dilator or catheter over the guidewire
into the vessel lumen with a gentle twisting motion.||—|
|15. Remove the dilator (if used), and advance the catheter
over the wire until the wire is advanced through the distal port.||Maintain a grip on the guidewire during this procedure.|
|16. Grab the end of the guidewire.||—|
|17. Advance the catheter to the appropriate depth.||—|
|18. Remove the guidewire.||—|
|19. Aspirate and flush all ports to confirm catheter function.||—|
|20. Secure catheter with suture and apply a sterile transparent
|21. Confirm catheter placement in the superior
vena cava with chest x-ray.||A catheter tip in the right atrium can perforate the right
atrium and cause hemothorax or hemomediastinum with pericardial
|Examine the chest x-ray for signs of complications.|
Catheter-over-needle technique for venous access. A. Catheter needle
inserted into skin and vessel until blood flash. B. Catheter
is advanced. C. Needle is withdrawn. D. Catheter
attached to IV tubing and secured.
Seldinger technique. A. Needle is inserted
through skin and vessel until venous blood aspirated. B. Guidewire
is inserted gently through the needle and advanced. C. Needle
is removed over guidewire. D. The skin is incised. E. Dilator
or catheter is inserted over the guidewire. F. The
guidewire is removed.
Complications of central venous catheterization are listed in Table 33-7.
Table 33-7 Complications
of Central Venous Catheterization |Favorite Table|Download (.pdf)
Table 33-7 Complications
of Central Venous Catheterization
|Chylothorax (injury to the thoracic duct on left-sided attempts)|
|Hydrothorax/hydromediastinum (infusion into the
|Great vessel or right atrial perforation (hemothorax, tamponade)|
|Airway compromise (tracheal injury, hematoma with airway
Serious and life-threatening complications are rare, especially
in the hands of experienced clinicians. Complication rates increase
with each additional attempt and percutaneous puncture. Some complications
are site specific. Accidental arterial puncture during internal
jugular cannulation can lead to hematoma formation and airway compromise. Carotid arterial puncture
may result in acute plaque rupture and stroke in patients with known
carotid artery stenosis or atherosclerosis. Femoral lines become
infected and thrombose (nearly 20% each in some studies).6
Do not use the subclavian approach in patients with coagulopathy.
Accidental subclavian arterial puncture or injury is not amenable
to direct vascular compression.
US-guided central venous access increases first attempt success
rates and decreases the number of attempts needed for success when
compared to the unassisted standard method.7 Complication
rates are similar in both techniques. The technique of US-guided
central venous access is similar to peripheral venous access described
Commonly Used Approaches
The external jugular vein is readily available due to its superficial
location in the subcutaneous tissue overlying the SCM muscle. Place
the patient in the Trendelenburg position or use Valsalva maneuvers
to distend the vein and improve visualization. Central venous catheterization
via the external jugular vein is difficult and rarely successful
without using a J wire. Puncture the skin at a 10-degree angle.
Successful placement is aided by tilting the head to the contralateral
side, applying skin traction to “straighten” the course
of the vein, and by rotating the guidewire 180 degrees before readvancement
if the first pass fails.
The internal jugular vein is easily located with
Place the probe on the SCM (Figure 33-6).
Identify the thyroid gland and carotid artery in addition to the
internal jugular vein. Do not attempt needle insertion before visualizing
all three structures.
US-guided localization of the internal jugular
vein. US image of the large internal jugular vein and deeper
carotid artery. Probe position (A) and corresponding
US image (B). CA = carotid artery, IJ = internal
The three traditional approaches to internal jugular vein catheterization
are central, posterior, and anterior. The right internal jugular
has a shorter, straighter course to the superior vena cava and should
be used unless contraindications exist. Using the right internal
jugular avoids injury to the thoracic duct on the left.
Place the patient in Trendelenburg position, head slightly tilted
to the contralateral side. The landmark for the central approach
is the triangle created by the clavicle and the sternal and clavicular
heads of the SCM. The internal jugular vein lies just deep to this triangle.
Insert the needle at a 30- to 45-degree angle to the skin, 1 cm
below the apex of the triangle, parallel to the carotid artery located
medially, and directed toward the ipsilateral nipple (Figure
33-7). Successful venous return typically occurs within 1 to
3 cm of needle advancement.
Central approach to the internal jugular vein.
The landmark for the posterior approach is the lateral aspect
of the clavicular portion of the SCM, one third of the distance from
the clavicle to the mastoid process. The needle is directed toward the
sternal notch (Figure 33-8). Successful venous
return typically occurs within 3 to 5 cm of needle advancement.
Posterior approach to the internal jugular vein.
Identify the pulse and course of the carotid artery, which lies
just medial to the site of entry for the anterior approach. Hold the
carotid artery with fingers of the nondominant hand. Hold the needle
and syringe in the dominant hand at an angle of 30 to 45 degrees
and enter at the midpoint of the medial aspect of the sternal portion
of the SCM muscle. Aim the needle toward the ipsilateral nipple
(Figure 33-9). Successful venous return typically
occurs within 3 to 5 cm of needle advancement.
Anterior approach to the internal jugular vein.
See Table 33-8 for a summary of traditional
approaches to internal jugular vein catheterization.
Table 33-8 Summary
of Approaches to Internal Jugular Vein Catheterization |Favorite Table|Download (.pdf)
Table 33-8 Summary
of Approaches to Internal Jugular Vein Catheterization
|Landmarks||Direction of Aim||Depth of Vein (cm)|
|Central||Apex of triangle formed by the clavicle and sternal and clavicular components
of the sternocleidomastoid muscle||Ipsilateral nipple||1–3 |
|Posterior||Lateral aspect of the clavicular portion of the sternocleidomastoid, one
third of the distance from the clavicle to the mastoid process||Sternal notch||3–5 |
|Anterior||Midpoint of the medial aspect of the sternal portion of the
sternocleidomastoid, lateral to the carotid artery||Ipsilateral nipple||3–5|
The location of the subclavian vein allows patient mobility and
is an excellent choice for long-term use.
The supraclavicular approach allows good sonographic visualization
of the proximal subclavian vein anatomy. The infraclavicular approach
to US-guided subclavian vein catheter placement is limited by the
large acoustic shadow created by the clavicle (Figure
US-guided localization of the subclavian vein. A. Placement
of the transducer to facilitate visualization of the internal jugular/subclavian
vein junction using a supraclavicular approach. In some patients,
a more lateral probe position is required. B. Transverse
view of the “venous lake” created by the combined
subclavian vein and internal jugular vein.
The two traditional approaches to the catheterization of the
subclavian vein are the infraclavicular and supraclavicular (Figure 33-11).
Anatomy of the subclavian vein.
Place the patient in Trendelenburg position with the head held
in neutral position. Place a small towel under the thoracic spine
in obese patients to help identify the clavicle. The landmark for
the site of entry is the junction of the middle and medial thirds of the clavicle.
Orient the bevel of the needle inferomedially to direct the guidewire
to the brachiocephalic trunk rather than the internal jugular vein.
Align the numbered markings on the syringe with the bevel of the
needle to guide the orientation of the bevel once the needle has
breached the skin. Place the index finger of the nondominant hand
at the suprasternal notch and the thumb at the midpoint of the clavicle.
Direct the needle toward the suprasternal notch at a 10-degree angle
parallel to the surface of the chest (Figure 33-12).
If the clavicle is encountered, “walk” the needle
down the clavicle until the needle is posterior to it. Successful
venous return occurs typically at a depth of 3 to 5 cm.
Infraclavicular approach to the subclavian vein.
The supraclavicular approach is often referred to as the “pocket-shot.” The
supraclavicular approach has fewer failures, fewer catheter malpositions,
and less interference with CPR than the infraclavicular approach.8 It
may also be performed in the upright position in patients unable
to lay supine in the setting of severe orthopnea.
The landmark for entry is 1 cm lateral to the clavicular head
of the SCM and 1 cm posterior to the clavicle. Enter at an angle
of 10 degrees above horizontal. Orient the bevel of the needle medially,
bisecting the angle formed by the clavicle and SCM toward the contralateral
nipple. Successful venous return typically occurs at a depth of
2 to 3 cm (Figure 33-13).
Supraclavicular approach to the subclavian vein.
The risk of pneumothorax is increased when cannulating the subclavian
vein. If attempts at subclavian venous access fail on one side,
assess for pneumothorax using chest x-ray or US before attempting
cannulation on the contralateral side.
The femoral vein is the most accessible central access site during
Place the transducer in a transverse position just below the
midportion of the inguinal ligament. Identify the femoral vein just
below the inguinal ligament and medial to the femoral arterial pulsation.
The vein is more easily compressed than the artery. The relationship
among the vessels varies depending on limb position (Figure
US-guided localization of the femoral vein. A. Gentle pressure
is applied to the transducer to identify venous structures by their
easy compressibility. B. Femoral vein (FV) collapses
with compression, and the femoral artery (FA) retains its shape
even with compression. C. FV position is seen to vary
with hip abduction and external rotation. In neutral position (left
frame), the vein is closely opposed to the FA; however, when the
hip is abducted and rotated, the vein is displaced from the artery
(right frame). (Part A courtesy of Michael Blaivas, MD.)
Place the patient supine in reverse Trendelenburg position with
the hip slightly abducted and leg slightly externally rotated.9,10 Palpate
the femoral artery, if possible. The femoral vein is just medial
to the femoral artery and 1 to 2 cm below the inguinal ligament (Figure 33-15). Use a 45-degree angle of approach.
Technique for femoral vein access.
In pulseless arrest, locate the femoral vein using the “V” technique.
Place the thumb on the pubic tubercle and the index finger on the
anterior superior iliac spine. The femoral vein is typically located
at the interdigital space (the “V” of the finger
and thumb) just inferior to the inguinal ligament.
Always insert the needle below the inguinal ligament, as
vascular injury above the inguinal ligament may cause severe hidden
hemorrhage into the retroperitoneal space.
Use of the femoral vein for central venous access should be limited
to avoid higher complication rates, such as increased infection
risk, higher rates of thrombosis, and the marked limitations of