Best Practices for Central Line Insertion

Avery Tung, MD
University of Chicago Chicago, Illinois

Since the central circulation was first accessed percutaneously in 1929,1 indications for central line placement have increased dramatically. Today, central lines are placed routinely for high-risk surgical procedures, and in hemodynamically unstable critically ill patients. Modern indications for central lines range from resuscitation to administration of hyperosmolar or vasoactive medications. Only recently, however, has attention been paid to optimizing the process by which such lines are inserted. Driven in part from a rising awareness of the role of medical error in patient outcomes, and a desire to minimize central line complications, new strategies for the safe placement of central lines have recently been developed. It is surprising that the teaching and performing of a procedure that requires operator skill and has real potential for patient harm have not already evolved a rigorously organized “best practice.” The process of learning how to place central lines has until recently been relegated to a “teach it to yourself” approach. In his book, “Complications,” the surgeon Atul Gawande describes the harrowing process of inserting his first central line.2 His ultimate failure (his resident needed to take over) highlighted the reader’s surprise that so little value was placed on the technical process itself. Other high-profile descriptions of difficulties in placing “my first central line”3 have carried a similar impact. This lack of focus is rapidly changing. Within the last 15 years, several recent advances have demonstrated that the process of placing central lines can be made safer and less risky to the patient. The first of these was the introduction of an organized, start-to-finish systematic process for placing central lines. Symbolized by the central line checklist, this concept changed the mental model of line placement from “just another clinical chore” to a highly technical, complex task. The central
INTERNATIONAL ANESTHESIOLOGY CLINICS Volume 51, Number 1, 62–78 r 2013, Lippincott Williams & Wilkins

62 |

By more accurately identifying the location of relevant veins. systematic approach to central line insertion could meaningfully affect the incidence of central line bloodstream infections. central lines were inserted using surface landmarks. physiology. since the widespread introduction of organized approaches to line placement (whether with a checklist or not). developed at Johns Hopkins and validated in a cohort of Michigan hospitals in 2006. practice the required tasks. however. Australian Clinical Excellence Commission (CEC) (http://www.14 American College of Surgeons.nsw. and the Centers for Disease Control16 have all www. Many of the checklist elements were seemingly mundane (handwashing).7 experienced clinicians were remarkably successful using the “blind” technique alone. Despite ample evidence suggesting that surface structures only incompletely identified the location of target veins.11 complications. raising initial questions about which elements were truly “important. Regardless of the actual mechanism of benefit. is an ideal application for simulator learning.pdf).health. Existing evidence suggests an effect of simulation on reducing the number of needle passes.4 targeted central line blood stream infections as potentially A task such as central line insertion. and rehearse rescue or troubleshooting strategies all without adverse effects on actual patients. have demonstrated that programs similar to the Hopkins model have succeeded in reducing infection British National Institute of Clinical Excellence ( These successes suggest that an organized. nice. safety. and clearly demonstrated that an organized.” Subsequent studies. refine their sterile technique. Historically.6 The second advance with a dramatic impact on central line insertion practices is the ready availability of high fidelity 2-dimensional ultrasound devices. au/programs/clab-icu). which were expected to correlate with the location of large veins below the skin surface. The American Society of Anesthesiologists (ASA).12 and overall success. however. In addition to medical centers and physicians.13 Refining simulator-based learning techniques for central line insertion will likely clarify the future benefit of simulator-based learning approaches. which requires integrated knowledge of anatomy.cec. ultrasound devices have greatly facilitated both the identification of relevant venous anatomy and the actual process of cannulation. medical specialty societies have responded to this increased focus on central line safety and evolution in insertion techniques by creating guidelines.anesthesiaclinics.8–10 The third advance is the explosive growth in simulator training for medical .Best Practices for Central Line Insertion ’ 63 line checklist. central line infections have fallen dramatically in many hospitals. Novices can become familiar with the insertion hardware. even in hospitals without preexisting safety infrastructures. and technical skill. systematic focus on the process of line placement may be as important as the individual checklist elements.

64 ’ Tung issued recommendations regarding best practice for some aspect of central line insertion. the internal jugular vein could not be visualized in up to 2. Increased head rotation generally increases carotid/internal jugular overlap.anesthesiaclinics. and briefly address specific complications of line insertion. previous central lines.17. the presence of hematomae or clot. these data have reduced the perceived need for central access for hemodynamic monitoring reasons. anatomic issues may significantly affect the choice of insertion site. Unanticipated abnormalities in the size or location of the target vein. The first is a decreasing emphasis on central access for hemodynamic monitoring purposes. Even if ultrasound is not used during the actual placement process. In 1 study of ultrasound surveillance. the indications for line placement and insertion site should be explicitly reviewed. prescanning may permit positioning the head to maximize lateral separation of the carotid and internal jugular vein.19 Placed in the same anatomic location as peripheral IVs. ’ Preinsertion Indications Before inserting a central line. Location and Resource Preparation Although not explicitly recommended by guidelines (and thus not explicitly best practice). raising the risk of inadvertent carotid puncture. history of prior neck surgery or venous thrombosis. The second is the rising acceptance of peripherally inserted central access (PICC) lines for intravenous infusions. surveying the anticipated site of central line insertion with ultrasound is reasonable to identify anatomic issues that may complicate placement. and/or foreign bodies may be identified on ultrasound. prescanning can facilitate blind placement by more precisely locating the target vein. Recent data have questioned the value of central venous pressure measurement or Swan Ganz catheterization for hemodynamic . these devices have further decreased the need for centrally inserted intravenous access. and can complicate line placement. For the internal jugular site. In patients with other central venous hardware.5% of patients.7 Recognizing these issues may affect site selection or even the decision to place a line itself. identify best practice where applicable.18 Along with increasing reliance on pulse pressure variation (which requires only an arterial line). This chapter will review existing literature (including these guidelines where appropriate) with respect to central line insertion. Two trends in clinical practice are worth noting.20 www. A full discussion of indications (and contraindications) for central line placement are beyond the scope of this chapter (and beyond a meaningful evidence base).

further supporting the Cochrane result. Nevertheless. Site Selection Historically. 6.21). and only 4 trials with a total of 1513 patients meeting inclusion criteria. In part because of this practice. access to a handwashing sink. femoral routes had a higher risk of catheter colonization (relative risk. would frequently make different decisions regarding the appropriate line site. 1. surgeons trained to place subclavian lines. Surprisingly.51).21 the authors found no randomized controlled trials comparing all 3 sites (internal jugular. particularly electively.Best Practices for Central Line Insertion ’ 65 More than 1 guideline has recommended a minimum level of ancillary resources for central line insertion. subclavian. the femoral site was associated with more thrombotic and mechanical complications than the subclavian site (relative risk. monitoring equipment for ECG. the location of central line placement has been left to provider discretion. Although the question of which insertion site is most prone to infection seems easy to answer. As with infectious complications. Cochrane found no evidence differentiating subclavian from internal www. . and pulse oximetry. in environments without resuscitation equipment or aseptic techniques are difficult to make.53 for thrombotic complications). As a result.652 catheter days also found no sitespecific infectious risk.”21 A recent meta-analysis of 10 trials totaling 17. and femoral).nsw. The Cochrane review also found “no overall differences in catheter-related complications between the subclavian and internal jugular sites. 0. and anesthesiologists more familiar with internal jugular lines. no difference in catheter-related blood stream infections or colonization was found between femoral and internal jugular line sites. Both the ASA14 and CEC (http://www. CEC guidelines further specify that such a space should feature adequate space and lighting. however. This section will summarize recent literature regarding the effect of insertion site on infectious and other complications of line placement. for guidelines. Both guidelines base these recommendations on expert opinion and explicitly acknowledge the lack of comparative data.cec.43. 95% CI.376 catheter insertions and 113. the evidence base is surprisingly thin. advocate performing central line insertion in an environment with a trained assistant. When femoral and subclavian line sites were compared.95-21. little comparative evidence exists to strongly recommend one insertion site over another.22 When mechanical and thrombotic complications were considered.anesthesiaclinics. and that permits use of aseptic techniques. arguments to perform central line and immediate access to resuscitation equipment and drugs. In a 2012 Cochrane review examining the relationship between insertion site and infection risk. but fewer mechanical complications than the internal jugular site (relative risk.

27 However. multiple case reports describe aortic injury. Because of anatomic considerations. the 2011 ASA guidelines14 found no difference between subclavian and internal jugular sites in the incidence of arterial puncture. hemothorax. ultrasound is a better guide to insertion in the internal jugular than the subclavian position. and skill. the lower right pleural dome. Current evidence favors the right versus the left internal jugular insertion site. Finally. Most prominent among these is the use of ultrasound. these retrospective. The ASA guidelines note that most anesthesiologists prefer the internal jugular approach. but ultimately recommend that the catheter insertion site should be selected on clinical need and practitioner judgment. and ease of access for the right-handed operator. however. absence of the thoracic duct.26 In addition.29 This complication is most prominent in hemodialysis patients and those with advanced kidney failure. Society guidelines concur with the Cochrane review. and no difference in hemothoraces or pneumothoraces. possibly due to kinking of the guidewire during vessel dilation.66 ’ Tung jugular insertion sites with respect to mechanical or thrombotic complications. and is a category 1A contraindication to subclavian dialysis access in current CDC guidelines.25.16 Subclavian stenosis may result in unilateral venous congestion of the arm. one 2002 meta-analysis28 assessed 6 comparative trials with >2000 internal jugular and subclavian catheters and found more arterial punctures with the jugular approach.23. hematoma.anesthesiaclinics. literature reviews suggest slightly higher risk for arterial puncture with the right subclavian approach. experience.” As the ASA guidelines note. pneumothorax. may also affect line site selection. or arrhythmia. CDC recommendations (2011) recommend the subclavian site for nontunneled lines. an increased risk of subclavian vein www.24 Although existing comparative evidence does not favor subclavian over internal jugular . particularly when patients are anticoagulated or have a history of difficult line insertion. but cautioned that these findings were based on nonrandomized comparative trials. This slight advantage to internal jugular line placement may affect clinical decision making. Individual studies permit slightly greater comparative detail regarding central line site selection. nonrandomized findings are clearly insufficiently detailed to be authoritative guides to central line site selection. hemothorax. a recently observed complication of central line placement is the proclivity for subclavian vein stenosis with subclavian lines. These results predate the widespread use of ultrasound. more malpositions with the subclavian approach. but may inform site selection for inserters not using ultrasound. Changes in clinical practice. citing the larger diameter and straighter course of the right IJ. but rate the evidence as “category B. and tamponade with subclavian central venous catheterization. After literature review.

Prioritize the femoral site LAST for thrombosis/mobility reasons. Practice Suggestions Included in This Review Article A. these data and guidelines dictate the following “best practice” approach to line site selection (Please see Table 1 for all practice recommendations in this review). Blood color. broken/infected skin. catheter tip electrocardiography. consider using ultrasound verification with the Seldinger technique.anesthesiaclinics.Best Practices for Central Line Insertion ’ 67 thrombosis. Because the consequences of arterial puncture are significant. Avoid sites with prior surgery. and consequent need for therapeutic anticoagulation. www. broken/infected skin. consider the smaller size and more variable location of the left IJ and risk of subclavian stenosis with large bore indwelling catheters as potential decision . verification that the target vein has been cannulated (vs. suggest a higher likelihood of aortic injury/tamponade with subclavian than internal jugular approaches. Because use of manometry with the Seldinger “wire through needle” technique is technically more difficult than with the modified “catheter over needle” Seldinger approach. Be aware that case reports identify the left IJ site as more complication prone than the right. Avoid sites with prior surgery. or existing hardware (such as transvenous pacemakers). known thrombotic complications. The 2 verification strategies with the greatest degree of overall support are pressure transduction of the target vessel (manometry) and ultrasound imaging of the catheter inside the target vessel 5. Scan available sites to identify potential barriers to site insertion 4. or existing hardware Table 1.30 Taken together. waveform analysis. If fluoroscopy. particularly if the duration of the line is expected to be long. Choice of verification technique should depend on operator experience and technical issues. known thrombotic complications. 1. or transesophageal echocardiography are available. Site selection 1. and/or pulsatility are not recommended for this purpose due to the high likelihood of confounding states 3. the artery) is strongly recommended by ASA and CEC guidelines 2. B. Verification strategies 1. Identify available sites. the National Kidney Foundation also no longer recommends the subclavian site for placement of dialysis access. Identify available sites. case reports and observational trials support their use for verification purposes 4. If placing a large-bore introducer. Emerging data suggest that avoiding the femoral site for infectious reasons may not be evidence based 3. and imply that the more tortuous path of the right subclavian approach may predispose to aortic injury due to guidewire kinking 2. In response to this issue.

anesthesiaclinics. In subsequent work. Emerging data suggest that avoiding the femoral site for infectious reasons may not be evidence based. 4. which combined inserter aseptic strategies (cap. significant reduction in central line infections. Others (cap) are less so. in the absence of data singling out any single element. Scan available sites to identify potential barriers to site insertion. consider the smaller size and more variable location of the left IJ and risk of subclavian stenosis with large bore indwelling catheters as potential decision factors. Elements of such bundles include cap. Be aware that case reports identify the left IJ site as more complication prone than the right. handwashing. Aseptic Technique Recent safety efforts have yielded dramatic improvements in central line infection rates. If placing a large-bore introducer. 3. How should the central line inserter prepare himself/herself to minimize central line associated infection? Although existing literature is unable to quantify the contribution to reducing central line infections from specific aseptic activities. The most prominent of these “bundles” is that used in the Michigan “Keystone” project. this approach. sterile gown and gloves. and imply that the more tortuous path of the right subclavian approach may predispose to aortic injury due to guidewire kinking. Although the specific mechanisms by which line infection rates have dropped is unclear. “bundles” of activities performed together have been extensively and empirically tested.32 Much of the “bundle” lacks comparative evidence of efficacy. the authors have applied the bundle elsewhere with similar reductions in infections. As a result. sustained reductions in line infections. Although studies of the effect of such bundles on catheter colonization are equivocal. mask. produced a sustained.4 Using a before/after study design. sterile gown and gloves) with specific patient preparation activities (chlorhexidine skin prep and full body sterile drape).com . reinforced by use of a checklist. empiric testing has identified strategies that have demonstrated clear efficacy in multiple clinical environments. Prioritize the femoral site LAST for thrombosis/mobility reasons. particularly if the duration of the line is expected to be long. and handwashing before performing the procedure. mask.31 multiple “before/after” trials have clearly demonstrated marked. Nevertheless. Some inserter elements (such as sterile gloves and gown) are self-evident.68 ’ Tung (such as transvenous pacemakers). 2. current best practice for www. suggest a higher likelihood of aortic injury/tamponade with subclavian than internal jugular approaches. attribution of benefit to inserter elements (rather than patient elements) is not possible.

anesthesiaclinics. gloves. the Centers for Disease Control. or if a comprehensive strategy to reduce infection rates does not work. As a result.Best Practices for Central Line Insertion ’ 69 inserter preparation should include all elements of the bundle (cap. and the inserter www. one (sterile skin prep) is self-evident. and ASA guidelines all recommend 2% chlorhexidine. the evidence supporting specific bundle elements is similarly mixed. best practice for skin prep cannot be clearly defined. The combination of alcohol and chlorhexidine is recommended because alcohol alone does not provide long-lasting antimicrobial activity. Nevertheless. mask. Note that the package insert for chlorhexidine/alcohol recommends a. Moreover. Several recent studies have found reduced surgical site infections with 2% chlorhexidine/70% alcohol for skin preparation versus povidone-iodine. or chlorhexidine with and without alcohol.35. ’ Insertion A detailed description of central line insertion technique is beyond the scope of this chapter. the Michigan checklist. and the other (full body drape) less so.36 As a consequence of incomplete data.38 Because of reports of anaphylaxis with antiseptic-coated catheters39 and increased cost. No data compare chlorhexidine with 70% alcohol (chloraprep) to povidone-iodine with 70% alcohol. Of the 2 patient-related elements. Many valid approaches exist. This “scrubbing” strategy is advocated to penetrate the first 5 cell layers where 80% of skin flora reside. gown. best practice for patient draping cannot be .37 Evidence for the full body drape is even less clear. “back and forth” scrubbing application pattern rather than the “inside to outside” circular pattern used for povidone-iodine. full body drapes prevent simultaneous procedures from being performed on a patient undergoing central line insertion. Comparative trials of povidone-iodine with chlorhexidine (without alcohol) find lower catheter colonization rates with chlorhexidine. With respect to patient preparation. The literature is equivocal on preinsertion intravenous antibiotics. Both antibiotic-impregnated and silver-impregnated catheters demonstrate reduced colonization rates when compared with nonimpregnated catheters. CDC guidelines recommend use of impregnated catheters only for prolonged use.34 but a difference in catheter infections for gram-positive infections only. and weakly supportive of antibiotic-impregnated catheters. with povidone-iodine with 70% alcohol for patients allergic to chlorhexidine. although both the Michigan bundle and ASA guidelines recommend a full body drape.33. with or without 70% alcohol as a first line agent. No comparative trials exist evaluating the benefit of full versus partial or no drapes. and hand hygiene).

This section will review the evidence base and guideline recommendations for selected aspects of central line insertion. Patient Position Existing evidence suggests that the Trendelenburg position. Existing evidence is mixed regarding the effect of Trendelenburg position on subclavian vein size. the inserter cannulates the vein using a thin walled. abdominal compression.42 and that more experienced operators have higher success rates. www. current evidence suggests that head rotation should be limited as increasing head rotation increases overlap between the internal jugular vein and carotid artery. If targeting the internal jugular site. which should thus be based on availability of equipment and operator skill with the different techniques. Arguments for the Seldinger technique include speed and simplicity.41 No comparative data exist to differentiate the Seldinger from the modified Seldinger technique. Guidelines are silent on choice of wire placement technique. best practice should include changing operators or techniques if multiple passes by a single operator are unsuccessful. Once blood return is obtained. a wire is placed through the needle and into the vein. the inserter cannulates the vein using a hollow needle.20 Evidence is mixed regarding head position for subclavian placement but recent data suggest modest improvements in subclavian vein size with the head in the neutral position. The guidewire is then passed through the plastic catheter into the vein and the plastic catheter is removed. Several observational studies find that central venous access complication rates increase with the number of needle passes.40 which assists in facilitating cannulation success. hollow needle. and increased intrathoracic pressure increase internal jugular vein . It is easy to see that local preferences.anesthesiaclinics. wire placement technique does affect the approach used to verify wire placement (see below). In the Seldinger technique. ASA guidelines and best practice strongly support the Trendelenburg position where clinically feasible for both access sites due to the reduced risk of air embolism with increased venous pressures. and equipment availability likely have a greater effect on cannulation success than intrinsic aspects of each technique. which is threaded through a plastic catheter.41 Nevertheless. Arguments for the modified technique include ease of use of manometry for venous confirmation and ease of use for the novice. However. the plastic catheter is threaded into the vein. Although the practice is nearly ubiquitous. no data exist to support the value of first accessing the vein using a small caliber finder needle if ultrasound is not used. operator skill.70 ’ Tung should choose one with which he/she is familiar and which conforms to local (hospital) practice.43 On the basis of these data. In the modified Seldinger technique. Once blood return is obtained.

” No direct evidence exists to specify how deep the wire should be inserted into the vein.anesthesiaclinics. and the ASA. Significant complications have been reported from deep insertion of the wire. the most prominent is the need to use ultrasound correctly. Because imaging the internal jugular vein for line insertion is best done in cross section.46 In addition. Existing literature is less robust for ultrasound use for the subclavian site. and cost). including dislodgement and ensnarement of vena caval filters. www. Ultrasound training is considered so important that CDC guidelines for prevention of central line infections consider training a category 1B recommendation and CEC guidelines explicitly state that “previous training or experience is required to use this technology effectively. inadequate training. pneumothorax. many physicians are reluctant to deviate from a practice that already results in a low complication rate.47 Insufficiently deep guidewire placement may also complicate central line placement. Numerous specialty societies and guidelines recommend the use of ultrasound to facilitate central line insertion.Best Practices for Central Line Insertion ’ 71 Considerable controversy exists among practitioners regarding the use of ultrasound for locating the vein and for guiding the actual cannulation (for a review. the above anecdotal and case report–based literature suggest that best practice should involve some surface assessment of how deep the wire must be inserted to facilitate free passage of the dilator and catheter. and the US Agency for Healthcare Research and Quality. ACS. Despite such universal endorsements. the British National Health Service. If the wire cannot be inserted to at least the depth of the planned catheter. see Keenan44). and reduces access time. leading to carotid puncture. and equivocal for the femoral site. Most central line wires are considerably longer than the catheter itself allowing for the wire to be inserted >30 cm into the patient during routine placement. dilation and catheter placement may result in perforation of venous structures. Inexperienced operators may thus fail to appreciate the location of the tip. Before/after studies. the American College of Surgeons. availability of equipment during emergencies.45 find significant reductions in the same institution with use of ultrasound. Of the arguments against routine use of ultrasound (time. and CEC guidelines do not address the question. however.46 and entanglement in the patient’s tricuspid valve. a tendency to focus on the ultrasound image instead of the patient during insertion may lead to overadvancing the needle. the needle also only appears in cross section and the tip and shaft of the needle may have the same appearance on . Comparisons between the anatomic landmark approach and an ultrasound-guided approach routinely find that real time ultrasound use increases success rates. and other complications. the Australian CEC. These include the ASA. hematomae. and avoid preventable complications of excessively deep insertion. decreases carotid puncture rates. Taken together.

however. Although many strategies have been advocated for confirming venous location of the guidewire. then verification using ultrasound will likely fail to catch that original error. is not foolproof. and the authors calculated that use of manometry prevented up to 56 possible arterial dilations.72 ’ Tung Once the wire is inserted into the vessel. The strongest published evidence for verifying wire location in the vein is manometry. ASA guidelines recognize the use of fluoroscopy. ultrasound may easily track the portion of the wire that is extrathoracic. In addition.50 or chest x-ray51 have slightly stronger supporting evidence. or absence of pulsatile flow. In part. the guidewire may be tracked from where it enters the skin to where it enters the relevant vessel. An ultrasound approach. With this technique. Other strategies such as fluoroscopy.52 No cases of dilator placement into adjacent arteries were noted. With the Seldinger technique. On the basis of expert opinion and observational studies of central line placement by interventional radiologists. If an error is made in identifying the vessel. Guidewires that pass completely through the vein and end up in the artery have been described. Whether the Seldinger or modified Seldinger technique is used to cannulate the vein can significantly affect the ease of using either manometry or ultrasound for verification. No comparative trials of verification strategies .anesthesiaclinics. blood gas analysis. 2-dimensional ultrasound may also be used to verify location of the wire in the vein. use of manometry to verify wire placement must be performed with the needle tip manually stabilized while in the vein. The pressure in the vessel is then measured either by holding the tubing vertically and visualizing the height of the column. In a 2009 retrospective review. a verification step is strongly recommended after cannulation and before passing the dilator to determine whether the wire is in the target vein.49 transesophageal echo.48 continuous electrocardiography. 9348 central venous catheters were placed during a 15-year period using manometry to verify venous location of the wire. the choice of verification technique depends on cannulation technique. In much the same way as it is used to guide insertion. Because hypoxemia. It is easy to see that this approach requires a high degree of manual dexterity. but may not be able to track >5 cm into the thoracic cavity. color of blood. few are validated by high quality current evidence. and/or hypotension may confound these strategies.46 and depending on the anatomic location of arterial puncture may then escape ultrasound-based verification. tricuspid regurgitation. By manipulating the ultrasound probe. for example. they are not recommended by ASA guidelines. and may www. a length of IV tubing is attached to an IV catheter or needle located inside the vessel in question. or by connecting the tubing to a pressure transducer. Strategies with equivocal evidence include pressure waveform analysis. and chest radiography as potentially useful tools for verification of catheter location.

The 2 verification strategies with the greatest degree of overall support are pressure transduction of the target vessel (manometry) and ultrasound imaging of the catheter inside the target vessel. the heart. Manometry can then be performed through this hollow plastic catheter.” Nevertheless. Blood color. a 1989 FDA Task Force recommends that “the catheter tip should not be placed in. 4. Both ASA and CEC guidelines recommend a chest x-ray as soon as clinically appropriate to verify appropriate location and depth of the catheter tip. waveform analysis. or transesophageal echocardiography are available. These include algorithms based on insertion markings at the skin. and/or pulsatility are not recommended for this purpose due to the high likelihood of confounding states. 3. with the modified Seldinger technique the inserter threads a plastic catheter over the hollow needle into the vein. observational trials. and expert opinion can be integrated to recommend a reasonable practice with respect to verifying wire placement in the target vein: 1. and to rule out pneumothorax. 5.56 transesophageal echocardiography. particularly when access is difficult or the patient is moving. verification that the target vein has been cannulated (vs.”53 Several strategies for accurately determining the optimal depth for central line placement exist. Although this strategy assumes that a wire passed through the plastic catheter terminates in the vein. with less difficulty in maintaining venous access.anesthesiaclinics. catheter tip electrocardiography. this assumption seems reasonable and no case reports have observed successful manometry with the plastic catheter and subsequent malposition of a wire inserted through that catheter. Choice of verification technique should depend on operator experience and technical issues. the artery) is strongly recommended by ASA and CEC guidelines. case reports and observational trials support their use for verification purposes. Because use of manometry with the Seldinger “wire through needle’ technique is technically more difficult than with the modified “catheter over needle” Seldinger approach.57 and right www. consider using ultrasound verification with the Seldinger technique. Because the consequences of arterial puncture are significant. the combination of case reports. If fluoroscopy. or allowed to migrate into. However. 2.54 topographical markings of the chest. clinical experience.Best Practices for Central Line Insertion ’ 73 result in loss of access. Overall. In contrast. No literature definitively establishes optimum positioning for the catheter tip. No literature exists to specify a best practice with respect to dilation and catheter .55 or chest radiography. existing evidence is insufficient to dictate a “best practice.

or continuous electrocardiography as valid methods. An important element of the Michigan bundle was daily attention to the ongoing need for central access. their presence as a closed claim suggests that they are considered at least partly preventable.nice. recommend transparent bio-occlusive www. thoracic duct damage. A 2003 New England Journal review estimated the incidence of arterial puncture as 6% to 9% for the IJ site and 3% to 5% for the subclavian GUIDANCE.nice. citing low quality literature and expert opinion. these numbers are likely lower for the IJ site. The ASA closed claims database provides another window into the landscape of central line complications. carotid artery punc ture/cannulation (http://www. and prompt removal if the line was no longer necessary. Other elements of central line aftercare include attention to infection prevention.2% for IJ site and 6% to 11% for subclavian site. ASA guidelines.pdf). Existing guidelines differ on the appropriate approach.62 and against routine wireguided line exchange. and hemothorax/pneumothorax. Existing literature clearly recommends against routine replacement of central venous catheters. These include arterial puncture. ’ Complications and Aftercare The list of complications referable to central line insertion is large. hematoma. incidences of these complications are difficult to assess accurately. but mention chest radiography.pdf). fluoroscopy.59 In the era of ultrasound. aortic injury. hemothorax. In contrast. followed by tamponade (http://www.61 against routine use of antibiotic ’ Tung atrial electrocardiography. vena caval or atrial perforation. and catheter-related infection. A 1970 to 2004 analysis of malpractice claims for central line complications found 110 claims for injuries related to central lines.60 The most common were wire/catheter embolus (N = 20). nicemedia/pdf/Ultrasound_49_GUIDANCE. and may also be falling for subclavian use. Because of rapid changes in insertion technique/training and new technologies such as .61 In addition. Postinsertion best practice should thus include maintaining a high degree of suspicion for the possibility of injury due to line insertion.27 Although it is likely that most of these events also predated the routine use of ultrasound. CEC guidelines provide a table to specify insertion depth as a function of patient height and insertion site. ASA guidelines do not specify the exact algorithm for localizing the catheter tip.anesthesiaclinics.58 No comparative trials have assessed all of these strategies together.1% to 0. and the incidence of pneumothorax as 0. and as a result the literature is equivocal regarding their relative benefits.

best practices are beginning to emerge. These include an organized. localization of the catheter tip. specific aseptic preparation of the patient and inserter. Eradicating central line-associated bloodstream infections statewide: the Hawaii experience. et al. Regardless of the specific practices recommended by each guideline.5 ’ Summary Recent advances in central line insertion techniques. Werner Forssmann: a pioneer of cardiology.Best Practices for Central Line Insertion ’ 75 dressings. Weeks K.anesthesiaclinics. www. AMA Medical News. and daily inspection of the line site for redness. 5.355:2725–2732. CEC guidelines further suggest weekly changes of sterile occlusive dressings unless there is evidence of inflammation. drainage. increased attention to preventing central line infections. or other signs of infection. Gawande A. even in hospitals without a preexisting quality infrastructure. Am J Cardiol. and increasing ultrasound use. Bauer . The ongoing attention to central line safety may lead to even further advances in central line safety. it is possible that other central line complications my also decrease in incidence. Forssmann-Falck R. Pronovost P. consistent. Complications: A Surgeon’s Notes on an Imperfect Science. 4. An intervention to decrease catheterrelated bloodstream infections in the ICU. Am J Med Qual. and allows for the use of chlorhexidineimpregnated sponges. 3. 2006. advances in simulator training. For many aspects of line insertion. August 21. 2. 2000 “New laws let doctors say “I’m Sorry” for medical mistakes”. ’ References 1. widespread.27:124–129. and improved training strategies have dramatically improved the process of central line insertion. With further implementation of “bundled” line insertion strategies. evidence-based site selection. verification of wire position. and postinsertion maintenance. The results of these recent advances are clear: a dramatic.79:651–660. and persistent fall in the rate of central line–associated bloodstream infections. Lin DM. systematic approach to inserter training and line insertion. keeping ports capped when not used. N Engl J Med. The author has no conflicts of interest to disclose. use of static and dynamic ultrasound when feasible. et al. wiping catheter access ports with antiseptic before use. Needham D. Berenholtz S. recent evidence suggests that deployment of central line use protocols with meticulous attention to cleanliness in the daily clinical management of central lines can significantly lower central line infections. 1997. 2002:11–15. 2012. New York: Henry Holt/Macmillan.

98:157–160. 15. Cohen ER. Dodge KL. et al. et al. Simulation-based mastery learning reduces complications during central venous catheter insertion in a medical intensive care unit. Crit Care Med. www. A A randomized study of left versus right internal jugular vein cannulation in adults. 7. 24. 9. Peripherally inserted central venous catheters in the acute care setting: a safe alternative to high-risk short-term central venous catheters. 2000.23: 916–919. 17. J Clin Anesth. et al. Uretsky BF. Harrison W. et al. 19. Crit Care Med. Slama M. Sulek CA. et al. 2003. Cohen ER.anesthesiaclinics.38:149–155.52:e162–e193. et al. Hull .348:5–14. Muralidhar K. Improvement of internal jugular vein cannulation using an ultrasound-guided technique. 2011. Labropoulos N.116:539–573. Anatomical variations of internal jugular vein location: impact on central venous access. Marik PE. 2009. Bryan-Nomides N. 1995.60:243–248. 2008. 13. Guidelines for the prevention of intravascular catheter-related infections. 12.12:142–145.14:3.82:125–128. J Cardiothorac Vasc Anesth. stenosis and infection. ASA Task Force on Central Venous Access. 1996. Simulation training in central venous catheter insertion: improved performance in clinical practice. Barsuk JH. 20. 1997. 11. Mallory DL. Canadian Critical Care Clinical Trials Group. 1990. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Head rotation during internal jugular vein cannulation and the risk of carotid artery puncture. et al. Clin Infect Dis. Vahid B. 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. Blas ML. 2010. et al. McGaghie WC. Intensive Care Med. Available at: http://www. 2010. Accessed June 2. and 2009. 2012. et al.19:1516–1519. 16. Shawker TH. De Groot E. Real-time ultrasound-guided catheterisation of the internal jugular vein: a prospective comparison with the landmark technique in critical care patients. Karakitsos D. Barsuk JH. controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. Acad Med. 2012. J Hosp Med. Am J Infect Control. Safavian A. Morb Mortal Wkly Rep. 2001. Anesthesiology. Marik PE. Use of simulation-based mastery learning to improve the quality of central venous catheter placement in a medical intensive care unit. 10. Anesth Analg. Denys BG. 2006. Lobato EB. 2009. Ultrasound guidance improves the success rate of internal jugular vein cannulation: a prospective randomized trial. Li C. Sulek CA.html. Al Raiy B. Shah TD. 18.4:397–403. 22. CD004084. Crit Care.76 ’ Tung 6.85: 1462–1469. 21. Vital signs: central line-associated blood stream infections—United States. 8. Central venous access sites for the prevention of venous thrombosis. Novara A. Crit Care Med. Flemmer M. Chest. Fakih MG.37:2697–2701. Cochrane Database Syst Rev. 2008.facs. N Engl J Med. Sandham JD.10:R162–R170. McGee WT. 2012. et al. Left internal versus right internal jugular vein access to central venous circulation using the Seldinger technique. 1991. McGaghie WC. 23. American College of Surgeons Revised statement on recommendations for use of real-time ultrasound guidance for placement of central venous catheters. Gravenstein N.9:115–116. Practice guidelines for central venous access. Evans LV. Baram M. O’Grady NP.40:2479–2485. Centers for Disease Control and Prevention (CDC). 2012. Ge X. Blackshear RH. 14. 2011. Brant RF.134:172–178. Chest. Cavallazzi R.

Raad II. Chlorhexidine-alcohol versus povidoneiodine for surgical-site antisepsis. Mimoz O. 2002.331:1735–1738. et al. 1994. Effect of the implementation of NICE guidelines for ultrasound guidance on the complication rates associated with central www.147:305–307. Paige GB. Chlorhexidine and alcohol versus povidoneiodine for antisepsis in gynecological surgery. 2011. 35. Anesthesiology. Terazawa E. 1998. Arch Intern Med. Sznajder JI. Central vein catheterization. III. 31.30: 454–460. 2010. 27. J Womens Health (Larchmt). J Crit Care. 1986. Darouiche RO. 32. 30. 2005. Gilbreath BJ.24:1818–1823. Cornell M. 34. Ruesch S. Arch Intern Med. 36. Severe anaphylactic reaction due to a chlorhexidine-impregnated central venous catheter. J Infect Dis. J Trauma. Perforation of the great vessels during central venous line placement. Fornage BD. and chlorhexidine for prevention of infection associated with central venous and arterial catheters. Nagase K.155:1225–1228. Smythe JF. 2003. Krauss D.143:570–580.160:644–650. 26. 1991.anesthesiaclinics. 1998. Cardiac tamponade and contralateral hemothorax after subclavian vein catheterization. NKF-K/DOQI Clinical Practice Guidelines for Vascular Access: update 2000. DePalo VA. Hacking MB. Galler M.338:339–343. Effect of a second-generation venous catheter impregnated with chlorhexidine and silver sulfadiazine on central catheter-related infections: a randomized. 1987.15:231–238. Maki DG. Lancet. Arch Surg. Brown E. et al.19:555–561. Use of ultrasound to place central lines. Robinson WA. Walder B.20: 321–324. Lipsett PA. Hohn DC. 2002. 43. et al. Arch Intern Med. Spinowitz BS. et al. Cross-sectional area and intravascular pressure of the right internal jugular vein during anesthesia: effects of Trendelenburg position.138:996–1000. Complications of central venous catheters: internal 28. Wall MJ Jr. Florete OG Jr. Am J Kidney Dis. N Engl J Med. Complications and failures of subclavianvein catheterization. et al. Failure and complication rates by three percutaneous approaches.47:403–405. Moore HG III. Bitterman H. Infect Control Hosp Epidemiol. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. positive intrathoracic pressure. Schmidt GA.146: 259–261.362:18–26. Pieroni L. 1999. 41. and hepatic compression. Lawrence C. 2010. Aortic injury resulting from attempted subclavian central venous catheter placement. et al. et al. Amer-Alshiek . Feustel P. 38. randomized trial of two antiseptic solutions for prevention of central venous or arterial catheter colonization and infection in intensive care unit patients. Mansfield PF. et al. Wenzel RP. 33. Lobato EB.10:1–5. Zveibil FR. Prospective randomised trial of providone-iodine. 2001. 42.Best Practices for Central Line Insertion ’ 77 25. et al. 1996. et al. et al. Itani KM. 1989. Ringer M. National Kidney Foundation. 39.37:S137–S181. 45. Lisco SJ. Qual Saf Health Care. Subclavian vein stenosis as a complication of subclavian catheterization for hemodialysis. Fortune JB. Pan D. Shimonaka H. 37. N Engl J Med. Ann Intern Med.17:126–137. `r MR. Golden RA.89: 1296–1298. 1991. Angood P. controlled trial. 29. Trame jugular versus subclavian access—a systematic review. McNicoll L. 40. J Clin Anesth. Prospective. Crit Care Med. Alvarado CJ. Cohn A. et al. Chest. 44. Rupp ME. Exploration of the microbial anatomy of normal human skin by using plasmid profiles of coagulase-negative staphylococci: search for the reservoir of resident skin flora. alcohol.99:517–518. Levin I. 1994. et al. Hendley JO. Keenan SP. Wigmore TJ. et al. The Rhode Island ICU collaborative: a model for reducing central line-associated bloodstream infection and ventilatorassociated pneumonia statewide. Crit Care Med. Effect of patient position on size and location of the subclavian vein for percutaneous puncture. 1995. Robinson JF. Hohn DC. Avni A.

38: 1199–1202.78 ’ Tung 46. 1997. 54.21: 1118–1123. Szmuk P. et al. et al.8:123–125.55:463–468. et al. J Trauma. Mangione MP. Pivalizza EG. randomized. Bahk JH. Br J Anaesth. et al. Reeves ST.102:662–666. Comparison of routine chest radiograph versus clinician judgment to determine adequate central line placement in critically ill patients. et al. Hoda MQ. 2007. A comparative study of polyantibiotic and iodophor ointments in prevention of vascular catheter-related infection. Can J Anaesth. McGee WT. et al. Inferior vena cava filter ensnarement by central line guide wires—a report of 4 cases and brief review. Blaivas M. The carina as a landmark in central venous catheter placement. 52.85:192–194. Accurate placement of central venous catheters: a prospective. Precautions necessary with central venous catheters. Cothren CC. 2000. multicenter trial. et al. 61. FDA Task Force. Br J Anaesth. Comparison of the bedside central venous catheter placement techniques: landmark vs electrocardiogram guidance. Correct depth of insertion of right internal jugular central venous catheters based on external landmarks: avoiding the right atrium. Cook D. Food and Drug Administration. Ackerman BL. Anesth . 56. Unusual site of guide-wire entrapment during central venous catheterization.109:130–134. Janik JE. 48. Ezri T. Am J Med. Lee JH. Gebhard RE. et al. Das G.99:662–665. 2009. Oravitz TM. Crit Care Med. venous catheter placement in patients presenting for routine surgery in a tertiary referral centre. 57. 2007. 1996. Abood GJ.28:1239–1244. 1993. Nave H. Sawchuk C. J Pak Med Assoc.100:1411–1418. Is a routine chest x-ray necessary for children after fluoroscopically assisted central venous access? J Pediatr Surg. Chattar-Cora D. Anesth Analg. 63. 2003.48:688–690.70:739–744. et al. J Cardiothorac Vasc Anesth. Eliminating arterial injury during central venous catheterization using manometry. 2004. 62. 2004. 51. 2001. Janik JS. Confirmation of internal jugular guide wire position utilizing transesophageal echocardiography. Posner KL. Ezaru CS. et al. N Engl J Med. Br J Anaesth. 58. 53. 1989. Esposito TJ. Davis KA. 47. Piepenbrock S.63:50–56. 2009.21:497–501. et al. Schuster M.15–16. Weisenberg M. Crit Care Med. Domino KB. Gould MK. 59. Video analysis of accidental arterial cannulation with dynamic ultrasound guidance for central venous access. 2007. J Neurosurg Anesthesiol. Mamsa KA. Fayad A.anesthesiaclinics. 2007. Bowdle TA. Kernerman P. Angiology. 50. Central venous catheter replacement strategies: a systematic review of the literature. Randolph A. Anesthesiology. et al. Sessler DI. Rouben LR. McGee DC. Maki DG. Band JD. Injuries and liability related to central vascular catheters: a closed claims analysis. 60. Positioning a right atrial air aspiration catheter using transesophageal echocardiography. FDA Drug Bull. J Ultrasound Med. The accuracy of electrocardiogramcontrolled central line placement. Ryu HG. 1981. Tulsyan N. Preventing complications of central venous catheterization.56:139–141. 2006. Tutela RR Jr. www.348:1123–1133. Bailey BN.25:1417–1424. 55. Bevis LA.104:65–70. 2009. 2003. 49.