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ORIGINAL RESEARCH REPORT

Central venous catheter insertion in critical illness:

Techniques and complications
Oyebola Olubodun Adekola, Nicholas Kaode Irurhe1, Victor Ayanwale Raji2, Ibironke Desalu

Departments of Anaesthesia and 1Radiodiagnosis and Radiography, College of Medicine, University of Lagos and Lagos University Teaching
Hospital, 2Department of Anaesthesia and Intensive Care Unit, Lagos University Teaching Hospital, PMB 12003, Lagos, Nigeria

Address for correspondence:
Dr. Oyebola Olubodun Adekola,
Department of Anaesthesia,
College of Medicine, University
of Lagos and Lagos University
Teaching Hospital, PMB 12003,
Surulere, Lagos, Nigeria.
E‑mail: oyebolaadekola@yahoo.
com
ABSTRACT
Background: Werner Forssman, in 1929, first described central venous catheter (CVC)
insertion when he canalized his own right atrium through the cephalic vein. It is now a routine
procedure in critical care. We investigated the pattern of insertion of CVC in our intensive care
unit. Patients and Methods: A prospective observational study conducted in a 5‑bed general
intensive care unit of a 770‑bed university teaching hospital. All prospective patients admitted
from January 2013 to June 2014 were recruited. The technique, site and complications following
insertion were documented. All had postprocedure chest radiography performed to confirm
catheter tip position. Results: The most common site and technique of CVC insertion were
the right internal jugular vein (IJV) 71 (79.8%), and the anatomic landmark (AL) 66 (74.2%),
respectively. The mean catheter depth was significantly shorter in the AL (15.0 ± 2.4) cm
than the Peres’ formula (16.5 ± 3) cm, P = 0.046. Catheter tips were correctly placed at the
carina in 62 (69.7%) patients. The complication rate was 28 (31.5%), which was significantly
higher in males 25 (45.5%) than females 3 (8.9%), P = 0.03, and increased by 57.9% with
attempts >2. The most common complications were failure to insert 9 (10.1%), right carotid
artery puncture (8.9%), and arrhythmias (5.9%). Pneumothorax was reported in (4.5%), all
occurred with the subclavian approach. Conclusion: Central venous catheter insertion is more
common through the right internal jugular vein, and with the anatomical landmark technique.
The complication increased with attempts >2, male gender, and subclavian approach.
Key words: Carina, central venous catheter, complications, critical illness, site, technique

INTRODUCTION Life‑threatening complications with an incidence <1%

The internal jugular, subclavian, and femoral veins are
common sites for central venous catheter (CVC) placement
in the intensive care unit.[1] The central vein is commonly
accessed using the anatomical landmark or simple formula
techniques in low‑resource nations.[2‑5] The recommended
depth of insertion in adults is 15 cm from the puncture site.[2,3]
The insertion of catheter is not free of complications during
and after the procedure, with an incidence between 5% and
19%.[6,7] Early complications include failure to place catheter
in (22%), arterial puncture (2.1%–14.28%), cardiac
arrhythmia (36.37%), arterial hematoma (0.7%–3.7%), and
catheter malposition (3.6%–60%).[8,9] Late complications
include infection, thrombosis, and sepsis. [6‑8,10]
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include pneumothorax, hemothorax, venous air embolism,
nerve and thoracic duct injury, and asystolic cardiac
arrest.[6,7,9,11] A delay in diagnosis and intervention can
lead to serious morbidity and mortality.[8,10,11] The site of
CVC insertion is a known risk factor for complication.[1]
Fewer rates of infection and thrombosis have been reported
with subclavian CVC placement when compared with
internal jugular and femoral CVC insertion.[1] The risk of
pneumothorax is, however, higher with the subclavian
approach, with rates varying between 1% and 6.6%.[1,9] The
highest risk of malposition occur with the right subclavian
vein (SCV) in 9.1%, followed by the left internal jugular
vein (IJV) (4.12%), and the right IJV (1.1%).[7] The use
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DOI: How to cite this article: Adekola OO, Irurhe NK, Raji VA, Desalu I.
10.4103/jcls.jcls_49_17
Central venous catheter insertion in critical illness: Techniques and
complications. J Clin Sci 2018;15:96-101.

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Adekola, et al.: An audit of techniques of central venous catheter insertion in critical illness

Table 1: The frequency distribution central venous was defined as CVC tip above or below the carina, in the
catheter insertion between internal jugular vein right atrium or any other vessel.[15] Complications were
and subclavian vein recorded as arterial puncture, arrhythmias, pneumothorax,
Variables Internal jugular Subclavian hematoma, and others.[9‑11]
vein (n=71), vein (n=18),
frequency (%) frequency (%) All procedures were performed under aseptic technique.
Correct placed CVC tips (carina level) 53 (74.7) 9 (50) CVC insertion was through the IJV or SCV. The CVC
Malpositioned CVC tips 21(29.6) 9 (50) depth was measured in the anatomic landmark  ( AL)
Right atrium 12 (16.9) 7 (38.9) method   using a sterile disposable paper ruler from the
Above carina 8 (11.3) 1 (5.6) proposed insertion site to the 3rd to 4th rib, and in the Peres’
Retrograde into right internal jugular vein 0 1 (5.6) formula (PF) method by a calculation based on using the
Into right brachiocephalic trunk 1 (1.4) 0 patient’s height. The technique of choice was determined
Complications 13 (18.3) 6 (33.3) by the attending anesthetist.
Carotid artery puncture 7 (9.9) 1 (5.6)
Failure to insert 5 (7) 4 (22.2) The calculation of catheter length determination using PF
Arrhythmias 4 (5.6) 1 (5.6) of height:[4]
Pneumothorax 0 4 (22.2)
Hematoma 2 (2.8) 0 Height (cm)
Values are frequency and percentage. CVC=Central venous catheter
Right SCC =
10

of ultrasound guidance has been recommended by the Height (cm) + 4 cm

Left SCC =
National Institute for Clinical Excellence (NICE) for 10
proper localization and reduction in complications.[12] We
investigated the pattern and complications following CVC Height (cm) − 1 cm
Right JC =
insertion in critically ill patients at our institution. 10

PATIENTS AND METHODS
This was a prospective study of CVC inserted in a cohort
of critically ill patients 18 years and older. The Human
Research and Ethics Committee approval and informed
consent was obtained from patients or their next of kin.
Only Patients with sinus rhythm on electrocardiography
were recruited. Those with cervical injury, obesity,
arrhythmias, and electrolyte abnormalities were excluded.
The sample size was based on a predetermined formula
using proportions, with an incidence of 3.3% for
misplacement of CVCs inserted through the IJV.[14] A sample
size of 60 was considered adequate for the study.
Height (cm) + 3 cm
Left JC =
10
Internal jugular vein approach
The patient was positioned supine, the head of the bed
was slightly tilted downward, and the patient’s head
was turned to the opposite side of needle insertion. The
carotid pulse was palpated at the level of the cricoid
cartilage. An 18‑G needle was inserted at 30° lateral to
the pulse, and directed toward the ipsilateral nipple;
the syringe plunger was withdrawn gradually for
backflow of venous blood as the needle was inserted.
A 7.5Fr × 4” 20 cm long, triple lumen CVC was inserted
using the Seldinger technique.[16]

Central venous catheter insertion Subclavian vein approach

CVC insertion was performed by a consultant or senior
registrar with proficiency in the procedure. The internal
jugular or subclavian approach was used depending on
the skill of the attending anesthetist. A multiparameter
monitor (Mindray MEC‑2000, Shenzhen Mindray
Bio‑Medical Electronics Co, Ltd., Shenzhen, China) was
attached to the patient and baseline vital signs were
measured. Thereafter, blood pressure, heart rate, oxygen
saturation, and electrocardiogram were continuously
monitored till the end of the procedure. The primary
outcome determined the complications secondary to
CVC placement, and the secondary outcome determined
the site, technique for CVC placement, and compared the
distribution of complication between different sites and
techniques. Correctly sited catheter tip was defined as CVC
tip at the level of the carina.[13,14] Malposition catheter tip
The patient was positioned supine and the neck and
infraclavicular region cleaned with antiseptic solutions
and draped. A point at the junction of medial one‑third
and lateral two‑thirds of the clavicle was identified and
used as the puncture point. A local wheal was raised at
the site of needle puncture with 1% lidocaine (0.5 mg/kg).
An 18 G introducer needle was inserted at the puncture
point, and directed toward the supra‑sternal notch. After
aspiration of the free flow of venous blood, a J‑tipped
guide wire was inserted, and the introducer needle was
removed. The skin and subcutaneous tissue overlying the
guide wire were dilated using the dilator provided with
the Arrow guard Blue® Multi‑Lumen Catheterization
Kits (Arrow Deutschland GmbH, Germany, Teleflex
Medical). A 7.5Fr × 4” 20 cm long, triple lumen CVC was then
railroaded over the guidewire using a modified Seldinger

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Adekola, et al.: An audit of techniques of central venous catheter insertion in critical illness

technique.[16] Free flow of venous blood from the ports of

CVC was confirmed.

Post‑CVC insertion, each lumen was flushed with

0.5units/ml of heparinized saline. A postinsertion chest
radiography (anteroposterior view) was immediately
performed and reviewed by the consultant radiologist
involved in the study.

Statistical analysis
Data collated included age, sex, duration of catheter
insertion, duration of Intensive Care Unit admission, and
the modified APACHE II score. The modified APACHE
II score was calculated on admission, [Appendix 1].[17]
Data were presented as frequencies, percentile, and
mean ± standard deviation. The independent t‑test,
Figure 1: Catheter tip in the right atrium
Chi‑square, or Fisher’s Exact Test were applied to test the
significant differences between the groups. All data were
analyzed using the   Statistical Package for Social Sciences
(SPSS, Chicago, IL). for windows; a P ≤ 0.05 was considered
to be statistically significant.

RESULTS
The study was conducted on 89 patients, of whom
55 (61.8%) were males. The mean age, modified APACHE
II score, duration of admission, and duration of catheter
were 37.51 ± 15.95 years, 27.97 ± 12.91, 7.56 ± 4.83 days,
and 5.08 ± 3.41 days, respectively. The most common site of
CVC insertion was the right IJV 71 (79.8%), followed by the
right SCV 15 (16.8%) and the left SCV with 3 (3.4%), [Table
1]. CVC insertion was performed with the AL in 66 (74.2%)
and PF technique in 23 (25.8%). Catheter tips were correctly
sited at the carina in 62 (69.7%) patients, [Figure 1]. The Figure 2: Catheter tip above the carina
calculation of CVC depth using AL resulted in 49 (76.6%)
successful placements compared to 15(60%) using Peres’
formula, P = 0.22. However, there was no significant
difference in mean duration of CVC insertion between the
methods [Table 2]. Cather tips were inappropriately placed
in the right atrium in 19 (21.4%) patients, above carina in
9 (10.1%), retrograde into the right IJV through the right
subclavian approach in one patient (1.1%), and into the right
brachiocephalic trunk (1.1%), [Figures 1‑3]. Table 1 shows
the comparison of complications between CVC insertion
through the internal jugular vein and subclavian vein.

The mean catheter depth was significantly shorter

in the AL (15.0 ± 2.4) cm than the PF (16.5 ± 2.3) cm,
P  = 0.046 [Table 2]. The comparison of complications
between anatomical landmark and Pere's technique is
detailed in Table 2.
Figure 3: Catheter tip in the trunk of brachiocephalic
The complication rate was 28 (31.5%), which was
significantly higher in males 25 (45.5%) than females
3 (8.9%), P = 0.03, and increased by 57.9% with attempts >2. and arrhythmias (5.9%). Pneumothorax was reported
The most common complications were a failure to in (4.5%), which occurred with the subcalvian approach,
insert 9 (10.1%), right carotid artery puncture (8.9%), however, there was no incidence of hemothorax, [Table 2].

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Adekola, et al.: An audit of techniques of central venous catheter insertion in critical illness
Table  2: The comparison of pattern of central venous catheter between anatomical landmark and Peres’
formula technique
Variables Anatomical landmark (n=66), frequency (%)
Age (years) 43.6±18.63
Depth of CVC inserted (cm) 15.0±2.4
Duration of CVC placement (min) 8.71±3.54
Correct placed CVC tips (carina level) 49 (76.6)
Complications 11 (16.7)
Carotid artery puncture 4 (6.1)
Arrhythmias 2 (3.0)
Pneumothorax 3 (4.5)
Hematoma 2 (3.0)
Malpositioned CVC tips 19 (28.8)
Right atrium 13(19.7)
Above carina 5 (7.6)
Retrograde into right IJV 0 1 (4.3)
Right brachiocephalic trunk 1 (0.5)
Values are mean±SD, frequency, and P value. *Indicate Fisher exact. SD=Standard deviation, CVC=Central venous catheter, IJV=Internal jugular vein
DISCUSSION
We have demonstrated that central venous catheterization
in our intensive care unit is frequently performed through
the right internal jugular approach. This is the pattern
of observation in previous studies,[6,8] which has been
attributed to reports of increased success, and reduced
complication rates with IJV catheterization.[6,13] The peculiar
anatomy of the jugular venous system and the design of the
catheter has been reported to facilitate proper insertion.[13]
The incidence of complications in our study is higher than
11%–17.9% reported in other studies.[6,7,9] The frequency
of complication increased with attempts at insertion >2,
the subcalvian approach and male gender. This observation
is in agreement with previous studies that reported a
significantly higher complication rates with the subclavian
approach than with the internal jugular approach, and
in the male patients than their female counterparts.[6,9] It
has been reported that pneumothorax and hemothorax
is more common with subclavian approach, while
arterial puncture is more common with IJV catheter
placement.[6,7] This was further reiterated in our study
with the presence of pneumothorax only in the subcalvian
approach, however, there was no report of hemothorax. The
diagnosis of pneumothorax was by post‑CVC insertion chest
radiography, and all had chest tube thoracostomy. This has
led to the suggestion that routine post‑CVC chest radiograph
be performed to exclude immediate life‑threatening
complications such as pneumothorax and hemothorax.[2,5]
We observed that the mean depth of catheter inserted
was significantly shorter in the AL method 15.0 ± 2.37 cm
than the PF method 16.5 ± 2.28 cm. In another study,
Sharma et al. [18] evaluated the depth and position of
central venous catheter using three different methods:
Peres’ formula, landmark, and endocavitory (atrial) ECG.
JOURNAL OF CLINICAL SCIENCES, VOLUME 15, ISSUE 2, April-June 2018
Pere’s formula (n=23), frequency (%) P
36.93±15.36 0.24
16.5±2.3 0.05
9.57±4.64 0.49
15 (60) 0.22
8 (36) 0006
4 (17.4) 0.03*
3 (8.7) 0.85*
1 (4.3) 0.52*
0 0.52*
11 (44.3) 0.041
6 (26.1) 0.44
4 (17.4) 0.45*
0.29*
0 0.36*
They demonstrated that the mean depth of central venous
catheter was significantly shoter with endocavitory (ECG)
technique (8.18 ±0.74) cm than with anatomic Landmark
(12.08 ±0.98) cm, or Peres’ Formula (14.20 ±0.69) cm. The
authors concluded that correct position of central venous
catheter by endocavitory (atrial) ECG appears not only
to reduce the procedure related complications but allow
post procedure manipulation of catheter tip detected using
post insertion chest X-ray. The mean depth in our study
is within the accepted range of 13–16.5 cm described
earlier.[18] The appropriate depth of catheter inserted has
been shown to depend on the site of insertion, catheter
length, patient’s height and body habitus.[14] In critically ill
Indians, the acceptable depth for correctly placed catheter
was 11–14 cm, while a depth of 16 cm was suggested for
the Western population.[19] CVC insertion with catheter
length from 13 to 16 cm has been reported to result in a
significantly greater proportion of safe catheter placements
than CVC with 20 cm length.[20,21]
In 32.6%, CVC tips were malpositioned, which is within the
reported range of 1%–60%.[7] The abnormal site includes
the right atrium, above the carina, and retrograde into the
right IJV (through the right subclavian approach). All the
malpositioned catheter tips were withdrawn before use.
A case of CVC malposition into the right ventricle (RV)
following catheter insertion through the right IJV using
the high approach anatomic surface landmark technique
was reported in our institution.[5] It was associated with
complaints of severe chest pain during catheter insertion
necessitating a postinsertion chest radiograph which revealed
the presence of the catheter tip in the RV The procedure was,
however, performed with relative ease.[5] The catheter tip was
subsequently withdrawn into the proper position before use.[5]
The desired position of the tip of the catheter is just above
the junction of the superior vena cava and the right atrium.
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Adekola, et al.: An audit of techniques of central venous catheter insertion in critical illness
Occasionally, however, despite proper technique, the tip of
the catheter may not terminate at the desired level, resulting
in aberrant placement in the internal thoracic vein, superior
vena cava, azygos vein, accessory hemiazygos vein, or axillary
vein.[20,22,23] The inadvertent cannulation of the azygos arch
occurred in about 0.7%–1.2% of insertions, and the rate was
about seven times higher when the left jugular vein was used
than when the right one was used.[22,23] The Food and Drug
Administration in the USA advocated that CVC tips should not
be placed in or allowed to migrate into the heart.[24] The NICE
guidelines recommend the use of a 2‑D imaging ultrasound
guidance as a preferred method for inserting a CVC into the
IJV in adults and children in elective situations and suggest
that ultrasound guidance should be considered in most
clinical situation where CVC insertion is necessary, whether
the situation is elective or in emergency.[12]
The study was limited by the fact that neither the site nor
the technique of CVP placement was randomized, which
may contribute to bias on the part of the performer. This
is because the site and technique of insertion depended on
the proficiency of the attending intensivist. We concluded
that CVC placement at our institution is more common
through the right internal jugular vein and with the
anatomical landmark technique. Complications such as
arterial puncture, malposition, and pneumothorax are
not uncommon, however, the frequency of complications
increased with attempts >2, male gender and subclavian
approach. We recommend regular training and the
acquisition of skill in CVC insertion. We also suggest that our
institution should imbibe the use of 2D Ultrasonography
for CVC insertion as a standard of care.
Acknowledgment
We appreciate the support of the anesthetist residents and
nursing staff of our intensive care unit during the study. “The
research was supported (in part) by the Medical Education
Partnership Initiative in Nigeria grant from the Fogarty
International Center of the National Institutes of Health
R24TW008878. The content is solely the responsibility of
the authors and does not necessarily represent the official
view of the National Institutes of Health.”
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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Adekola, et al.: An audit of techniques of central venous catheter insertion in critical illness

Appendix I: Modified APACHE Score

+4 +3 +2 +1 0 +1 +2 +3 +4
Temp >41 39‑40.9 38.5 36‑38.4 34 32‑33.9 30‑31.9 <29.9
38.9 35.9
MAP >160 130‑159 110‑129 70‑109 55‑69 40‑54 <39
HR >180 140‑179 110‑139 70‑109 55‑69 40‑54 <39
RR >50 35‑49 25‑34 12‑24 10‑11 6‑9 <5
FiO2 >0.21 >0.21 >0.21 >0.21 =0.21
Na >180 160‑179 155‑159 150‑154 130‑149 120‑129 111‑119 <110
K >7 6‑6.9 5.5‑5.9 3.5‑5.4 3‑3.4 2.5‑2.9 <2.5
Creatinine >3.5 2‑3.4 1.5‑1.9 0.6‑1.4 <0.6
PCV >60 50‑59.9 46‑49.9 30‑45.9 20‑29.9 <20
WBC >40 20‑39.9 15‑19.9 3‑14.9 1‑2.9 <1
HCO3 >52 41‑51.9 32‑40.9 22‑31.9 18‑21.9 15‑17.9 <15
GCS

<44 45‑54 55‑64 65‑74 >75

Age (years) 0 2 3 5 6
Chronic evaluation score

Non operative or emergency postoperative patient Elective postoperative patient

(Immunosuppression, liver disease, cardiovascular, respiratory 5 2
and renal insufficiencies)

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