Central Venous Catheter Insertion: Performing (Advanced Practice) – Overview

Overview: Central venous catheters are inserted to measure and obtain (RAP) and CVP with
jugular or subclavian catheter placement. Clinically useful information can be
obtained about right ventricular preload, cardiovascular status, and fluid balance in
patient's who do not require pulmonary artery pressure monitoring. Central venous
catheters also are placed for infusion of vasoactive medications, total parenteral
nutrition, and hemodialysis access. In addition, central venous catheters are used to
administer medication and intravenous (IV) products to patient's with limited
peripheral IV access, as well as to provide access for pulmonary artery catheters
and transvenous pacemakers.
The CVP can be particularly helpful after major surgery and during active bleeding.
It can be helpful in differentiating right ventricular failure from left ventricular failure.
The CVP is commonly elevated during or following right ventricular failure,
ischemia, or infarction because of decreased compliance of the right ventricle while
the pulmonary artery wedge pressure is normal. The CVP value is low if the patient
is hypovolemic; venodilation also decreases CVP. The CVP provides information
regarding right heart filling pressures and right ventricular function and volume.
The CVP can be measured using a water manometer system or via a hemodynamic
monitoring system. The CVP waveform is identical to the RAP waveform. Normal
CVP value is 2 to 6 mm Hg.
Central venous access may be obtained in a variety of sites [See Table 1]. The risk
for pneumothorax is minimized by using an internal jugular vein. The preferred site
for catheter insertion is the right internal jugular vein. The right internal jugular vei n
is a straight shot to the right atrium. The right or left subclavian veins are also sites
for central catheter placement. Placement of a central catheter through the right
subclavian vein is a shorter and more direct route than the left subclavian vein,
because it does not cross the midline of the thorax. Femoral veins may be accessed
but have the strong disadvantage of forcing the patient to be on bed rest with
immobilization of that leg, and there is an increased risk for infection with placement
in the groin.
Individuals who perform this procedure should have the following prerequisite
knowledge:

 Normal anatomy and physiology of the cardiovascular system

 Clinical and technical competence in central line insertion and suturing
 Understanding of principles of sterile technique
 Anatomy and physiology of the vasculature and adjacent structures of the neck,
groin, and arm
 Competence in chest-x-ray interpretation
 Advanced cardiac life support (ACLS) knowledge and skills
 Understanding of a, c, and v waves

Table 1: Sites, Complications, and Success Rates

Access Site Complications Success Rates (% )

Internal jugular vein
Right subclavian vein
Left subclavian vein
Femoral vein
Carotid artery puncture 60-90
Carotid artery cannulation
Pneumothorax 70-98
Tension pneumothorax
Thoracic duct puncture
Decreased success rate
with inexperience
Pneumothorax 70-98
Tension pneumothorax
Thoracic duct puncture
Decreased success rate
with inexperience
Infection 75-99
 Arterial puncture
Failure rate during
hypotension and shock
Inability to thread central
catheters

Central Venous Catheter Insertion: Performing (Advanced Practice) – Outcomes

Expected Outcomes  Successful placement of the central venous catheter

 If infusing IV solution, the solution infuses without problems
 The a, c, and v waves identified in hemodynamic monitoring
 CVP measurement determined

Unexpected  Pain or discomfort during the insertion procedure

Outcomes  Pneumothorax, tension pneumothorax, hemothorax, or
chylothorax
 Nerve injury
 Sterile thrombophlebitis
 Infection
 Cardiac dysrhythmias
 Misplacement (e.g., carotid artery, subclavian artery)
 Inadvertent lymphatic or thoracic duct perforation
 Hemorrhage
 Hematoma
 Venous air embolism
 Pulmonary embolus
 Cardiac tamponade
 Sepsis
 Heparin-induced thrombocytopenia or thrombosis

Central Venous Catheter Insertion: Performing (Advanced Practice) - Assessment and Preparation

Preparation  Ensure that the patient and family understand preprocedural teaching. Answer
questions as they arise, and reinforce information as needed.
 Obtain informed consent.
 Prescribe sedation if needed.
 Place the patient in a supine position, and prepare the area with an antiseptic
solution (e.g., 2% chlorhexidine-based solution).
 If the patient is obese or muscular and the preferred site is the internal jugular
vein or subclavian vein, place a towel posteriorly between the shoulder blades.
 Place sterile drapes over the prepped area.

Supplies  CVC insertion kit

 Teflon®-coated or antimicrobial/antiseptic impregnated catheter of choice(single,
dual, or triple lumen) usually supplied with insertion needle, dilator, syringe,
guidewire
 Large sterile drapes or towels
 1% lidocaine without epinephrine
 One 25-G 5/8 needle
 Large package of 4 x 4 gauze sponges
 Suture kit (hemostat, scissors, needle holder)
 0 or 4-0 nylon suture with curved needle
 Three-way stopcock
 Syringes: one 10- to 12-ml syringe, two 3- to 5-ml syringes, two 22-G, 1½-inch
needles
 Masks, caps, goggles (shield and mask combination be used), sterile gloves,
and sterile gowns
 Number 11 scalpel
 Skin protectant pad or swab stick
 Roll of 2-inch tape
 Dressing supplies
 Moisture proof underpad
 Antiseptic solution (such as 2% chlorhexidine-preparation)
 Nonsterile gloves
 0.9% sodium chloride, 10 to 30 ml.

Additional equipment as needed includes the following:

 Hemodynamic monitoring system

 IV solution with Luer-Lok administration set for infusion
  Luer-Lok extension tubing
 Bedside monitor and oscilloscope with pulse oximetry
 Supplemental oxygen supplies
 Emergency equipment
 Package of alcohol pads or swabsticks
 Package of povidone-iodine pads or swabsticks
 Heparin flushes
 Needleless caps
 Arm board

Assessmen 1. Determine the patient's medical history of

pneumothorax/emphysema.
2. Determine the patient's medical history of anomalous veins.
3. Assess the intended insertion site.
4. Assess the patient's cardiac and pulmonary status.
5. Assess vital signs and pulse oximetry.
6. Assess electrolyte levels.
7. Assess the patient for heparin sensitivity or allergy.
8. Assess coagulopathic status or whether the patient has recently
received anticoagulant or thrombolytic therapy.

Central Venous Catheter Insertion: Performing (Advanced Practice) – Procedure

1. Determine the anatomy of the access site.

Rationale: Helps ensure proper placement of the catheter.
Catheter placement on the right side is preferred to avoid cannulation of the thoracic
duct.
2. Wash hands, and don caps, masks, sterile gowns, goggles or face shields, and gloves for all health
care personnel involved with the procedure.
Rationale: Reduces the transmission of microorganisms and body secretions. Prepares for
sterile technique.
3. Check landmarks again for the intended catheter insertion site.
Rationale: Ensures proper placement of the catheter.
4. Estimate the length of the catheter needed. This can be done by holding the catheter from the insertion
site to the sternal notch.
Rationale: Helps ensure proper placement.

Internal Jugular Vein See Figure 2

1. Locate the carotid artery by palpation.
Rationale: Helps prevent placing the introducer in the carotid artery.
2. Identify the jugular vein, and mark it if necessary.
Rationale: Identifies the intended insertion site.
3. Instruct the patient to turn his or her head away from the insertion site.
Rationale: Helps identify the landmarks.
Turn the patient's head if the patient is unable to.
4. Place the patient in a 15- to 25-degree Trendelenburg position.
Rationale: Helps to decrease the risk for air embolism. Helps engorge the veins to help identify
the correct site.
5. Identify the internal jugular vein from the triangle between the medial aspect of the clavicle, the medial
aspect of the sternal head, and the lateral head of the sternocleidomastoid muscle See Figure 2.
Rationale: A high entry can be made from a posterior approach, a lateral approach, an anterior
approach, or a central approach.
The midanterior approach may be preferred in an obese patient. The posterior approach
may present a slightly higher risk.
6. Administer a local anesthetic and locate the internal jugular vein with a small needle 3 to 4 cm above
the medial clavicle and 1 to 2 cm within the lateral border of the sternocleidomastoid muscle.
Rationale: Provides patient comfort and aids in insertion.
7. Attach a 3-ml or 5-ml syringe with 2 or 3 ml of 1% lidocaine (without epinephrine) to the 18-G needle.
Align the needle with the syringe parallel to the medial border of the clavicular head of the
sternocleidomastoid muscle. Aim at a 30-degree angle to the frontal plane over the internal jugular vein,
toward the ipsilateral nipple.
Rationale: Helps to anesthetize below the subcutaneous tissue. If the needle bevel is directed
medially, the bevel aids in directing the guidewire medially.
8. Use the Seldinger technique for placement of the catheter See Figure 3.
Rationale: This technique is the preferred method of central venous catheter placement. This
technique uses a dilator and guidewire.
9. Puncture the skin, and advance the needle while maintaining slight negative pressure until a free flow
of blood is obtained.
Rationale: Slight negative pressure helps to ensure placement into the vein and decreases the
risk for air embolism and pneumothorax.
 If a free flow of blood is not obtained, remove and redirect the needle 5 to 10 degrees
more laterally.
10. After a free flow of blood is obtained, have the patient hold his or her breath or hum while the syringe is
detached, and insert the soft-tipped guidewire 10 to 15 cm through the needle. Remove the needle,
wipe the guidewire with the sterile 4 x 4 gauze, and instruct the patient to breathe normally.
Rationale: A free flow of blood indicates the needle is in the vessel. Holding the breath or
humming decreases the risk for air embolus. Wiping the guidewire dry eases manipulation.
11. With a number 11 blade, knife edge up, make a small (2-mm to 3-mm) stab wound at the insertion site.
Rationale: Eases the insertion of the dilator through the skin.
12. Insert the dilator through the skin, over the guidewire, until 10 to 15 cm of wire extends beyond the
dilator. Remove the dilator.
Rationale: The dilator enlarges the vessel and skin opening, easing the insertion of the
catheter.
13. Insert the catheter over the guidewire until 10 to 15 cm of wire extends beyond the catheter. Remove
the guidewire. Advance the catheter. Note the catheter length at the insertion site.
Rationale: Helps identify the location.
14. Aspirate and flush the ports with normal saline.
Rationale: Prevents clotting of the catheter
15. Connect to the hemodynamic monitoring system or intravenous fluid.
Rationale: Necessary for pressure monitoring and maintaining catheter patency.
16. Suture the catheter in place.
Rationale: Secures the catheter.
Some institutions use stat locks or a sutureless mechanism for securing the catheter.
17. Apply an occlusive, sterile dressing.
Rationale: Decreases the risk for infection.
Some institutions use stat locks or a sutureless mechanism for securing the catheter.
18. Return the patient to a neutral or head-up position
Rational: Provide comfort.
19. If monitoring, identify the appropriate waveforms.
Rational: Ensures accurate monitoring of values.
20. Assess lung sounds and obtain a chest x-ray film.
Rational: Confirms placement and assesses for pneumothorax.
The radiograph needs to be read before administration or total parenteral nutrition or
chemotherapeutic agents.
21. Discard supplies, and wash hands.
Rationale: Decreases the risk for transmission of micro organisms; standard precautions.

Subclavian Vein See Figure 4

1. Identify the junction of the middle and medial thirds of the clavicle. The needle insertion should be 1 to
2 cm laterally.
Rationale: Identifies landmarks for catheter placement.
Access from the right side is preferred to avoid inadvertent puncture of the thoracic
duct.
2. Depress the area 1 to 2 cm beneath the junction with the thumb of the nondominant hand and the index
finger 2 cm above the sternal notch.
To avoid the subclavian artery, select a puncture site away from the most lateral course
of the vein, and do not aim too posteriorly.
3. Administer a local anesthetic and locate the vein with a 21- to 25-G needle directed to the index finger
at a 20- to 30-degree angle.
Rationale: Provides patient comfort and assists patient cooperation and ease of insertion.
Extends the vein to ease the location.
4. Instruct the patient to turn his or her head away from the insertion site.
Rationale: Helps identify the landmarks.
Turn the patient's head if he or she is unable to.
5. Place the patient in a 15- to 25-degree Trendelenburg position.
Rationale: Helps to decrease the risk for air embolism. Helps engorge the veins to help identify
the correct site.
6. Insert the needle under the clavicle and "walk down" until it slips below the clavicle into the vein while
maintaining negative pressure within the syringe until free-flowing blood is returned See Figure 5.
Rationale: Decreases the risk for pneumothorax. Slight negative pressure helps to ensure
placement into the vein and decreases the risk for air embolism and pneumothorax.
Insert at a 45-degree angle to prevent pneumothorax. If it is difficult to depress the
needle down, the needle may be bent to form an arc. For the elderly: the subclavian vein
may be more inferior. Avoiding a too lateral or too deep a needle insertion can reduce
the risk for pneumothorax.
7. When a free flow of blood is returned, turn the bevel to the 3 o'clock position. Once in the vein, remove
the syringe and insert the flexible guidewire after asking the patient to hum or hold his or her breath.
Rationale: A free flow of blood indicates a vein is entered. Turning the bevel helps the
guidewire advance to the correct position. Holding the breath or humming decreases the risk
for air embolus.
 8. Insert the guidewire 10 to 15 cm through the needle. Remove the needle, and wipe the guidewire with a
sterile 4 x 4 gauze.
Rationale: Wiping the guidewire eases the manipulation of the guidewire.
If the guidewire insertion is not smooth, it may be in the internal jugular vein.
9. Advance the dilator over the guidewire with a light twisting motion.
Rationale: This aids dilation of the subcutaneous tissue to ease insertion and prevents the
formation of a false channel.
10. Remove the dilator from the wire.
11. Insert the catheter of choice over the guidewire; then remove the guidewire.
12. Aspirate and flush the ports with normal saline.
Rationale: Ensures blood return, and maintains catheter patency.
13. Suture the line in place.
Rationale: Secures the catheter.
14. Connect the catheter to the hemodynamic monitoring system or to intravenous fluid.
Rationale: Necessary for pressure monitoring and catheter patency.
15. Apply an occlusive, sterile dressing to the site.
Rationale: Decreases the risk for infection.
16. If monitoring, identify appropriate waveforms.
Rationale: Ensures accurate monitoring of values.
17. Assess lung sounds, and obtain a chest x-ray film.
Rationale: Confirms placement and assesses for pneumothorax.
The radiograph must be read before administration of total parenteral nutrition or
chemotherapeutic agents.
18. Discard supplies, and wash hands.
Rationale: Decreases the risk for transmission of microorganisms; standard precautions.

Femoral Vein See Figure 1

1. Identify the anatomy, including the femoral artery (remember "NAVEL").
Rationale: NAVEL is an acronym for remembering the anatomy (Nerve, Artery, Vein, Empty
space, Ligament; from lateral to medial).
2. Administer a local anesthetic and locate the vein with a 21- to 25-G needle lateral to the femoral artery.
Aim the needle at a 20- to 30-degree angle.
Rationale: Anesthetizes the area to provide patient comfort.
3. Attach a 3- or 5-ml syringe with 2 or 3 ml 1% lidocaine without epinephrine to the 18-G needle.
Rationale: Anesthetizes the area to provide patient comfort.
4. Use the Seldinger technique for placement of the catheter See Figure 3.
Rationale: This technique is the preferred method of central venous catheter placement. This
technique uses a dilator and guidewire.
5. Puncture the skin and advance the needle while maintaining slight negative pressure until a free flow of
blood is obtained.
Rationale: Negative pressure helps to identify a free flow of blood and ensures proper
placement into the vein.
If a free flow of blood is not obtained, remove and redirect the needle 5 to 10 degrees
more laterally.
6. After a free flow of blood is obtained, detach the syringe and insert a soft-tipped guidewire through the
needle 10 to 15 cm. Remove the needle and wipe the guidewire with a sterile 4 x 4 gauze.
Rationale: A free flow of blood indicates that the vessel has been accessed. Wiping the
guidewire eases the manipulation of the guidewire.
7. With a number 11 blade, knife edge up, make a small (2-mm to 3-mm) stab wound at the insertion site.
Rationale: Eases insertion of the introducer through the skin.
8. Insert the dilator over the guidewire until 10 to 15 cm of wire extends beyond the sheath. Advance the
dilator through the skin.
Rationale: The dilator dilates the vessel and skin to assist in the ease of the catheter insertion.
9. Remove the dilator.
10. Insert the catheter of choice over the guidewire and into the vein; then remove the guidewire.
11. Aspirate and flush the ports with normal saline.
Rationale: Ensures blood return and maintains catheter patency.
12. Suture the catheter in place.
Rationale: Secures the catheter.
Some institutions use sutureless systems.
13. Connect to the hemodynamic monitoring system or to intravenous fluid.
Rationale: Necessary for pressure monitoring and catheter patency.
14. Apply an occlusive, sterile dressing.
Rationale: Decreases the risk for infection.
May be gauze or transparent, semipermeable sterile dressing.
15. Identify the appropriate waveforms.
Rationale: Ensures the accurate monitoring of values.
16. Discard supplies, and wash hands.
Rationale: Decreases the risk for transmission of microorganisms, standard precautions.
Arm Vein See Figure 6
1. Identify the median basilic vein.
Rationale: Identifies the site for catheter placement.
The basilic vein is deeper and ascends along the ulnar surface of the forearm, joined by
the median cubital vein in front of the elbow.
2. Further patient preparation includes applying a tourniquet to locate the vein. Abduct the selected arm
30 to 45 degrees, and secure it on a flat, padded arm board resting on a flat surface.
Rationale: Aids preparation and allows for engorgement of the vessel.
3. Use the Seldinger technique for placement of the catheter See Figure 3.
Rationale: This technique is the preferred method of central venous catheter placement. This
technique uses a dilator and guidewire.
4. Apply a venous tourniquet to the upper arm. Maintain traction on the skin distal to the insertion with one
hand; puncture the vein with the needle bevel up at a 15- to 20-degree angle.
Rationale: Allows better visualization of veins. Helps with insertion, and prevents the needle
from penetrating too deeply.
Do not attempt to place a central venous catheter in a vein that cannot be seen or
palpated.
5. When blood appears in the needle, insert the guidewire into the vein approximately 2 to 4 cm beyond
the tip.
Rationale: Ensures appropriate placement of the catheter.
If resistance is met, do not force the catheter to advance. Withdraw the catheter 2 to 3
cm, rotate it, and readvance it.
6. Release the tourniquet, and advance the guidewire several centimeters. Remove the needle; wipe the
guidewire with a sterile 4 x 4 gauze.
Rationale: Eases manipulation of the guidewire.
7. Insert the catheter of choice over the guidewire. Remove the guidewire. Note the centimeter marking at
the skin.
8. Aspirate and flush the ports with normal saline.
Rationale: Maintains line patency.
9. Suture in place.
Rationale: Secures the line.
10. Connect to intravenous fluid.
Rationale: Maintains line patency.
11. Apply an occlusive, sterile dressing to the insertion site.
Rationale: Reduces the incidence of infection.
12. Immobilize on an arm board.
Rationale: Ensures that minimal movement of the catheter and sheath occurs.
13. Discard supplies, and wash hands.
Rationale: Reduces the transmission of microorganisms; standard precautions

Central Venous Catheter Insertion: Performing (Advanced Practice) - Post Procedure and Variations

Post Procedure 1. Perform cardiovascular, peripheral vascular, and hemodynamic

assessments immediately before and after the procedure and as the
patient's condition necessitates.
Rationale: Assess for signs of adequate perfusion; air embolism
may present with restlessness; patient may present with decreased
level of consciousness if the catheter is advanced into the carotid
artery.
This includes:
a. Level of consciousness
Rationale: Change in pressure may indicate change in
volume status.
b. Vital signs, central venous waveform, central venous pressure
Rationale: Changes in the waveform may indicate change in
right ventricular function or catheter migration.
Change in level of consciousness, changes in vital
signs, or abnormal waveforms or pressures should be
reported if they persist despite nursing interventions.
2. Monitor the site for hematoma and hemorrhage.
Rationale: If the patient is coagulopathic, a pressure dressing may
be required.
Bleeding that does not stop or hematoma and/or expanding
hematoma should be reported if they persist despite nursing
interventions.
3. Assess heart and lung sounds before and after the procedure.
Rationale: Abnormal heart or lung sounds may indicate cardiac
tamponade, pneumothorax, chylothorax, or hemothorax.
 Diminished or muffled heart sounds or absent or diminished
breath sounds unilaterally should be reported if they persist
despite nursing interventions.
4. Assess results of chest x-ray film.
Rationale: Ensures adequate placement and identification of
pneumothorax, if present.
Abnormal x-ray film results should be reported if they persist
despite nursing interventions.
5. Monitor for signs of complications.
Rationale: May decrease mortality and morbidity if recognized early.
Signs and symptoms of complications should be reported if
they persist despite nursing interventions.
6. Follow institution guidelines for changing CVC.
Rationale: CVCs are changed according to CDC guidelines when
an infection is suspected, when the CVC is placed in the femoral
vein, or when the catheter is placed emergently.
Signs or symptoms of catheter infection should be reported if
they persist despite nursing interventions.

Documentation  Patient and family education

 Signature on informed consent form
 Insertion of central venous catheter
 Insertion site of central venous catheter
 Vein selected and type and size of catheter placed
 Right atrial pressure and CVP waveform
 Central venous pressure values after insertion
 Centimeter marking at the skin
 Patient response to the procedure
 Confirmation of placement (e.g., chest x-ray film)
 Occurrence of unexpected outcomes
 Additional nursing interventions

Patient Education  Explain the need for the CVC insertion, and assess patient
and family understanding of CVP.
 Explain the procedure and the time involved.
 Explain the need for sterile technique and that the patient's
face may be covered.
 Explain the benefits and potential risks for the procedure.