Central Venous Access Techniques

Sidney L. Bourgeois Jr, DDS

KEYWORDS
 Central venous access  Internal jugular vein catheterization  Subclavian vein catheterization
 Femoral vein catheterization  Vascular access  Catheter

KEY POINTS
 Central venous access can be obtained if peripheral venous access is inadequate or if there is a need for total parenteral
nutrition administration, invasive hemodynamic monitoring, transvenous pacing, and placement of pulmonary artery
catheters.
 Absolute contraindications to central venous access are venous thrombosis, untreated coagulopathy, thrombocytopenia
(<50,000), fungating tricuspid valve endocarditis, and renal cell tumor extending into the right atrium.
 Femoral venous access is used as a site of last resort because of the increased risk of thrombosis, embolism, and infection.
 Complications associated with central venous catheterization include catheter misplacement, arterial puncture, hemor-
rhage, pneumothorax, thoracic duct injury, extravasation of fluids, medications, hyperalimentation, dysrhythmias,
brachial plexus injury, air embolism, catheter or wire embolization, hydrothorax, thrombosis, and infection (central-line-
associated bloodstream infection [CLABSI]).
 Complications can be minimized by good sterile technique during placement, proper patient positioning and procedure
performance, appropriate catheter maintenance postplacement, and proper removal technique.
 Use of image guidance should be considered if available to improve success and reduce the incidence of complications.

Introduction
A German surgical resident, Werner Forssmann, self-cathe-
terized one of his own left antecubital veins and then radio-
graphically confirmed the tip placement within his right atrium
in 1929. Thus began a new era in venous access for multiple
purposes. At present, in the United States alone almost 15
million central venous access procedures are performed
annually. Patients presenting for surgical procedures using
intravascular administration of medication, patients present-
ing to the emergency department for acute care, and most
patients admitted to the hospital require some sort of vascular
access device. For most of these patients, a peripheral venous
access device suffices with low morbidity. Upper extremity
veins are the most recommended and used veins including the
median, basilic, and cephalic veins. Lower extremity venous
access can also be achieved but has a much higher complica-
tion rate of phlebitis and infection and is not routinely
recommended.
Central venous access can be obtained if peripheral venous
access is inadequate or if there is a need for total parenteral
nutrition administration, invasive hemodynamic monitoring,
transvenous pacing, and placement of pulmonary artery cath-
eters (Box 1). Large vessel lumens lessen the risks of vessel
irritation and phlebitis and provide rapid administration of
medications to the central circulation. A few catheter types in
Disclosures: The author has no financial conflicts or disclosures
related to this topic.
Oral and Maxillofacial Surgery, 9107 Whistling Swan Lane, Manlius,
NY 13104, USA
E-mail address: dr.bourgeois@twcny.rr.com
use are Hickman, Groshong, and Broviac catheters. There are
also various implantable ports that can be placed to maintain
long-term central venous access. Absolute contraindications to
central venous access are venous thrombosis, untreated coa-
gulopathy, thrombocytopenia (<50,000), fungating tricuspid
valve endocarditis, and renal cell tumor extending into the
right atrium. Anticoagulation is a relative contraindication (Box
2).
This article discusses obtaining central venous access with
multilumen Silastic catheters in 3 sites: internal jugular vein,
subclavian vein, and femoral vein.
Equipment
Arrow Pressure Injectable Multi-Lumen CVC Kit or similar
(Box 3, Figs. 1 and 2).
ChloraPrep or povidone-iodine scrub (if not included in the
kit).
Absorbent pads (Chux pads).
Internal jugular venous access
A specific contraindication to internal jugular venous access is
ipsilateral carotid endarterectomy if image guidance is not
used. Internal jugular catheterization is intermediate in risk
between subclavian venous catheterization and femoral artery
catheterization for postplacement infection.
Pertinent anatomy
The internal jugular vein arises at the base of the skull and is
located in the carotid sheath posterior to the internal carotid
artery. The internal jugular vein terminates as the subclavian

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138
Box 1. Indications for central venous access
 Inadequate peripheral venous access
 Need for total parenteral nutrition administration
 Invasive hemodynamic monitoring
 Transvenous pacing
 Placement of pulmonary artery catheters
vein anterior and lateral to the common carotid artery. The
course of the internal jugular vein is medial to the sterno-
cleidomastoid muscle at its superior extent and posterior in the
triangle formed by the sternal and clavicular heads. At the
inferior part, the vein is deep to the clavicular head (Figs. 3
and 4).
Technique
There are 2 approaches for internal jugular venous catheteri-
zation, the central approach and the posterior approach. Right
internal jugular veins have the straightest course to the right
atrium and the lowest complication rate.
Central approach
1. Place absorbent pads beneath the patient (Fig. 5).
2. Position patient in Trendelenburg position.
3. Rotate the patient’s head 45 to the contralateral side.
4. Locate the apex of the triangle formed by the heads of the
sternocleidomastoid muscle and the clavicle.
5. Prepare and drape the neck.
6. Scrub and gown for sterile procedure.
7. Using the 3-mL Luer lock syringe and 25-gauge needle,
anesthetize the skin and subcutaneous tissues at the apex
of the triangle.
8. Palpate the carotid pulse and apply gentle medial traction.
9. Insert the finder needle, 22 gauge with a 5-mL Luer lock
syringe attached, at the apex of the triangle at a 45 to 60
angle to the skin surface advancing slowly toward the
ipsilateral nipple and aspirating.
a. If venous blood return is not noted after the needle has
been inserted 3 cm, slowly withdraw the needle while
aspirating.
b. If venous blood return is still not noted, reintroduce the
needle through the same puncture site but direct the
needle 1 to 3 cm more laterally.
c. If venous blood return is still not noted, reintroduce the
needle through the same puncture site but direct the
needle 1 cm medially.
d. If venous blood return is still not noted, consider
changing to the posterior approach.
10. If good venous blood return is noted, leave the finder
needle in place as a guide for the introducer needle. Using
Box 2. Contraindications to central venous
access
 Venous thrombosis
 Untreated coagulopathy
 Thrombocytopenia (<50,000)
 Fungating tricuspid valve endocarditis
 Renal cell tumor extending into the right atrium
 Anticoagulation (relative contraindication)
Bourgeois Jr
Box 3. Contents of Arrow Pressure Injectable
Multi-Lumen CVC Kit, CDC-45703-XP1A
(Teleflex, Morrisville, NC)
 Multilumen indwelling catheter 7F  20 cm (16 and
30 cm catheter lengths are also available)
 Spring-wire guide, marked 0.81 mm  60 cm
 18-gauge  2.5-in catheter, with 20-gauge needle
 Pressure transduction probe
 Injection needle, 22 gauge  1.5 in
 Injection needle, 25 gauge  1 in
 3-mL Luer lock syringe
 5-mL Luer lock syringe
 Introducer needle, echogenic, 18 gauge  2.5 in
 5-mL Arrow Raulerson (Teleflex, Morrisville, NC) spring-
wire introduction syringe
 Tissue dilator
 3-mL applicator pouch, 2% chlorhexidine gluconate, and
70% isopropyl alcohol ChloraPrep one-step solution with
Hi-Lite Orange tint
 5-mL ampule 1% lidocaine solution
 1 pack 62% alcohol hand gel
 10-mL Luer lock syringe (quantity 2)
 Catheter clamp
 Fastener, catheter clamp
 SharpsAway II, locking disposal cup
 CSR wraps
 Maximal barrier drape with 4-in fenestration
 Towel
 Needle holder
 Safety scalpel, No. 11 blade
 Checklist/CLIP (Central Line Insertion Practices) sheet
 Flow rate information card with injection log
 Medication label, 1% lidocaine
 Sterile procedure sign
 Dressing, BIOPATCH (Ethicon, Cincinnati, OH)
 Dressing, Tegaderm (3M, St. Paul, MN), 10 cm  12 cm
 Gauze pads, 2 in  2 in; quantity 2
 Gauze pads, 4 in  4 in; quantity 5
 Surgical apparel: bouffant cap, impervious gown, mask
with eye shield
 3-0 silk suture with curved needle
 HemoHopper (Teleflex, Morrisville, NC) fluid receptacle
a Raulerson syringe on the introducer needle, follow the
tract of the finder needle while aspirating.
11. Once venous blood return is noted in the introducer nee-
dle, insert the guidewire through the Raulerson syringe
(Seldinger technique). If a Raulerson syringe is not avail-
able, remove the syringe and occlude the needle to pre-
vent air embolism and then introduce the guidewire.
a. Never lose control of the guidewire (Fig. 6).
b. The guidewire should advance freely.
c. If resistance is encountered, remove the wire and
confirm positive venous blood return before reintro-
ducing the guidewire.
d. Insert the wire to about 20 cm.
12. Make a nick in the skin with the scalpel blade.
13. Place the dilator over the guidewire and push the dilator
into the vein. Do not push the dilator in more than half its
length to avoid vein injury.
Central Venous Access Techniques 139

Fig. 3 Pertinent regional anatomy for central approach internal

jugular venous access. (From MacLennan SE. Chapter 70. Vascular
access techniques. In: Berry SM, editor. The Mont Reid surgical
handbook. 4th edition. St Louis (MO): Mosby-Year Book, Inc; 1997.
p. 678; with permission.)

Fig. 1 Arrow triple-lumen catheterization kit. (Teleflex, Mor-

risville, NC.)

Fig. 4 Pertinent regional anatomy for posterior approach inter-

nal jugular venous access. (From MacLennan SE. Chapter 70.
Vascular access techniques. In: Berry SM, editor. The Mont Reid
surgical handbook. 4th edition. St Louis (MO): Mosby-Year Book,
Fig. 2 Contents of Arrow triple-lumen catheterization kit. Inc; 1997. p. 679; with permission.)
140
Fig. 5 Central approach, internal jugular venous access.
14. Remove dilator while maintaining control of the guidewire.
15. Insert catheter over the guidewire to proper depth (15 cm
for right internal jugular catheterization and 17 cm for left
internal jugular catheterization).
16. Remove the guidewire.
17. Secure the line to the skin with suture.
18. Aspirate each lumen to fill line with blood and then flush
with a saline flush, clearing all blood from each lumen.
19. Place appropriate sterile dressing over site.
20. Obtain chest radiograph to verify catheter position.
Posterior approach
1. Place absorbent pads beneath patient (Fig. 7).
2. Position patient in Trendelenburg position.
3. Rotate the patient’s head 45 to the contralateral side.
4. Identify the point where the external jugular vein crosses
the lateral border of the sternocleidomastoid muscle,
about 4 to 5 cm above the clavicle.
5. Prepare and drape the neck.
Fig. 6 Use of guidewire.
Bourgeois Jr
Fig. 7 Posterior approach, internal jugular venous access.
6. Scrub and gown for sterile procedure.
7. Using the 3-mL Luer lock syringe and 25-gauge needle,
anesthetize the skin and subcutaneous tissues 0.5 cm
superior to where the external jugular vein crosses the
lateral border of the sternocleidomastoid muscle,
approximately 3 fingerbreadths above the clavicle.
8. Insert the finder needle, 22 gauge with a 5-mL Luer lock
syringe attached, at the point 0.5 cm superior to where the
external jugular vein crosses the lateral border of the
sternocleidomastoid muscle, approximately 3 finger-
breadths above the clavicle, directing the needle anterior
to the sternal notch at a 45 angle to the sagittal and
horizontal planes.
a. If venous blood return is not noted after the needle has
been inserted 3 cm, slowly withdraw the needle while
aspirating.
b. If venous blood return is still not noted, reintroduce the
needle through the same puncture site but direct the
needle slightly ipsilateral to the sternal notch.
c. If venous blood return is still not noted after 3 at-
tempts, obtain a chest radiograph to rule out a pneu-
mothorax before switching sides.
9. If good venous blood return is noted, leave the finder
needle in place as a guide for the introducer needle. Using
a Raulerson syringe on the introducer needle, follow the
tract of the finder needle while aspirating.
10. Once venous blood return is noted in the introducer nee-
dle, insert the guidewire through the Raulerson syringe. If
a Raulerson syringe is not available, remove the syringe
and occlude the needle to prevent air embolism and then
introduce the guidewire.
a. Never lose control of the guidewire (see Fig. 6).
b. The guidewire should advance freely.
c. If resistance is encountered, remove the wire and
confirm positive venous blood return before reintro-
ducing the guidewire.
d. Insert the wire to about 20 cm.
11. Make a nick in the skin with the scalpel blade.
12. Place the dilator over the guidewire, and push the dilator
into the vein. Do not push the dilator in more than half its
length to avoid vein injury.
13. Remove dilator while maintaining control of the guidewire.
Central Venous Access Techniques
14. Insert catheter over the guidewire to proper depth (15 cm
for right internal jugular catheterization and 17 cm for left
internal jugular catheterization).
15. Remove the guidewire.
16. Secure the line to the skin with suture.
17. Aspirate each lumen to fill line with blood, then flush with
a saline flush, clearing all blood from each lumen.
18. Place appropriate sterile dressing over site.
19. Obtain chest radiograph to verify catheter position.
Potential pitfalls
If air or arterial blood is encountered during the performance
of the procedure, stop immediately. If arterial blood is
encountered, remove the needle immediately and apply
manual pressure. If catheterization occurred, surgical inter-
vention may be required. If air is encountered, attempt to
withdraw the air by aspirating through the catheter. If sta-
ble, position the patient in the lateral decubitus and Tren-
delenburg position to contain the air in the right ventricle. If
hemodynamically unstable (cardiac arrest), initiate
advanced cardiovascular life support (ACLS) and consider a
thoracic surgery consult for a thoracotomy. If a tension
pneumothorax is suspected, perform immediate needle
decompression and consider a tube thoracostomy (see article
on tube thoracostomy by Savage elsewhere in this issue). If a
pneumothorax is suspected and is less than 10% of lung vol-
ume and the patient is stable, the patient can be managed
with 100% oxygen and serial chest radiographs every 4 hours
until resolution.
Subclavian venous access
Subclavian venous access has the lowest risk of post-
catheterization infection. However, subclavian venous cathe-
terization also has the highest risk of mechanical and
malposition complications.
Fig. 8 Pertinent regional anatomy for subclavian venous access. (From MacLennan SE. Chapter 70. Vascular access techniques. In: Berry
SM, editor. The Mont Reid surgical handbook. 4th edition. St Louis (MO): Mosby-Year Book, Inc; 1997. p. 674; with permission.)
141
Pertinent anatomy
The subclavian vein is a continuation of the axillary vein at the
lateral border of the first rib. The vein passes over the first rib
anterior to the anterior scalene muscle. The vein then courses
deep to the medial third of the clavicle. The subclavian vein
then joins with the internal jugular vein to form the innomi-
nate vein deep to the sternoclavicular joint. At the medial
third of the clavicle, the subclavian artery and apical pleura
are deep to the vein (Fig. 8).
Technique
1. Place absorbent pads beneath the patient (Fig. 9).
2. Position patient in Trendelenburg position.
3. In the case of obese patients, a towel roll can be placed
between the scapulae underneath the thoracic vertebrae
to facilitate better access to the site.
4. Prepare and drape the neck.
5. Scrub and gown for sterile procedure.
6. Identify the sternal notch and the intersection of the
clavicle and first rib.
7. Using the nondominant hand, the index finger can be
placed at the sternal notch and the thumb at the inter-
section of the clavicle and first rib to act as a guide. Using
the 3-mL Luer lock syringe and 25-gauge needle, anes-
thetize the skin and subcutaneous tissues.
8. Insert the finder needle, 22 gauge, with a 5-mL Luer lock
syringe attached, just lateral to the thumb between
0.5 cm and 1 cm inferior to the clavicle. While aspirating,
slowly advance the needle, bevel up, deep to the clavicle
and toward the index finger at the sternal notch. The
needle should be maintained in a horizontal plane at all
times to avoid a pneumothorax. A supraclavicular
approach is possible but has a higher incidence of arterial
puncture and is not recommended. If venous blood return
is not noted after the needle has been inserted 5 cm,
slowly withdraw the needle while aspirating.
142
Fig. 9 Subclavian venous access.
a. If venous blood return is still not noted, reintroduce the
needle through the same puncture site but direct the
needle 1 cm above the sternal notch.
b. If venous blood return is still not noted, consider
moving the initial skin entry point 1 cm lateral.
c. Obtain a chest radiograph to rule out a pneumothorax
before switching sides.
9. If good venous blood return is noted, leave the finder
needle in place as a guide for the introducer needle. Using
a Raulerson syringe on the introducer needle, follow the
tract of the finder needle while aspirating.
10. Once venous blood return is noted in the introducer nee-
dle, insert the guidewire through the Raulerson syringe. If
a Raulerson syringe is not available, remove the syringe
and occlude the needle to prevent air embolism and then
introduce the guidewire.
a. Never lose control of the guidewire (see Fig. 6).
b. The guidewire should advance freely.
c. If resistance is encountered, remove the wire and
confirm positive venous blood return before reintro-
ducing the guidewire.
d. Insert the wire to about 20 cm.
11. Make a nick in the skin with the scalpel blade.
12. Place the dilator over the guidewire and push the dilator
into the vein no more than 3 to 4 cm to avoid vein injury.
13. Remove dilator while maintaining control of the guidewire.
14. Insert catheter over the guidewire to proper depth (15 cm
for right subclavian catheterization and 18 cm for left
subclavian catheterization).
15. Remove the guidewire.
16. Secure the line to the skin with suture.
17. Aspirate each lumen to fill line with blood and then flush
with a saline flush, clearing all blood from each lumen.
18. Place appropriate sterile dressing over site.
19. Obtain chest radiograph to verify catheter position.
Potential pitfalls
If air or arterial blood is encountered while performing the
procedure, stop immediately. If arterial blood is encountered,
remove the needle immediately and apply manual pressure.
The operator should also monitor the patient closely for a
possible hemothorax that may require surgical intervention. If
air is encountered, attempt to withdraw the air by aspirating
through the catheter. If stable, position the patient in the
lateral decubitus and Trendelenburg position to contain the air
in the right ventricle. If hemodynamically unstable (cardiac
Bourgeois Jr
arrest), initiate ACLS and consider a thoracic surgery consult
for a thoracotomy. If a tension pneumothorax is suspected,
perform immediate needle decompression and consider a tube
thoracostomy (see article on tube thoracostomy elsewhere in
this issue). If a pneumothorax is suspected and is less than 10%
of lung volume and the patient is stable, the patient can be
managed with 100% oxygen and serial chest radiographs every
4 hours until resolution.
Femoral venous access
Femoral venous access is used as a site of last resort because of
the increased risk of iliofemoral thrombosis and infection. If
femoral venous access is obtained in an urgent/emergent sit-
uation, it is recommended to obtain central venous access
through either the subclavian or internal jugular veins once the
patient is stabilized and preferably within 48 hours to reduce
the risk of CLABSI. The femoral venous catheter should then be
removed. When used for venous access during cardiac arrest,
misplacement of the catheter occurs in up to 30% of cathe-
terization attempts. Patient must remain on bed rest while the
catheter is in place.
Pertinent anatomy
The femoral artery may be found at the midpoint of a line
connecting the anterior superior iliac spine and the pubic
symphysis. The femoral vein is typically 1 fingerbreadth medial
to the artery in the femoral sheath inferior to the inguinal
ligament (Fig. 10).
Technique
1. Place absorbent pads beneath the patient (Fig. 11).
2. Position patient supine in reverse Trendelenburg position
with the leg slightly abducted and rotated externally.
3. Shave, prepare, and drape the groin area.
4. Scrub and gown for sterile procedure.
5. Identify the femoral artery pulse and the inguinal
ligament.
6. Using the 3-mL Luer lock syringe and 25-gauge needle,
anesthetize the skin and subcutaneous tissues.
7. Insert the finder needle, 22 gauge with a 5-mL Luer lock
syringe attached, 1 cm medial and 2 to 3 cm below the
inguinal ligament angling 30 to 40 to the floor and aiming
sagittally toward the head and slightly medially.
a. If venous blood return is not noted after the needle has
been inserted 5 cm, slowly withdraw the needle while
aspirating.
b. If venous blood return is still not noted, redirect the
needle gradually more laterally 1 to 3 cm.
c. If venous blood return is still not noted, consider
moving the initial skin entry point to a position 0.5 cm
medial to the femoral pulse.
d. If venous blood return is still not noted, discontinue
efforts.
8. If good venous blood return is noted, leave the finder
needle in place as a guide for the introducer needle. Using
a Raulerson syringe on the introducer needle, follow the
tract of the finder needle while aspirating.
9. Once venous blood return is noted in the introducer nee-
dle, insert the guidewire through the Raulerson syringe. If
a Raulerson syringe is not available, remove the syringe
and occlude the needle to prevent air embolism and then
introduce the guidewire.
Central Venous Access Techniques 143

Fig. 11 Femoral venous access.

A sandbag is then placed over the site for an additional 30 mi-

nutes. The patient must maintain bed rest for a minimum of
4 hours.

Complications and prevention

Fig. 10 Pertinent regional anatomy for femoral venous access.
Art, artery; IVC, inferior vena cava. (From MacLennan SE. Chapter
70. Vascular access techniques. In: Berry SM, editor. The Mont Reid
surgical handbook. 4th edition. St Louis (MO): Mosby-Year Book,
Inc; 1997. p. 675; with permission.)
a. Never lose control of the guidewire (see Fig. 6).
b. The guidewire should advance freely.
c. If resistance is encountered, remove the wire and
confirm positive venous blood return before reintro-
ducing the guidewire.
d. Insert the wire to about 20 cm.
10. Make a nick in the skin with the scalpel blade.
11. Place the dilator over the guidewire and push the dilator
into the vein no more than 3 to 4 cm to avoid vein injury.
12. Remove dilator while maintaining control of the guidewire.
13. Insert catheter over the guidewire to proper depth,
approximately 15 cm.
14. Remove the guidewire.
15. Secure the line to the skin with suture.
16. Aspirate each lumen to fill line with blood and then flush
with a saline flush, clearing all blood from each lumen.
17. Place appropriate sterile dressing over site.
18. A postplacement radiograph is not required for femoral
venous access.
Potential pitfalls
If arterial blood is encountered, remove the needle immedi-
ately and apply manual pressure for a minimum of 20 minutes.
Complications associated with central venous catheterization
include catheter misplacement, arterial puncture, hemor-
rhage, pneumothorax, thoracic duct injury, extravasation of
fluids, medications, hyperalimentation, dysrhythmias, brachial
plexus injury, air embolism, catheter or wire embolization,
hydrothorax, thrombosis, and infection (CLABSI) (Box 4).
Approximately 250,000 CLABSIs occur each year in the United
states with a mortality risk of 12% to 25% and at a cost of
approximately $25,000 per event. Use of sterile technique
Box 4. Complications associated with various
central venous access sites
 Catheter misplacement (0%e3%)
 Arterial puncture
 Hemorrhage
 Pneumothorax
 Thoracic duct injury
 Extravasation of fluids, medications, hyperalimenta-
tion, and so in.
 Brachial plexus injury
 Air embolism
 Catheter or wire embolization
 Dysrhythmias
 Hydrothorax
 Infection (CLABSI) (2%e10%)
 Thrombosis (2%e40%)
144
during central line placement and proper catheter mainte-
nance can reduce the incidence of CLABSI. Past medical and
surgical histories of the patient requiring central venous access
should be obtained before placement of central catheters if
possible, paying particular attention to the possible presence
of inferior vena cava filters because the guidewire can become
entangled in the filter. Proper positioning of the patient in the
Trendelenburg position for internal jugular or subclavian
venous access and reverse Trendelenburg position for femoral
venous access can reduce the risk of air embolism, but even
with proper positioning, the incidence of air embolism is 0.13%.
Attention should be given to occluding the needle hub/cath-
eter during placement to also reduce the risk of air embolism.
Possible use of ultrasound guidance, radiographic confirmation
of correct catheter position after placement, and postplace-
ment central line care can also reduce the risk of a compli-
cation occurring.
Central venous catheter maintenance
A sterile dressing is applied over the catheter; the dressing
should be changed weekly. Topical antibiotic use at the
insertion site has not been shown to reduce CLABSI rates and is
not recommended. Catheters should not be routinely replaced
unless there is evidence of localized infection or sepsis. It is
recommended that the infusion tubing be changed every 48 to
72 hours. Confirmation of internal jugular and subclavian
catheters by chest imaging is recommended. The catheter tip
should lie within the superior vena cava, outside of the right
atrium. On chest radiographs for internal jugular and subcla-
vian vein catheters, the tip should lie above the level of the
carina (Box 5, Fig. 12).
Removal of catheters
It is recommended to remove central venous catheters as soon as
the patient’s medical condition has improved to the point where
central venous access is no longer required. For internal jugular
and subclavian catheters, the patient is positioned in the Tren-
delenburg position and removal of the catheter is synchronized
with active exhalation if the patient is awake, cooperative, and
spontaneously breathing. In cooperative patients, the Valsalva
maneuver is recommended over breath holding to reduce the
risk of an air embolism. Special attention should be paid to oc-
clusion of the entry site on catheter removal.
Evolving technology
Use of interventional radiological techniques and ultrasound
guidance in particular are becoming more commonplace.
Box 5. Central line maintenance
 Apply sterile dressing postcatheter placement, change
weekly
 Replace catheters only if there is evidence of localized
infection or sepsis
 Change infusion tubing every 48 to 72 hours
 Perform chest imaging for confirmation of internal
jugular and subclavian catheterization.
Bourgeois Jr
Fig. 12 Chest radiograph demonstrating proper catheter tip
location. AP, anteroposterior.
Although controversial, it can be argued that ultrasound-
guided central venous access is the current standard of care. If
ultrasound-guided vascular access is used, it is recommended
that a long, sterile sheath be used to cover the ultrasound
probe. Also, use of a real-time image acquisition technique is
preferred. Operator experience and skill in the technique are
important factors for success.
Summary
Central venous access remains a vital part of hospital-based
medical treatment when inadequate peripheral venous access
is identified or when hemodynamic monitoring and hyperali-
mentation are required. Complication costs and morbidity and
mortality with central venous access are significant. All surgi-
cal specialists should be familiar with the relevant anatomy,
indications, and contraindications of central line placement;
placement techniques; catheter maintenance procedures; and
prevention of complications. Subclavian venous access fol-
lowed by internal jugular venous access is preferred over
femoral venous access. Over the past 2 decades, image-guided
placement is becoming more commonplace and has reduced
but not eliminated the incidence of complications with
placement of central venous catheters.
Further readings
Beheshti MV. A concise history of central venous access. Tech Vasc
Interv Radiol 2011;14(4):184e5.
Bhutta ST, Culp WC. Evaluation and management of central venous
access complications. Tech Vasc Interv Radiol 2011;14(4):217e24.
Corripio M. Chapter 197. Central venous access. In: Atchabahian A,
Gupta R, editors. The anesthesia guide. New York: McGraw-Hill; 2013.
Available at: http://accessanesthesiology.mhmedical.com/content.
aspx?bookidZ572&SectionidZ42543790. Accessed December 12,
2014.
Dao H. Air embolism. In: Freeman BS, Berger JS, editors. Anesthesiology
core review: part one basic exam. New York: McGraw-Hill; 2014.
Available at: http://accessanesthesiology.mhmedical.com/content.
aspx?bookidZ974&SectionidZ61588931. Accessed December 12,
2014.
Central Venous Access Techniques
Duong MH, Jensen WA, Kirsch CM, et al. An unusual complication during
central venous catheter placement. J Clin Anesth 2001;13(2):131e2.
Halstead Residents of The Johns Hopkins Hospital. Chapter 2. Arter-
ial/venous access. In: Chen H, Lillemoe KD, Sola JE, editors. Manual
of common bedside surgical procedures. Baltimore (MD): Williams &
Wilkins; 1996. p. 29e76.
Kumar A, Kethireddy S, Darovic GO. Catheter-related and infusion-
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