Procedures

Central venous catheter insertion

Reviewed Nov 2026·7 references
New· views rounded down, updated weekly

Site choice, real-time ultrasound, confirming venous placement before dilation, tip position and complications.

Definition
CVC indications: vasopressors or irritant infusions, poor peripheral access, CVP/ScvO₂ monitoring, RRT or plasmapheresis (dialysis catheter), transvenous pacing. ASA 2020 recommends real-time ultrasound for internal jugular access and confirmation of venous placement before dilation.

At the bedside

  1. 1

    Prepare

    Consent where possible; check coagulation and platelets (correction rarely needed for compressible sites); time-out; full sterile barrier and alcoholic chlorhexidine.

  2. 2

    Choose site

    IJ with ultrasound: lowest mechanical risk and easy compression; subclavian: lowest infection and thrombosis risk but pneumothorax risk; femoral: fast in arrest/coagulopathy but highest infection and thrombosis risk.

  3. 3

    Ultrasound

    Pre-scan vessel patency and size; real-time needle guidance (short- or long-axis) with the needle tip visualised.

  4. 4

    Position

    Head-down (Trendelenburg) for IJ/subclavian to distend veins and reduce air embolism risk.

  5. 5

    Confirm venous placement before dilating

    Before dilation

    Ultrasound view of the wire in the vein (long axis), manometry or pressure waveform transduction; never dilate an uncertain vessel.

  6. 6

    Keep control of the wire

    Never let go of the guidewire; check the wire is complete after removal.

  7. 7

    Confirm tip and exclude pneumothorax

    Tip at the lower SVC / cavo-atrial junction; chest X-ray, or ultrasound with agitated saline (bubbles in RA within 2 s) and lung sliding check.

  8. 8

    Arterial cannulation with dilator or catheter

    Leave the device in place, do not remove; call vascular surgery / interventional radiology.

Local anaesthetic

Lidocaine (lignocaine)

Infiltration
Dose
1-2% lidocaine; stay under 4.5 mg/kg plain
Worked example
70 kg: max ~300 mg plain = 30 mL of 1% (10 mg/mL) or 15 mL of 2%.

CVC site comparison

SiteAdvantagesDisadvantages
Internal jugularUltrasound-friendly; compressible; straight path to SVC (right)Carotid puncture; patient comfort; tracheostomy contamination
SubclavianLowest infection and thrombosis; comfortablePneumothorax; non-compressible artery; harder with ultrasound
FemoralFast, away from airway and CPRHighest infection and DVT; immobilises patient

Bleeding risk and coagulation for bedside procedures (SIR 2019)

Bleeding-risk classExamplesSuggested thresholds
LowCVC, paracentesis, thoracentesisINR ≤ 2.0-3.0; platelets > 20 × 10⁹/L
HighPericardiocentesis (non-emergency), deep organ proceduresINR ≤ 1.5-1.8; platelets > 50 × 10⁹/L

Consensus thresholds; emergencies proceed with the most experienced operator and ultrasound.

Red flag · call your senior now
New hypotension, hypoxaemia or neurological deficit during or after insertion: consider pneumothorax, haemothorax, air embolism (left lateral head-down, 100% oxygen) or arterial injury.
Red flag
Perioral tingling, seizures or arrhythmia after local anaesthetic: stop injecting, call for help, manage airway and give 20% lipid emulsion (1.5 mL/kg bolus) for LAST.
Pitfall
Dilating before confirming the wire is in the vein.
Pitfall
Routine FFP or platelets before ultrasound-guided CVC in mild coagulopathy.
Pearl
PACER: with platelets 10-50 × 10⁹/L, omitting a prophylactic platelet unit before CVC placement increased catheter-related bleeding (11.9% vs 4.8%).

References

  1. 1

    American Society of Anesthesiologists Task Force on Central Venous Access. Practice Guidelines for Central Venous Access 2020. Anesthesiology 2020;132:8-43.

  2. 2

    Lamperti M, Bodenham AR, Pittiruti M, et al. International evidence-based recommendations on ultrasound-guided vascular access. Intensive Care Med 2012;38:1105-17.

  3. 3

    Lamperti M, Biasucci DG, Disma N, et al. European Society of Anaesthesiology guidelines on peri-operative use of ultrasound-guided for vascular access (PERSEUS vascular access). Eur J Anaesthesiol 2020;37:344-76.

  4. 4

    Buetti N, Marschall J, Drees M, et al. Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 update. Infect Control Hosp Epidemiol 2022;43:553-69.

  5. 5

    Patel IJ, Rahim S, Davidson JC, et al. Society of Interventional Radiology consensus guidelines for the periprocedural management of thrombotic and bleeding risk in patients undergoing percutaneous image-guided interventions - part II: recommendations. J Vasc Interv Radiol 2019;30:1168-84.

  6. 6

    van Baarle FLF, van de Weerdt EK, van der Velden WJFM, et al. Platelet transfusion before CVC placement in patients with thrombocytopenia (PACER). N Engl J Med 2023;388:1956-65.

  7. 7

    Neal JM, Barrington MJ, Fettiplace MR, et al. The third American Society of Regional Anesthesia and Pain Medicine practice advisory on local anesthetic systemic toxicity: executive summary 2017. Reg Anesth Pain Med 2018;43:113-23.

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