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Central venous catheter insertion animated demonstration

Ultrasound-guided insertion of a non-tunnelled central venous catheter (CVC) into the right internal jugular vein using the Seldinger insertion technique.

Equipment needed

Ultrasound appliance, with sterile probe cover and sterile transducer gel
CVC pack containing CVC and screw caps, guidewire, introducer, scalpel blade, cannulation needle, and syringe
Antiseptic preparation plus swabs for skin preparation or pre-packaged skin preparation device
Sterile gloves, sterile gown, and eye protection
Local anaesthetic (e.g., 1% or 2% lignocaine) drawn up in syringe, with 23-gauge blue and 25-gauge orange needles
Fenestrated sterile drape or occlusive transparent drape
Extra 10 mL syringes with heparin sodium solution or 0.9% saline flush
Suture and occlusive dressing
Container for the disposal of sharps.

It is important to take into account the patient’s size when deciding how deeply to insert the central venous catheter. Use of an inappropriately long length of catheter may increase the risk of serious complications such as cardiac tamponade, cardiac perforation, and arrhythmias such as ventricular tachycardia, due to irritation of the endocardium.[77] [78]

Contraindications

Absolute contraindications:

Infection at insertion site[79]
Anatomical obstruction (thrombosis, anatomic variance, stenosis)[79]
Superior vena cava syndrome.[80]

Relative contraindications:

Coagulopathy: it is generally accepted that the platelet count should be above 50 x 109/L prior to insertion of a CVC and the international normalised ratio should be below 1.5[81]
Systemic infection
Presence of pacing wires or other indwelling catheters at insertion site[79]
Right ventricular assist device
Ipsilateral pneumothorax/haemothorax.[79]

Indications

Monitoring central venous pressure
Poor peripheral venous access or when there is a need for repeated phlebotomy
Prolonged intravenous chemotherapy and/or total parenteral nutrition, or repeated administration of blood products[82]
To deliver drugs unsuitable for peripheral infusion, such as venous sclerosants
For multiple, continuous, or incompatible infusions.

Complications

Technical or equipment failure: re-attempt with assistance, possibly at an alternative site
Haemorrhage and haematoma formation: direct pressure is required to control bleeding, particularly if accidental arterial puncture has occurred
Arterial cannulation: remove needle/wire/catheter as soon as identified, and apply pressure to control haemorrhage and reduce haematoma formation
Catheter malpositioning: either cranially or extravenous. Remove catheter as soon as identified. If the catheter is positioned in the right ventricle, withdraw 5 cm or more and repeat chest radiograph
Venous air embolism: minimise the risk of air being sucked into the vein by negative intrathoracic pressures by using head-down tilt and careful technique
Venous thrombosis: higher risk with subclavian or femoral lines
Cardiac arrhythmias: withdrawing the guidewire or catheter should terminate arrhythmias caused by ventricular irritation; patients should have cardiac monitoring throughout the procedure[79]
Cardiac tamponade: this may require pericardiocentesis or surgical intervention
Carotid artery dissection: involve vascular surgeons immediately
Loss of guidewire: will require retrieval by an interventional radiologist or vascular surgeons; hold onto the guidewire with one hand at all times to avoid losing it in the patient’s vein
CVC-related sepsis: serious and potentially preventable; observe strict sterile procedure and local infection control policy[83]
Lung injury: haemothorax, pneumothorax, and chylothorax; this should not occur when performing right internal jugular vein central line insertion, unless adopting a very low approach in the neck.

Aftercare

After insertion of the CVC, it is essential to confirm correct positioning before using the line for its intended purpose. This is important because ineffective positioning increases the risk of cardiac tamponade and thrombosis.[79] The optimal position of the CVC tip is a subject of ongoing debate, as no position is absolutely safe.[79] [84]

Positioning the tip in the high right atrium (intracardiac placement) carries the risk of cardiac tamponade, and should be avoided,[84] although positions in the high and low superior vena cava (SVC) are also not without risk: for example, risk of thrombosis.[84] For right internal jugular vein CVC insertion it may be acceptable to aim for tip placement in the lower SVC, although this is by no means universally accepted.[84] [85] Patients with additional risk factors for thrombosis, such as those with cancer, may require different (e.g., lower) positioning of the CVC. In practice, this would be a decision to make only with senior advice.[86]

Determine whether the CVC is correctly positioned using an erect chest radiograph. An erect chest radiograph is mandatory following insertion of a CVC, both to confirm the position of the tip and to check for evidence of complications such as pneumothorax and haemothorax. Alternative methods for confirming the position include fluoroscopy, or point-of-care transthoracic echocardiography or continuous electrocardiography.[83]

On the chest radiograph, the catheter should be seen to pass directly down the right side of the neck, continuing inferiorly to the right side of the mediastinum such that the tip lies at the approximate level of the carina. The carina is a radiological landmark, below which the tip is likely to be below the pericardial reflection, and therefore within the pericardial sac.[86]

Therefore, the tip should ideally lie at or above the level of the carina.[79] If the catheter is in too far, the sutures/fixation can be removed and the catheter withdrawn back slightly before suturing/fixing again. It is important to repeat the chest radiograph to reconfirm the position. However, if the catheter is too high (i.e., not deep enough) it is not advisable to advance the catheter further as you risk introducing bacteria into the circulation. A new catheter would need to be inserted, if necessary.

Ensure the patient and site of catheter insertion are regularly observed for signs of complications.[83] In the days to come, signs of CVC-related sepsis should prompt immediate action in keeping with local guidance, with respect to removal of the line, culture, and antibiotic treatment.

If the CVC is to be used for measurement of central venous pressure, the catheter should be correctly connected to a transducer and calibrated properly to ensure accurate readings.