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Central IV Access
Aka: Central IV Access, Central Line, Central Line Placement, Central Venous Cetheterization, Central Line Management, Central Line Occlusion, Misplaced Central Venous Catheter, Malpositioned Central Venous Catheter
- See Also
- Intravenous Access
- Peripheral IV Access
- Intraosseous Access
- Ultrasound-Guided Internal Jugular Vein Catheterization
- Ultrasound-Guided Antecubital Line
- Umbilical Artery Catheter
- Umbilical Vein Catheter
- Central Venous Pressure
- Indications
- Medications causing tissue necrosis on extravasation or otherwise harmful via peripheral IV
- Large volume infusion required
- Hemodialysis
- Unobtainable or unreliable Intravenous Access
- Pulmonary artery pacing
- Invasive Monitoring
- Right Ventricular Filling Pressures (Central Venous Pressure) and oxygenation (ScvO2)
- Left ventricular filling pressure (pulmonary artery catheter or wedge pressure)
- Preparation
- Perform under dynamic Ultrasound guidance
- Confirms vessel location and patency
- Real-time confirmation of vessel cannulation
- Decreases the number of access attempts
- Decreases the time to central vein catheterization
- Decreases central access complication rate
- Perform under sterile conditions to reduce infectious complications
- Mask, cap, sterile gown and sterile gloves
- Large sterile drape
- Antimicrobial Dressing at catheter insertion site
- Sterile transducer sleeve around Ultrasound probe and cord
- Complications: Site specific risks (may direct site selection)
- Internal Jugular Central Line
- Venous thrombus (>2 fold increased risk over subclavian Central Line)
- Timsit (1998) Chest 114: 207-13 [PubMed]
- Parienti (2015) N Engl J Med 373(13):1220-9 [PubMed]
- External Jugular Central Line
- Failed placement
- Pneumothorax
- Subclavian Central Line
- Pneumothorax (highest risk site)
- Noncompressible (uncontrolled bleeding risk)
- Lowest risk site for Central Line-Associated Bloodstream Infection (compared with femoral, internal jugular)
- Femoral Central Line
- Deep Vein Thrombosis
- Infection risk
- Preferred site in children (lower risk than IJ)
- In 2015 study, femoral lines had similar risks to internal jugular: infection rate (1.2%), thrombus rate (1.4%)
- Femoral also had the lowest failed placement rate (5%) compared with 9% IJ and 15% subclavian
- Parienti (2015) N Engl J Med 373(13):1220-9 [PubMed]
- Approach: Site Selection in stabilized patients
- Precaution
- Site selection should avoid sites with overlying infection, altered anatomy, Trauma or distortion
- General patient without other risk factors
- Internal Jugular Central Line is preferred (lowest risk site)
- Avoid femoral Central Line overall (aside from codes) due to the highest rate of complications (DVT, infection)
- Consider alternatives to central access
- Ultrasound-Guided Antecubital Line
- PICC Line
- Morbidly obese
- Subclavian Central Line is preferred
- Internal Jugular Vein landmarks are typically difficult to localize in the morbidly obese
- Avoid femoral vein Central Line due to infection risk
- Pneumothorax or Hypoxemia
- Internal Jugular Central Line is preferred
- Avoid subclavian Central Line (unless on same side as the Pneumothorax)
- Coagulopathy (increased bleeding risk such as Hemophilia, Thrombocytopenia)
- Internal Jugular Central Line is preferred
- Avoid subclavian Central Line as it is a noncompressible site
- Hypercoagulable state (increased thrombosis risk)
- Subclavian Central Line is preferred
- Avoid Internal Jugular Central Line (highest risk site for DVT)
- Approach: Site Selection by circumstance
- Crashing patient (Code, CPR) or Trauma patient (C-Spine Immobilization)
- Intraosseous Access
- Femoral Line
- Replace with supraclavicular line (IJ, EJ, Subclavian) when stabilized
- Children
- Femoral line (if intraosseous fails)
- Central Venous Pressure monitoring or Sepsis catheter
- Supraclavicular line (IJ, EJ, Subclavian)
- Approach: Pediatric Patients
- Central catheter sizes in children
- Infant: 3 French (24 gauge)
- Toddler/Preschool: 4 French (20 gauge)
- School age: 5 French (18 gauge)
- Catheter placement pearls
- Sedation allows for procedure (e.g. Ketamine 4 mg/kg IM)
- May use introducer (catheter over needle only) for initial Resuscitation
- May later, use guidewire through introducer catheter to place standard Central Line
- Catheter wire kinking, looping or fracturing (or dilator displacement)
- Gently move the wire in and out of dilator while dilator is being advanced
- Dilator misdirected down divergent path
- Rotate the dilator while inserting through subcutaneous tissue
- References
- Claudius, Behar, Chang and Santillanes in Herbert (2016) EM:Rap 16(4): 3-4
- Claudius, Behar and Hofmann, Santillanes, Bowman in Herbert (1018) EM:Rap 18(6):13-4
- Approach: Line Maintenance
- Check Central Lines daily for signs of infection
- Change Central Lines at 10 days or at signs of infection
- Consider Central Line removal when not used for >1 day
- Preparations: Devices
- Triple lumen catheter (typical Central Line)

- Double lumen catheter
- Hemodialysis catheter
- Cordis catheter
- Indicated for Hemodialysis or critically ill patients requiring advanced hemodynamic monitoring
- Complications: General
- Catheter Related Bloodstream Infections (CRBI)
- See Catheter Related Bloodstream Infections (CRBI)
- Collateral injury to surrounding structures
- Pneumothorax (IJ, EJ, Subclavian Line)
- Bladder or retroperitoneal injury (Femoral line)
- Immobilization-related effects
- Deep Vein Thrombosis (especially femoral line)
- Central Line Occlusion
- Attempt to flush the line with saline first
- Next, inject a few milligrams of Alteplase into the line and wait a few minutes
- Repeat saline flush
- References
- da Costa (2019) Pediatrics 144(6) +PMID:31757859 [PubMed]
- Complications: Misplaced or Malpositioned Central Venous Catheter
- Background
- Central venous catheter (CVC) is considered malpositioned if its tip is not in the superior vena cava or right atrium
- Mild catheter tip migration is common, often with torso or neck movement
- More significant misplaced CVCs include catheter tip floated distally (e.g. from IJ into subclavian towards hand)
- Procedure: Arterial Misplacement
- Leave in Place Pending Consultation
- Risk of Hemorrhage on large bore Arterial Line removal
- Consult vascular surgery or Intervention Radiology regarding guidance
- Procedure: Venous Misplacement - Catheter Repositioning or Replacement
- Catheter Repositioning
- Increases risk of infection and may be more difficult to redirect
- Perform under same sterile conditions as if placing a new catheter
- Requires determining length the catheter needs to be withdrawn before advancing again
- Consider Balloon tipped 2F Fogarty Catheter (longer than CVC) to help float tip into correct position
- Compress the unintended vessel (e.g. subclavian vein) when attempting to reposition into SVC and right atrium
- Catheter Replacement
- Risks loss of access, but is preferred for decreased infection risk
- Practice same sterile technique and procedure as per new CVC placememt
- New sterile catheter set reduces risk of infection
- Guidewire from new set may be used to change over the old catheter
- Precautions
- Use portable XRay or Bedside Ultrasound to monitor catheter positioning during procedure
- References
- Warrington (2021) Crit Dec Emerg Med 35(4): 9
- Roldan (2015) West J Emerg Med 16(5): 658-64 +PMID: 26587087 [PubMed]
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4644031/
- Complications: Catheter Site Bleeding
- Apply manual pressure to bleeding site for 20 minutes (e.g. sandbag, compression device)
- Purse Stitch
- Other measures
- See Hemorrhagic Shock
- Reverse Coagulopathy
- Topical Hemostatic Agents
- Resources
- Internal Jugular Vein cannulation video (ACEP Critical Decisions Video)
- http://www.acep.org/cdem_2014_lesson_10-1/
- Subclavian vein cannulation from a supraclavicular approach video (ACEP Critical Decisions Video)
- http://www.acep.org/cdem_2014_lesson_10-2/
- Subclavian vein cannulation from an infraclavicular approach video (ACEP Critical Decisions Video)
- http://www.acep.org/cdem_2014_lesson_10-3/
- Femoral vein cannulation video (ACEP Critical Decisions Video)
- http://www.acep.org/cdem_2014_lesson_10-4/
- References
- Killu and Sarani (2016) Fundamental Critical Care Support, p. 93-114
- Jacquet and Hong (2014) Crit Dec Emerg Med 28(5): 15-22
- Swaminathan and Herbert in Majoewsky (2013) EM:Rap 13(9): 6