Intensive care
Cannulation of central veins
Michael Duffy
Mark Sair
Abstract
Central venous cannulation is a common procedure in anaesthesia and
intensive care. The main indications for central venous catheters (CVCs)
are to measure central venous pressure, administer vasoactive or cyto-
toxic drugs, and for renal replacement therapy. Common sites for cath-
eterization are the internal jugular vein, the subclavian vein and the
femoral vein. The internal jugular vein is the most frequently chosen site
for insertion of CVCs. Complications occur in up to 10% of central venous
cannulations and can be categorized according to mechanical, infectious
and thromboembolic aetiologies. The rate of complications depends on
a number of factors. These include the site chosen, the condition of the
patient, the presence of atypical anatomy and the experience of the
operator. The risk of pneumothorax is less common with internal jugular
vein placement than with cannulations of the subclavian vein. Carotid
artery puncture is uncommon and can be controlled with manual com-
pression. The subclavian route may be preferred for long-term central
venous access as there is less patient discomfort post placement and
the risk of infection and other long-term complications is lower than at
other insertion sites. The femoral route is particularly useful when urgent
central venous access is required and the patient is coagulopathic. The
femoral route is associated with a high risk of catheter-related infections
and venous thrombosis in the long term. In the UK the National Institute
for Clinical Excellence (NICE) recommends the use of ultrasonography for
the elective insertion of CVCs into the internal jugular veins of adults
and children.
Keywords cannulation; catheterization; central veins; internal jugular;
ultrasound
Central venous cannulation is a commonly performed procedure
in anaesthesia and intensive care. An estimated 200,000 central
venous access procedures are done in the UK per year. Histori-
cally, central venous access was gained by surgical cut-down
onto an appropriate vessel, but central venous catheters (CVCs)
Michael Duffy, FRCA, is Specialist Registrar in Anaesthesia and
Intensive Care in the South West of England. He qualified from
St Bartholomew’s and the Royal London Medical School, and has
worked in Essex, London, and the South West.
Mark Sair, PhD, MRCP, FRCA, is Consultant in Intensive Care at Derriford
Hospital, Plymouth, UK. He qualified from the University of Bristol and
trained in anaesthetics and intensive care in London. His research
interests are the effects of sepsis on the circulation and tissue
oxygenation.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:1
are now predominantly inserted percutaneously using a tech-
nique first described by Seldinger in 1953. The main indications
for CVCs are listed in Table 1.
General preparation
CVCs should be inserted whilst in an appropriate clinical area
where full aseptic technique can be observed. A trained assistant
is required and the patient must be monitored throughout the pro-
cedure. The equipment required for insertion is listed in Table 2.
There is evidence that the use of a dedicated ‘lines trolley’
increases compliance with best practice. Chlorhexidine in alco-
hol is the preferred skin preparation as this has a greater effect on
the risk of catheter colonization than iodine-based solutions.
General technique for all routes
The most common method of insertion of CVCs is with a catheter
over a guidewire (the Seldinger technique). The vein is punc-
tured with a small-diameter needle (18 or 20G) attached to an
empty syringe. The syringe should not be primed with saline as
this makes the differentiation of venous and arterial blood more
difficult. Blood is aspirated freely and a guidewire passed down
the needle into the vein and the needle removed. The guidewire
commonly has a flexible J-shaped tip to reduce risk of vessel
perforation and to help negotiate tortuous vessels. The guidewire
should be easy to advance and withdraw at all times. A dilator
is passed over the guidewire and a small incision can be made
in the skin at the site of entry to facilitate its passage. The dila-
tor should be passed only a little beyond the depth of the vein
because further passage along the vein may tear the wall or other
distal structures.
Gentle traction of the skin with the free hand whilst dilating
using a twisting motion may help with the passage of the dilator
and prevent kinking of the guidewire. Once the soft tissues have
been dilated, the dilator is withdrawn and the catheter passed
over the guidewire. The catheter is threaded over the guidewire
until the end of the guidewire protrudes from the proximal end of
the catheter. The guidewire is then held still whilst the catheter
is advanced into the vein to the desired length. Care should be
taken to ensure that the guidewire always protrudes from the
end of the catheter and is not pushed further into the vein when
advancing the catheter as this may precipitate arrhythmias. The
guidewire is then removed and the catheter checked by aspirat-
ing blood freely from each lumen and then flushing with saline.
Indications for central venous catheterization
• Measurement of central venous pressure
• Infusion of irritant drugs and total parenteral nutrition
• Difficult peripheral access or frequent blood sampling
• Insertion of pacing wires or pulmonary artery catheters
• Haemofiltration/haemodialysis
• Monitoring of mixed venous and jugular bulb oxygen
saturations
• Replacement of circulating volume
Table 1
17 © 2006 Elsevier Ltd. All rights reserved.
 Intensive care

sites for catheterization are the internal jugular vein, the sub­
Equipment required for central venous access clavian vein and the femoral vein.

• Patient on tilting bed, trolley or operating table
• Sterile hat, gown, gloves, mask
• Large sterile drapes and gauze swabs
• Chlorhexidine solution
• Local anaesthetic with needle and syringe
• Saline flush
• Appropriate central venous catheter set (age/route/purpose)
• Three-way taps
• Scalpel blade
• Sutures
• Sterile dressing
• Ultrasound machine available
Table 2
The catheter should be secured in place with a suture and cov-
ered with a sterile non-occlusive dressing.
Checks before using the line: it is important to confirm that the
catheter has not been inadvertently placed in an artery rather
than a vein. The emergence of dark blood under apparently low
pressure is not always a reliable test of venous placement. Com-
parative synchronous arterial and venous blood gases can be
performed, but wherever possible the pressure waveform should
be transduced to confirm venous cannulation before the line
is used.
For catheters entering the chest, a chest radiograph is required
to confirm correct positioning of the catheter and ensure there is
no pneumothorax. The catheter tip should be above the carina,
which indicates placement outside the right atrium. The tip
should lie in the long axis of the superior vena cava without
acute abutment to the vein wall.
Sites for central venous catheterization
Different surface landmarks are used to guide cannulation of
individual veins (Figure 1) and successful catheterization relies
on a thorough understanding of anatomy (see page 15). ­Common
The internal jugular vein is most frequently chosen for inser-
tion of CVCs. There are anatomical advantages with this route,
and the risk of pneumothorax is less than for cannulation of the
subclavian vein. Inadvertent puncture of the carotid artery can
be controlled with manual compression.
Cannulation of the internal jugular vein can be difficult in
morbidly obese patients in whom the usual neck landmarks are
often obscured. The right internal jugular vein is most frequently
cannulated because it tends to be larger and straighter than that
on the left side. It is more convenient for right-handed practi­
tioners and avoids the possibility of thoracic-duct injury.
Approaches can be classified as high or low, which refers to
the position of needle insertion in relation to the apex of the tri-
angle formed by the two heads of sternomastoid and the clavicle.
Techniques are classified as medial, lateral, or central, depend-
ing on their relation to the sternomastoid muscle. The patient is
supine with both arms by his or her side. The table is tilted head
down to distend the central veins and prevent air embolism. The
patient’s neck can be extended by placing a small towel under the
shoulders. The head is turned slightly away from the site of punc-
ture. Extreme extension of the neck and rotation of the head are
avoided as these manoeuvres tend to collapse the vein. In the high
medial approach the needle is inserted along the medial border of
the sternomastoid muscle at its midpoint just lateral to the carotid
artery (Figure 2). It is directed caudally towards the ipsilateral
nipple at an angle of 30–40° to the skin. The internal jugular vein
is superficial and is usually within 2–3 cm of the skin’s surface.
The operator should avoid exerting pressure on the carotid artery
as this will compress the vein, reducing its diameter.
The subclavian vein has a wide calibre (1–2 cm diameter in
adults) and is believed to be held open by surrounding tissue,
even in severe circulatory collapse. This may be the preferred
route for long-term central venous access as there is less patient
discomfort post placement and the risk of infection and other
long-term complications is lower than at other insertion sites.
The subclavian route may also be preferred in trauma patients
with suspected cervical spine injury. This route is best avoided in

Access sites of choice f

g a Clavicle
2 1
b 1st rib
1 High internal jugular a 3 c Suprasternal notch
4 c
2 External jugular d Sternal angle
i
5 e Right atrium
3 Low internal jugular b f External jugular vein
4 Supraclavicular k
d h g Internal jugular vein
5 Infraclavicular h Subclavian vein
j
i Left innominate vein
j Superior vena cava
k Suggested catheter tip positioning zone
e

Figure 1

ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:1 18 © 2006 Elsevier Ltd. All rights reserved.
 Intensive care
High medial approach to the internal jugular vein
Figure 2
patients requiring long-term renal replacement therapy, as there
is a significant risk of venous stenosis, which may cause prob-
lems with existing or future arteriovenous fistulae.
Serious immediate complications are uncommon but occur
more frequently than with other routes. Pneumothorax is one of
the most common major complications with an overall incidence
between 1% and 2%. This figure increases to 10% if multiple
attempts are made. Subclavian vein puncture should be avoided
in patients with abnormal clotting because it is difficult to apply
pressure in the event of inadvertent subclavian artery puncture.
The right subclavian vein is preferred because this approach
avoids damage to the thoracic duct. However, in the presence
of unilateral lung pathology, subclavian catheterization is per-
formed on the ipsilateral side. Various approaches to the sub-
clavian vein have been described. The patient is positioned as
for cannulation of the internal jugular vein. In the frequently
used infraclavicular approach the needle is inserted into the skin
just below the lower border of the clavicle at the junction of the
medial and middle thirds. The needle is kept in the horizontal
plane and advanced medially and posteriorly to the clavicle, aim-
ing for the sternal notch. The needle should not pass further than
the sternal head of the clavicle.
The femoral vein may be cannulated with low risk of serious
short-term complications. This route is useful when urgent cen-
tral venous access is required and the patient is coagulopathic.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:1
The large diameter of the femoral vein allows infusion and
removal of large volumes of fluid, and because of this it is com-
monly used in the ICU for placement of short-term haemofiltration
catheters. Femoral catheters are more appropriate in ventilated,
sedated patients as movement may cause mechanical problems
and kinking of the lines. In ventilated patients, values of central
venous pressures obtained through femoral catheters correlate
well with measurements obtained via thoracic veins.
The risk of infections in the medium and long term is higher
with femoral catheters compared with subclavian and internal
jugular lines. This is because of the greater degree of bacterial
colonization of the groin compared with the shoulder or the
neck. There is also an increased risk of thromboembolism com-
pared with subclavian and internal jugular routes. Femoral cath-
eters should ideally be removed or replaced within 48–72 hours
of insertion.
The patient is positioned supine and a pillow is placed under
the patient’s buttocks to thrust the groin upwards. The thigh is
abducted and externally rotated. The pulsation of the femoral
artery is palpated 2 cm caudal to the inguinal ligament. The
needle is inserted 1 cm medial to the pulsation, aiming medially
towards the head at an angle of 20–30° to the skin. In adults, the
vein is normally found 2–4 cm from the skin’s surface. Cannula-
tion can be difficult because of a lack of anatomical landmarks,
especially in obese patients.
Complications
Complications occur in up to 10% of CVCs and they can be
cat­egorized according to mechanical, infectious and thrombo­
embolic aetiologies. Common complications are listed in Table 3.
The rate of complications depends on a number of factors, which
include the site chosen, the condition of the patient, the presence
of atypical anatomy, and the experience of the operator.
Complications of central venous catheterization
Mechanical
• Arterial puncture
• Haematoma
• Pneumothorax
• Haemothorax
• Haemorrhage
• Arrhythmias during procedure
• Cardiac tamponade
• Respiratory obstruction
• Thoracic duct damage
• Brachial plexus damage
Infectious
• Local infection
• Bacteraemia, sepsis
Thromboembolic
• Thrombosis of vessel
• Thrombus formation
• Venous air embolism
• Catheter/guidewire embolism
Table 3
19 © 2006 Elsevier Ltd. All rights reserved.
 Intensive care
Figure 3 Transverse view of right internal jugular vein. (a) Carotid
artery; (b) internal jugular vein.
Ultrasound guidance for placing central venous catheters
The National Institute for Clinical Excellence (NICE) recommends
the use of ultrasonography for the elective insertion of CVCs
into the internal jugular veins in both adults and children. Ultra­
sonography should be considered in most circumstances where
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:1
CVC insertion is necessary in elective and emergency situations.
Figure 3 shows a transverse view of the right internal jugular
vein obtained using ultrasound. The ultrasound image provides
information about the patency of the vessel and confirms that it
is in the predicted anatomical location. In approximately 10% of
cases, the internal jugular vein is either absent, small, or medial
or lateral to its usual position. Ultrasound guidance can be per-
formed in real-time enabling the operator to monitor the pas-
sage of the needle throughout the procedure as the needle enters
the vein. ◆
Further reading
Hall A P, Russell W C. Towards safer central venous access: ultrasound
guidance and sound advice. Anaesthesia 2005; 60: 1–4.
Hind D, Calvert N, McWiliams R et al. Ultrasonic locating devices for
central venous cannulation: Meta-analysis. BMJ 2003; 327: 361–4.
Latto I P, Ng W S, Jones P L, Jenkins B J. Percutaneous central venous
and arterial catheterisation. 3rd ed. London: WB Saunders, 2000.
McGee D C, Gould M K. Preventing complications of central venous
catheterizations. New Engl J Med 2003; 348: 1123–33.
The National Institute for Clinical Excellence. Guidance on the use of
ultrasound locating devices for placing central venous catheters
(NICE technology appraisal No. 49). London: NICE, 2002.
20 © 2006 Elsevier Ltd. All rights reserved.