| Temporary single and multilumen central venous catheters are important acute and emergency access devices that establish dependable venous access for monitoring, invasive procedures, pharmacologic therapy, fluid and blood resuscitation, and blood exchange therapies in acute and critical illness. |
| Preparation |
- Obtain procedural consent as appropriate.
- Obtain the equipment and devices needed for catheter placement.
- Select access site appropriate to the clinical situation.
- Prepare and position the patient, with attention to ensuring patient monitoring and support as needed for the situation.
- Identify pertinent surface landmarks with special attention to access to the intended puncture site.
- Confirm the location and patency of the target vein and relationship to surface landmarks with ultrasound, as available.
- Pause for a procedural time-out to verify the procedure, site, and technique with team members.
- Use sterile technique to prepare the skin and drape the patient.
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| Needle access to the target vein |
- Flush the catheter lumens with sterile saline. Arrange and position central venous access supplies to expedite the procedure.
- Re-identify pertinent anatomic landmarks, even if ultrasound will be used. Reconfirm the vein target with ultrasound.
- Infiltrate the skin with local anesthetic (eg, 1 to 2% lidocaine or an alternative agent) at the intended insertion site.
- Use real-time ultrasound imaging to cannulate the vein using a standard introducer needle, micropuncture needle, or angiocatheter.
- Using landmark and ultrasound guidance of the needle trajectory, insert and advance the needle while applying continuous negative pressure on the syringe plunger.
- Monitor needle insertion depth, even during ultrasound guidance, to avoid deep tissue penetration, which risks procedure complication.
- Aspiration of free-flowing venous-colored blood confirms vein cannulation*.
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| Advance guidewire |
- Gently remove the syringe from the needle hub while confirming low-pressure venous-colored blood return. Cover the needle hub with a finger between manipulations to avoid air entrainment.
- Insert the guidewire through the access needle or angiocatheter. The guidewire should advance with minimal resistance. Maintain awareness of guidewire depth during insertion.
- Advance the guidewire just beyond the anticipated catheter depth, which is approximately 20 cm for adults and is often marked by two hash marks on the guidewire.
- Avoid intracardiac advancement that may trigger arrhythmias.
- Confirm intravenous guidewire placement via ultrasound, if available.
- Remove the needle or angiocatheter while controlling the guidewire.
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| Place catheter |
- Use a #11 scalpel blade to make a single stab skin incision at the puncture site and along the guidewire path.
- Advance the tissue dilator over the guidewire to the approximate depth of the vein but not deeper, then remove the tissue dilator while maintaining guidewire position.
- Load the venous catheter onto the guidewire while maintaining control of the guidewire at the skin entry site.
- Back the guidewire out of the vein through the catheter until it emerges from the distal access port. This allows continuous manual contact with the guidewire to avoid inadvertent catheter insertion without guidewire removal, which is the common mistake leading to a retained guidewire.
- Stabilize the distal guidewire as it exits the distal access port while advancing the catheter over the guidewire into the vein.
- With the catheter in place, remove the guidewire, taking care to stabilize the catheter to maintain intravascular placement.
- Place the removed guidewire in a visible location on the sterile field as a confirmation step for guidewire removal. This also maintains guidewire sterility in case the guidewire is again needed to troubleshoot catheter malposition.
- Aspirate blood from each access hub and flush with sterile saline to ensure a functioning catheter.
- Secure catheter and place sterile dressing.
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| Confirm catheter position |
- In emergency situations, the central venous access may be used immediately*.
- Obtain chest radiography to confirm catheter tip position for jugular and subclavian approaches. Femoral catheters do not require radiologic confirmation*.
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| Catheter and site care and maintenance |
- If adherence to sterile technique during placement cannot be assured, the catheter should be replaced as soon as possible (and within 48 hours after insertion).
- Replace dressings whenever soiled. Otherwise, routinely change polyurethane dressings every 7 days.
- Routine catheter replacement is not necessary. When replacement is needed based on clinical examination, replace at a new site, rather than using guidewire exchange.
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