Central Venous Cannulation

This procedure can be associated with significant complications and must always be performed under supervision until competence is attained.

Commonly used sites are the internal jugular vein (IJV), subclavian vein and femoral vein, which are all located close to arteries and nerves that can be damaged by a misplaced needle. In addition the subclavian vein lies near the pleura of the lung with the risk of pneumothorax.

Indication

  • Intravenous administration of specific drugs (e.g. dopamine or adrenaline)
  • Inability to obtain adequate peripheral IV access in the critically unwell patient, in a timely fashion
  • Haemodialysis
  • Central venous pressure monitoring, the insertion of a pulmonary artery (Swan-Ganz) catheter to measure wedge pressure
  • Hyperalimentation (TPN administration)
  • Cardiopulmonary resuscitation.

Contraindication

  • Less invasive forms of IV access are possible and adequate
  • Overlying skin lesion such as cellulitis or burns
  • Uncorrected bleeding diathesis
  • Obstruction of the vein by tumour, mass or thrombosis
  • Uncooperative patient.

Guidewire insertion length

Formulas for Catheter Insertion Length Based on Patient Height and Approach

Site Formula
(Height in cm)
In SVC (%) In RA (%)
Right Subclavian (RSCV) (Height/10) – 2 cm 96 4
Left Subclavian (LSCV) (Height/10) + 2 cm 97 2
Right Internal jugular (RIJV) Height/10 90 10
Left Internal jugular (LIJV) (Height/10) + 4 cm 94 5
  • How correct is the correct length for central venous catheter insertion [Reference]
  • Czepizak C, O’Callaghan JM, Venus B: Evaluation of formulas for optimal positioning of central venous catheters. Chest 107:1662, 1995. [Reference]

Handy Hints:

  • Do not shave hair at insertion site unless it interferes with dressing adhesive, as it may increase the risk of infection from disruption of the epidermal barrier by skin lacerations.
  • Draw up normal saline in a 10-mL syringe and lignocaine in a 5-mL syringe to ensure these two agents are not mixed up during the procedure.
  • Use ECG monitoring during insertion of IJV and subclavian lines
  • CVC insertion is not necessary, or even optimal, for fluid resuscitation. A short wide-bore cannula is better.
  • Ultrasound guidance is virtually the standard of care, where available and time permits. However the proceduralist must have adequate training.
  • Abdominal compression or valsalva can increase the diameter of the internal jugular vein.
  • Before inserting a CVL anticipate the future management of the patient, e.g. avoid IJV if PAC likely to be required, avoid SVC is likely to need fistula formation for hemodialysis, etc.
  • Access to the SCV during CVC insertion may be facilitated by caudal traction (5 cm extension) on the ipsilateral upper limb, or by placing a roll under the ipsilateral shoulder.
  • The chance of a complication escalates with repeated attempts, especially for SCV CVC insertion.

Image Gallery

Central line kit preparation Skin preparation Advance needle slowly under clavicle Confirm venous placement
CVL insertion Right SCV Introduce guidewire CVL insertion Right SCV Advance Dilator CVL insertion Right SCV Thread CVC over guidewire CVL insertion Right SCV Check lumen patency
Secure CVC Secure CVC

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