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Overview of central venous access

Authors Section Editors Deputy Editor

Alan C Heffner, MD Allan B Wolfson, MD Kathryn A Collins, MD, PhD, FACS
Mark P Androes, MD John F Eidt, MD
Joseph L Mills, Sr, MD

Contributor disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2016. | This topic last updated: Jul 12, 2016.

INTRODUCTION — Central venous access is a commonly performed procedure with approximately 8 percent of
hospitalized patients requiring central venous access during the course of their hospital stay. More than five million
central venous catheters are inserted in the United States each year [1,2].

Central venous access is also needed to place pulmonary artery catheters, plasmapheresis and hemodialysis
catheters, as well as to place inferior vena cava filters, introduce wires for transvenous pacing and defibrillator
devices, and for venous interventions. The central venous access site and manner in which access is achieved
depend upon the indication for placement, patient anatomy, and other patient-related factors.

The indications for central venous access, types of central catheters, catheter selection, site selection, and general
issues of preparation and placement will be reviewed here. The role of catheters and devices for monitoring cardiac
parameters, or administering chemotherapy or parenteral nutrition is discussed in separate topic reviews.

The placement of jugular, subclavian, and femoral catheters; issues specific to these anatomic sites; routine
maintenance and care of catheters and port devices; and complications of central venous catheters and related
devices are discussed elsewhere. (See "Placement of jugular venous catheters" and "Placement of subclavian
venous catheters" and "Placement of femoral venous catheters".)

INDICATIONS

● Common indications for the placement of central catheters include [3-5]:

• Inadequate peripheral venous access

• Administration of noxious medications – Medications such as vasopressors, chemotherapy, and

parenteral nutrition are typically administered by central venous catheters because they can cause vein
inflammation (phlebitis) when given through a peripheral intravenous catheter.

• Hemodynamic monitoring – Central venous access permits measurement of central venous pressure,
venous oxyhemoglobin saturation (ScvO2), and cardiac parameters (via pulmonary artery catheter).

• Extracorporeal therapies – Large bore venous access is required to support high-volume flow required for
many extracorporeal therapies, including hemodialysis, continuous renal replacement therapy, and
plasmapheresis.

● Venous access is also needed to place venous devices and for venous interventions including:

• Transvenous cardiac pacing

• Inferior vena cava filter placement

• Venous thrombolytic therapy

• Venous stenting

CONTRAINDICATIONS — Contraindications to central venous catheterization are relative and depend upon the
urgency and alternatives for venous access. Cannulation is generally avoided at sites with anatomic distortion or
other indwelling intravascular hardware, such as a pacemaker or hemodialysis catheter. Vascular injury proximal to
the insertion site represents another relative contraindication.

Coagulopathy and/or thrombocytopenia — Moderate-to-severe coagulopathy is a relative contraindication to

central venous catheterization, although significant bleeding is uncommon. The need for urgent and emergent
venous access may require cannulation in spite of coagulopathy, and the safety of standard nontunneled and large-
bore tunneled catheter placement in this circumstance has been documented [6]a [7-10]. Thrombocytopenia poses a
greater risk compared with a prolonged clotting time [11,12]. In general, nontunneled catheters placed at sites that
are easy to monitor for bleeding are preferred in patients with coagulopathy. The subclavian approach is often
avoided in patients with severe coagulopathy due to inability to effectively monitor or compress the venipuncture site,
unless an alternative site is not suitable. When available, cannulation by an experienced provider and via ultrasound
guidance is suggested for patients with severe coagulopathy [13]. (see 'Use of ultrasound' below).

Plasma based products (eg, FFP, PF24, Prothrombin complex concentrate) or platelets can be administered prior to
the procedure in patients with severe coagulopathy or thrombocytopenia in an attempt to reduce the risk of bleeding
complications, but there is insufficient evidence to support this as routine practice [10,14,15]. The indications for
correcting coagulopathy in patients undergoing invasive procedures and dosing are discussed in detail elsewhere.
(See "Clinical use of plasma components", section on 'Plasma products' and "Clinical and laboratory aspects of
platelet transfusion therapy", section on 'Preparation for an invasive procedure' and "Approach to the adult with
unexplained thrombocytopenia", section on 'General management principles'.)

CENTRAL CATHETERS AND DEVICES — Central venous catheters can be inserted percutaneously or surgically.

Nontunneled — Nontunneled central catheters (figure 1) are placed percutaneously with the catheter exiting the
skin in the vicinity of the venous cannulation site. These catheters are most commonly used for temporary access to
the central circulation. Catheters are available in a variety of lengths (15 to 30 cm) and catheter materials (eg,
polyurethane, silicone). Specialized catheters for longer-term infusion may contain a valve mechanism to limit
backflow of blood for the purpose of preventing infection and catheter thrombosis. Power injectable catheters for
administration of intravenous contrast are also available.

Nontunneled central catheters may be single, double, triple, or quadruple lumen. The different lumens infuse fluid
through holes located on the side of the catheter. The distal hole is more reliable for drawing blood because it is less
likely to be suctioned against the wall of the vein during aspiration. As the number of lumens increase, the overall
diameter of the catheter increases, and the diameter of the individual luminal channels generally decreases. The use
of multilumen catheters reduces the maximum infusion rate of the catheter and increases the rate of catheter
thrombosis. (See "Catheter-related upper extremity venous thrombosis", section on 'Catheter-related factors'.)

Peripherally inserted central catheters (PICCs) are another type of commonly used central access device. These
devices are gaining in popularity due to the relative ease of insertion into the upper arm veins (cephalic or basilic
veins) (figure 2), a lower risk of some complications, and patient tolerance. Single and double lumen PICCs and
valved devices are available. PICCs are less favored in patients with significant renal dysfunction due to the risk of
venous thrombosis or stenosis that could complicate long-term access options for hemodialysis; however, the
incidence of this potential complication is not well established [16,17]. As with centrally-inserted catheters, the rate of
venous thrombosis for PICCs increases with increasing number of lumens and catheter diameter. (See "Catheter-
related upper extremity venous thrombosis", section on 'Catheter-related factors'.)

Antibiotic and antiseptic-impregnated central catheters are available, and may decrease rates of bacterial
colonization and catheter-related infection. (See "Prevention of intravascular catheter-related infections", section on
'Antimicrobial-impregnated catheters'.)

Introducer sheath — An introducer sheath (eg, Cordis) is a special type of venous access catheter that is single-
lumen, but with a larger bore (8.5 F) and shorter length than standard central catheters. The proximal end of these
devices contains a hemostatic valve through which other devices are introduced into the venous circulation (eg,
pulmonary artery catheter). However, the device can be used alone for rapid fluid infusion due to the large luminal
diameter. (See 'Specialized venous devices' below.)

Implanted — Implanted catheters are meant to be semipermanent with removal reserved if complications occur or
the device is no longer needed (eg, completion of chemotherapy). Two types of implanted central venous catheters
are available: tunneled catheters and totally implantable venous access devices (figure 1). Power injectable tunneled
catheters and port devices are available. PICCs may also be attached to an implanted port device. They are typically
used for shorter duration than most implanted catheters, such as for prolonged courses of intravenous antibiotics.

Tunneled — Tunneled central venous catheters traverse a subcutaneous tunnel between the catheterized vein
and the skin exit site. The catheter may be round or flat and catheter sizes can range from 2.7 to 12.5 F (eg,
Hickman, Broviac). A cuff (velour, Dacron) is positioned in the subcutaneous tissue adjacent the exit site. In general,
rates of infection associated with tunneled catheters are lower than those reported with the use of nontunneled
central venous catheters [18]. Dialysis and pheresis catheters are specialized large-bore double lumen catheters
designed for the exchange of large volumes of blood at high flow rates. (See "Prevention of intravascular catheter-
related infections", section on 'Determinants of infection risk' and "Central catheters for acute and chronic
hemodialysis access", section on 'Dialysis catheters'.)

Subcutaneous port — Totally implantable venous access devices have been used widely since their
introduction in the 1980s (eg, Port-a-Cath, BardPort, PowerPort, Infuse-a-Port, Medi-port) [19-22]. The catheter of
these devices is passed from the cannulated vein beneath the skin and attached to a subcutaneous infusion port or
reservoir that is placed into a subcutaneous pocket. PICC devices can also be attached to a subcutaneous port (eg,
Passport).

The port or reservoir is accessed through the skin by needle puncture into the port’s self-sealing septum. Single and
dual port devices are available. The main factor limiting infusion rate with these devices is the bore of the access
needle (eg, Huber, 19 [0.053” = 1.33 mm diameter] to 22 gauge [0.045” = 1.2 mm diameter]), which is nearly always
smaller than the internal diameter of the catheter attached to the port. Subcutaneous ports are commonly used to
administer chemotherapy agents because of their low rates of extravasation and infection [23]. Subcutaneous ports
also have the advantage of concealment from view, making this option more cosmetically appealing. Magnetic
resonance compatible devices are available.

Specialized venous devices — Several medical devices require central venous access for placement. These
devices are typically deployed through an introducer sheath. (See 'Nontunneled' above and 'Introducer sheath'
above.)

● Vena cava filters – Vena cava filters are indicated to decrease the risk of fatal pulmonary embolism in selected
patients with deep vein thrombosis. Central venous access is obtained through the internal jugular or femoral
vein and a long sheath facilitates device introduction under fluoroscopy or ultrasound-guidance. The placement
of inferior vena cava filters and their complications are discussed elsewhere. (See "Placement of vena cava
filters and their complications".)

● Pulmonary artery catheters – Pulmonary artery catheters are inserted through a venous sheath and the tip of
the catheter is positioned in the pulmonary artery as a means to monitor on cardiac function (figure 3). Insertion
of pulmonary artery catheters is discussed in detail elsewhere. (See "Pulmonary artery catheters: Insertion
technique in adults".)

● Pacemakers/Defibrillators – The placement of pacemaker/defibrillator leads also requires central venous

access (figure 4). After the vein is accessed, a sheath is introduced through which the pacemaker leads are
introduced and positioned into the heart. The leads are attached to the pacemaker, which is placed into a
subcutaneous pocket similar to other subcutaneous port devices (see 'Subcutaneous port' above). Issues
related to cardiac pacemakers and defibrillators are discussed elsewhere. (See "Temporary cardiac pacing".)

DEVICE SELECTION — A wide range of central venous catheters and devices are available. Device selection
depends primarily upon the indication for access but patient anatomy and other patient-related factors may also
have a bearing.

The choice between temporary (nontunneled) versus permanent (tunneled, port) placement, depends upon the
indication for central access. Patients who require access for only a short period of time (days) need not be exposed
to the discomfort or risks associated with tunneled devices [24]. Patients requiring long-term access (weeks,
permanent) benefit from tunneled or port devices, which are associated with lower rates of catheter infection
compared with nontunneled catheters. Selected patients may benefit from antibiotic-coated catheters based upon
infectious risk, cost, and anticipated duration of the catheter. (See "Prevention of intravascular catheter-related
infections", section on 'Type of catheter'.)

A single lumen, large-bore introducer sheath facilitates rapid administration of large volumes of fluid during
emergencies. For less emergent fluid resuscitation, a nontunneled central line is preferred over peripherally inserted
central catheters (PICC), which do not provide adequate flow rates due to their small caliber and longer catheter
length.

Multiple lumen catheters are used more often than single lumen catheters, primarily because of the need to
administer multiple pharmaceutical agents. In general, the smallest diameter catheter (fewer lumens) appropriate for
the clinical situation should be used to reduce the risk of venous thrombosis [3].

Compared with port devices, tunneled catheters have some disadvantages. Tunneled catheters may have higher
infection rates related to care of the external catheter. (See "Diagnosis of intravascular catheter-related infections"
and "Prevention of intravascular catheter-related infections".).

In addition, activities such as showering or swimming with tunneled catheters are limited. Because subcutaneous
ports allow more normal activities and cannot be seen (and thus are not an external reminder of the patient’s illness),
ports are often preferred when intermittent infusion therapy (eg, chemotherapy) is needed. The disadvantages of
subcutaneous port devices are the need to puncture the port through the skin to access the device and the small
caliber of the catheter, and thus, limited infusion rate. Port devices are not appropriate for patients who require
frequent dosing or continuous infusion of larger fluid volumes such as with total parenteral nutrition.

SITE SELECTION — Selection of the most appropriate site for central venous cannulation is based upon the
expertise and skill of the operator, patient anatomy (eg, known venous occlusion, presence of lymphedema), the
risks associated with placement (eg, coagulopathy, pulmonary disease), and access needs (eg, patient needs and
duration of catheter use) [25-29]. Although it is tempting to always use the same approach, knowledge of access
techniques at multiple access sites is important to meet varying patient needs [30]. Higher success rates and lower
rates of mechanical complications are clearly related to operator experience [31-34].

Commonly used vein cannulation sites for central venous access include:

● Jugular vein

• External jugular vein

• Internal jugular vein (central, posterior, anterior approaches)

● Subclavian vein (supraclavicular, infraclavicular, axillary approaches)

● Femoral vein

Specific techniques for placement of central venous catheters at these sites are discussed elsewhere. (See
"Placement of jugular venous catheters" and "Placement of subclavian venous catheters" and "Placement of femoral
venous catheters".)

The needle insertion site should be chosen in an area that is not contaminated or will potentially become
contaminated (eg, burned or infected skin, adjacent to tracheostomy or open surgical wound) [3].

Specific anatomic sites and cannulation approaches have inherent advantages and disadvantages (table 1). Access
sites with altered local anatomy (eg, prior clavicle fracture), sites with multiple scars from prior access, and the
presence of another central venous catheter or device (such as a pacemaker or internal defibrillator) are associated
with higher rates of access failure, malposition, dysrhythmia, and other complications, and should be avoided if
alternative sites are available [12,35,36]. If a patient has significant unilateral lung disease, the hemithorax ipsilateral
to the disease should be cannulated (internal jugular, subclavian access) to minimize respiratory decompensation in
the event of a procedure-related pneumothorax. Subclavian venous access for hemodialysis catheters is avoided
due to the risk of venous stenosis complicating subsequent hemodialysis access [27]. (See "Central catheters for
acute and chronic hemodialysis access", section on 'Basic principles'.)

Right subclavian anatomy carries the theoretical advantage of lower pneumothorax risk due to the lower pleural
apex and absence of the thoracic duct. However, this access site is associated with higher rates of catheter
malposition and vessel trauma [37].

Subclavian versus internal jugular access — Systematic reviews show little variation in major mechanical
complications between the subclavian and internal jugular access sites [1,38-41]. Specifically, the rate of hemothorax
and pneumothorax appear equivalent. A prior metaanalysis suggested that nontunneled subclavian access is
associated with a lower risk of catheter-related infection compared with alternative sites [42], while a trial comparing
internal jugular with subclavian port access for cancer therapy found no significant difference in infection rates or
mechanical complications [39]. A later, large multicenter trial that focused on intravascular complications of
nontunneled central catheters in intensive care unit patients found that subclavian access was associated with a
lower risk of bloodstream infection and symptomatic deep vein thrombosis compared with jugular vein
catheterization [43]. Subclavian access was associated with a higher rate of insertion failure, but the incidence of
major mechanical complications (eg, pneumothorax requiring chest tube placement, arterial injury, hematoma) was
not significantly different between sites. The findings of this trial support the United States Center for Disease Control
and Prevention guideline to preferentially use subclavian access for nontunneled catheters to minimize infection risk
[44]. However, differences between prior reviews and this later trial may relate to the patient populations studied. For
patients who are cachectic or have respiratory compromise, a jugular approach may be preferred to avoid
pneumothorax. The subclavian site may be preferentially avoided in patients with severe coagulopathy unless
alternative sites are suboptimal. Although arterial puncture may occur more frequently with the jugular approach,
recognition of bleeding and its control are easier at this site. (See 'Coagulopathy and/or thrombocytopenia' above.)

Femoral access versus other sites — We generally favor nonfemoral access points due to ease of care and ability
to permit ambulation, in the absence of clinical factors such as emergency situations, respiratory distress,
uncooperative patient, absence of another alternative site, and when the operator is sufficiently experienced with
nonfemoral central venous access [3].

Warnings to avoid femoral cannulation have focused on higher risks of infectious and thrombotic complications
compared with torso access sites [33,38,45]. However, a systematic review found no difference in the rate of
nontunneled-catheter-related bloodstream infection when comparing femoral, subclavian, and jugular sites [27].
Contemporary trials examining femoral access sites show decreasing rates of infection that are comparable with
jugular access [43,46]. These rates parallel an overall reduction in catheter-related bloodstream infection, which is a
testament to the impact of improved adherence to aseptic technique and proper catheter management. Higher body
mass index was a factor associated with nontunneled-catheter-related infection at the femoral site in one trial [41]. In
a larger trial, the composite outcome of bloodstream infection and symptomatic deep vein thrombosis was
significantly greater for the femoral compared with the subclavian site (hazard ratio [HR] 3.5, 95% CI 1.5-7.8), but
similar to the internal jugular site [43]. Femoral access was associated with the fewest mechanical complications.

Peripheral versus central vein insertion — Peripherally inserted central catheters (PICCs) have gained popularity
for ease of insertion and lesser procedural risk (eg, hemo- or pneumothorax). Typically, PICCs are placed by
intravenous (IV) nurses and are most commonly used for temporary access needs (expected infusion >15 days to 30
days) [24]), such as outpatient IV antibiotic administration.

Catheter placement is often performed with the assistance of ultrasound to access the peripheral vein. Once
accessed, a catheter is placed over a guidewire and positioned in the central veins. The initial catheter length is
based on estimates using anatomic landmarks. Position is confirmed radiographically.

PICC lines should be avoided or used with great caution in patients with chronic kidney disease or end-stage renal
disease due to the incidence of peripheral and central venous stenosis/thrombosis which complicates future
hemodialysis access [24,47-49]. Perception of decreased risk of catheter-associated bloodstream infection with
PICCs compared with alternative central catheters is not supported in the literature, especially among hospitalized
patients [50,51]. As such, we discourage routine use of PICCs in patients at risk for future hemodialysis access.

Emergency central access — Achieving rapid intravenous access is essential in the care of critically-ill patients,
including those undergoing cardiopulmonary resuscitation (CPR). Volume resuscitation does not generally require
central access if sufficient peripheral IV access can be obtained (eg, 14 or 16 gauge IV catheters). Peripheral IV
access is preferred due to the higher flow rates that can be achieved through these short, large-bore catheters.
However, peripheral access may be challenging in patients with hypovolemic shock. Under these circumstances, a
single-lumen, large-bore central venous introducer sheath is often used. (See 'Nontunneled' above.)
Femoral venous access is less likely to disrupt CPR, whereas subclavian or internal jugular insertion may interfere
with chest compressions or intubation efforts. In a small, randomized study of patients receiving CPR, real-time
ultrasound-guided femoral catheterization was faster and more likely to be successful than other approaches [52].
(See "Placement of femoral venous catheters".)

Internal jugular access (especially right-sided) carries the lowest rate of catheter malposition and may be the optimal
central venous access site in emergency situations when correct positioning is needed for immediate use, such as
for drug administration or transvenous pacing (table 1) [1,27]. The supraclavicular approach is another option [53].
Instillation of medications via the subclavian or internal jugular veins allows rapid delivery to the heart [54,55]. (See
"Placement of jugular venous catheters" and "Placement of subclavian venous catheters".)

PREPARATION — Nontunneled percutaneous central catheters are usually placed at the bedside, while tunneled
catheters and port devices can be placed in an interventional suite or operating room using fluoroscopic guidance.
The equipment needed for central venous catheterization is given in the table (table 2).

Informed consent — Informed consent should be obtained for any central venous catheter including those placed
percutaneously or requiring an incision (eg, port). Consent for vascular access is implied for emergency situations.

The procedure plan, including indications, benefits, and potential complications of the procedure (eg, pneumothorax)
should be discussed with the patient and/or legal guardian. The potential need to perform a secondary procedure,
such as chest tube placement to evacuate a pneumothorax, should also be conveyed. (See "Informed procedural
consent".)

Monitoring — All patients should be monitored during central venous access procedures, including continuous
cardiac rhythm and pulse oximetry. Supplemental oxygen should be immediately available and, for some patients, it
may be prudent to administer oxygen by nasal cannula prior to covering the patient’s head with any drapes.

Positioning — Once the access sites and approach are chosen, the patient is positioned to maximize comfort.
While preparing and draping the patient, a supine position is adequate. The bed or table should be placed at a
height that allows the operator to remain comfortable throughout the procedure. The patient is positioned to
maximize the diameter of the vein during the vascular access procedure, which depends upon the site selected.
Although Trendelenburg position facilitates venous filling for jugular and subclavian access and may reduce the risk
of venous air embolism [56-60], critically ill and obese patients may not tolerate this position. Patients at risk for
respiratory compromise may require anesthesia with a controlled airway to safely place a central catheter or device.
(See "Anesthesia for the obese patient", section on 'Patient positioning'.)

Site preparation — Hair should be clipped from the access site prior to skin preparation. Clipping is preferred to
shaving [61]. A chlorhexidine-alcohol skin antiseptic solution should be applied to the access site and allowed to dry
prior to draping the patient [62]. An additional preparation kit may be required for those that contain only iodine
solutions, as chlorhexidine skin antisepsis is superior at reducing short-term catheter-related infection. When jugular
or subclavian access is planned, preparing the skin of the neck and chest bilaterally facilitates access to alternative
sites in the event the planned venous site cannot be cannulated. (See "Adjunctive measures for prevention of
surgical site infection in adults", section on 'Skin antisepsis' and "Prevention of intravascular catheter-related
infections", section on 'Insertion site preparation'.)

Sterile technique — To reduce infectious complications, all central venous access procedures, including emergency
procedures, should be performed in a location that permits the use of aseptic technique with full barrier precautions,
including sterile drapes large enough to cover the entire patient, surgical antiseptic hand wash, sterile gown, mask,
gloves, and cap [3,63,64]. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults", section
on 'Device placement' and "Prevention of intravascular catheter-related infections".)

Antimicrobial prophylaxis — Antimicrobial prophylaxis prior to percutaneous central venous catheter placement is
not standard practice. A metaanalysis comparing antibiotics versus no antibiotics for totally implanted venous access
devices also showed no significant difference in infection rate [65].

Analgesia and sedation — Patient movement may preclude successful cannulation and, in a conscious patient,
every effort should be taken to ensure patient comfort and cooperation. This is accomplished using sedation and
local anesthesia (topical, infiltrated). For patients who are awake and anxious, minimal sedation can be achieved
with a low-dose, short-acting benzodiazepine to help the patient relax. Deeper sedation may be needed, especially
in uncooperative children or adults. (See "Procedural sedation in children outside of the operating room" and
"Procedural sedation in adults".)

Topical anesthetics are helpful and effective when time permits, particularly in children. The algorithm provides
guidance regarding selection of an appropriate topical agent in children (algorithm 1). (See "Topical anesthetics in
children".)

Infiltration of the skin overlying the access site is usually accomplished with lidocaine (eg, 1 or 2 percent). Lidocaine
with epinephrine is generally unnecessary but may be useful during the placement of tunneled catheters to decrease
bleeding from the subcutaneous tunnel. (See "Infiltration of local anesthetics".)

Subcutaneous infiltration of local anesthetics may also be helpful, but overzealous infiltration can distort landmarks,
increase the depth of penetration needed to access the vessel, and can cause vein compression making needle
access more difficult.

Care should be taken not to inject air into the subcutaneous tissues, because it will interfere with the transmission of
ultrasound waves. (See 'Use of ultrasound' below.).

For tunneled catheters or port placement, infiltration of a longer acting local anesthetic (eg, bupivacaine) into the
tract or subcutaneous pocket will help to limit postoperative pain. (See "Management of acute perioperative pain",
section on 'Preventive analgesia'.)

USE OF ULTRASOUND — Prior to the placement of central catheters, ultrasound imaging evaluates venous
patency in patients who have a history of prior instrumentation or deep vein thrombosis in the region of the proposed
access site [66]. (See "Catheter-related upper extremity venous thrombosis", section on 'Duplex ultrasonography'.)

Preprocedure ultrasound also identifies anatomic variations, which is particularly useful for reducing trauma
associated with line placement in children. In a study of 140 children, anatomic variations occurred in about 7
percent [67].

Familiarity with ultrasound-guided access is a critical aspect for the practitioner performing frequent central venous
catheterization. Static ultrasound can be helpful to localize the vein when using techniques that rely on knowledge of
anatomic landmarks (ie, landmark technique), while dynamic ultrasound is used to guide vein puncture in real-time.
(See "Principles of ultrasound-guided venous access", section on 'Dynamic ultrasound to guide vein cannulation' and
"Principles of ultrasound-guided venous access", section on 'Ultrasound-guided techniques'.)

Real-time ultrasound imaging during needle placement reduces time to venous cannulation and the risk of
complications for jugular and femoral access. Periprocedure ultrasound also assists with early detection of arterial
and venous guidewire malposition [68,69]. Training and use of ultrasound guidance is recommended, and is
particularly useful in pediatric access and for high-risk patients, including those with coagulopathy. When ultrasound
is not available, central catheters are placed using landmark techniques. The principles of ultrasound and techniques
to identify venous structures for venous access are discussed in detail elsewhere. (See 'General technique' below.)

Bedside ultrasound is also useful to detect guidewire position and postprocedure pneumothorax [69]. A metaanalysis
pooling the results of 20 studies found a sensitivity of 88 percent and specificity of 99 percent for the detection of
pneumothorax using ultrasonography, compared with 52 and 100 percent for chest radiography. An important caveat
to these studies was that accuracy of diagnosis was dependent upon ultrasound operator skill. (See 'Confirmation of
catheter tip positioning' below and "Thoracic ultrasound: Indications, advantages, and technique".)

GENERAL TECHNIQUE — The placement of central catheters and other venous devices follows similar principles.
Specific details of central catheter placement for the various anatomic locations (jugular, subclavian, femoral) and
other devices are discussed elsewhere. (See "Placement of jugular venous catheters" and "Placement of subclavian
venous catheters" and "Placement of femoral venous catheters" and 'Other devices' below.)

Nontunneled central catheters — The general method for placing nontunneled central catheters is as follows:

● Obtain the equipment and devices needed for catheter placement (picture 1 and table 2)

● Prepare (consent, sedation, antibiotics) and position the patient

 ● Using sterile technique, prepare the skin and drape the patient

● Identify pertinent anatomic landmarks

● Identify the vein with ultrasound when available (preferred)

● Infiltrate the skin with local anesthetic

● Cannulate the vein (needle or angiocatheter) and confirm the intravenous location of the needle

● Insert the guidewire into the vein through the access needle or angiocatheter

● Remove the needle or angiocatheter while controlling the guidewire

● Make a small stab incision in the skin at the puncture site adjacent to the guidewire

● Advance the dilator over the guidewire into the vein, taking care to control the guidewire, then remove the
dilator

● Thread the catheter over the guidewire, taking care to control the guidewire

● Remove the guidewire, taking care to control the catheter

● Sequentially aspirate blood from each access hub and flush with saline to ensure functioning of the catheter

● Suture the catheter into place and dress the site using sterile technique

● Confirm the position of the tip of the catheter

Other devices — The basic principles for placing other central venous devices are similar to those outlined above;
however, a venous sheath is typically placed over the guidewire into the vein first, and the catheter, device, or
pacemaker lead is introduced through it. Once the device is in place, the sheath is removed. A brief description of
the placement of these devices compared with standard percutaneous central catheters is given below.

Venous sheath placement — The introducer sheath (eg, Cordis) is a combined dilator and sheath assembly
with a side port for intravenous access. Once the guidewire is in place and the vessel is dilated, the dilator and
sheath are advanced over the guidewire together. The dilator and guidewire are then removed, leaving the sheath in
place. Once the sheath is in place, the side port is aspirated and irrigated to check function, and the sheath is
sutured to the skin at its exit site.

Tunneled catheters — Venous access for tunneled catheters is obtained in a manner similar to nontunneled
catheters. The exit site of the catheter on the skin is chosen, which determines the length of catheter that will be
needed for proper catheter tip positioning. For some tunneled catheters, the excess length of catheter provided is
trimmed before the catheter is tunneled; for others, it can be trimmed afterward. Other types of catheters come in
fixed lengths (eg, dialysis catheters) and the position of the exit site is chosen to accommodate the predetermined
length of the catheter. For subclavian and jugular tunneled catheters, the exit site on the chest wall should be located
below the midclavicle in a position that does not interfere with clothing or upper extremity mobility.

Percutaneous access is performed as outlined above. Once the guidewire is in position, the skin at the guidewire
exit site is incised to accommodate at least the diameter of the catheter. Following administration of local anesthesia
to the catheter exit site and planned subcutaneous tunnel, an incision is made at the planned catheter exit site. A
tunneling device is usually included in the catheter kit, and it is attached to the end-hole of the catheter. The catheter
is advanced subcutaneously from the catheter exit site to the guidewire exit site, and the tunneler is removed. Care
is taken to ensure that the tunnel provides a gentle curve in the catheter from the catheter exit site to the guidewire
site. Acute angulation may lead to poor flow rates and catheter malfunction. After dilating the vein, the dilator/sheath
combination is placed over the wire. The dilator is removed, and the catheter is advanced through the sheath and
the sheath peeled away. The position of the tip of the catheter is checked and adjusted, as needed. The cuff of the
tunneled catheter is ideally located at the exit site of the catheter, but it may come to rest more cranially.

Subcutaneous ports — For subcutaneous port placement, a pocket is created for the port device after venous
access has been established. Prior to placing the port, the function should be checked by inserting a needle and
irrigating with saline, which should flow freely through the port hub.
Once the guidewire is in place, local anesthetic is administered into the skin and subcutaneous tissue of the planned
pocket. An incision is made through the skin and subcutaneous tissues. With electrocautery, a pocket is created to
accommodate the device by undermining the subcutaneous tissue. The device is placed into the pocket, and the
size of the pocket and orientation of the device is adjusted as needed.

Once the pocket is completed, the catheter is tunneled from the pocket to the guidewire exit site, if needed (eg,
jugular venous access). Care is taken to avoid catheter angulation which will lead to mechanical dysfunction. After
dilating the vein, the dilator/sheath combination is placed over the wire. The dilator is removed and the catheter is
placed through the sheath, and the sheath peeled away. The catheter is positioned and adjusted as needed. The
excess catheter is trimmed and attached to the hub of the port device, which is placed into the pocket and sutured
into place. Placing sutures in at least three points of fixation into fascial tissue is important to prevent port rotation,
which can transpose the access hub away from the skin surface making access impossible. The subcutaneous
tissues and skin are sutured closed. Prior to dressing the wound, the port should be accessed through the skin, and
the port aspirated and irrigated to confirm its proper functioning.

CONFIRMATION OF CATHETER TIP POSITIONING — Confirmation of catheter tip positioning can use one or
more of the following methods: chest radiography, ultrasound, fluoroscopy, and transesophageal echocardiography
(typically intraoperative) [69-77]. Chest radiography and fluoroscopy are the most commonly used methods. The use
of ultrasound is discussed above. (See 'Use of ultrasound' above.)

A postprocedure chest radiograph is generally obtained to confirm the course of the catheter and position of the tip
prior to use of jugular and subclavian catheters in nonemergency situations. Femoral catheters do not generally
require radiologic confirmation of position. Some studies have questioned the need for routine radiography for
uncomplicated right internal jugular catheters placed with a single needle pass [72,74,75].

The optimal positioning of the tip of the catheter depends on the specific access site. In general, catheters function
well with the tip situated in any major vein. However, suboptimal tip position may be related to delayed
complications. If a catheter is malpositioned within the venous system, it may still be used under emergency
circumstances but should be repositioned as soon as feasible. In contrast, inadvertent placement of a catheter into
the arterial system mandates immediate attention [78].

Catheter tip confirmation and positioning, management of malpositioned catheters, and management of inadvertent
arterial puncture are discussed separately for the commonly used access sites (See "Placement of jugular venous
catheters", section on 'Catheter placement' and "Placement of femoral venous catheters", section on 'Confirmation of
femoral catheter position' and "Placement of subclavian venous catheters", section on 'Confirmation of subclavian
catheter position'.)

CATHETER MANAGEMENT — Management of central catheters is aimed at preventing catheter infection and
thrombosis, and handling mechanical complications.

Proper catheter maintenance involves minimizing the duration of temporary catheter access, performing routine
catheter site inspections, periodically changing the catheter site dressing, using aseptic technique when handling
catheters, and changing the catheter, when indicated. Catheter site management and catheter care are discussed
elsewhere. (See "Prevention of intravascular catheter-related infections", section on 'Site care' and "Prevention of
intravascular catheter-related infections", section on 'Catheter care'.)

Catheter lumen thrombosis may be reduced using catheter lock solutions, and when thrombosis occurs thrombolytic
therapy may restore lumen patency. Thrombosis related to mechanical problems often requires catheter
replacement. These issues are discussed elsewhere. (See "Antibiotic lock therapy for treatment of catheter-related
bloodstream infections", section on 'Anticoagulant' and "Catheter-related upper extremity venous thrombosis",
section on 'Thrombosis prevention' and "Catheter-related upper extremity venous thrombosis", section on 'Catheter
management'.)

COMPLICATIONS — The complications related to central venous access (table 3) are discussed separately. (See
"Complications of central venous catheters and their prevention".)

SUMMARY AND RECOMMENDATIONS

● Common indications for central venous access include inadequate intravenous access, medication and fluid
 administration, hemodynamic monitoring and extracorporeal therapy (eg, renal replacement therapy,
plasmapheresis). Central venous access is also used to facilitate insertion of vascular devices, including
inferior vena cava filters, pacemakers, and defibrillators, and to perform venous interventions. (See 'Indications'
above.)

● Severe coagulopathy is a relative contraindication to central venous catheterization, with thrombocytopenia

posing a greater risk than prolonged clotting time. The subclavian approach is often avoided in patients at high
risk for bleeding due to an inability to effectively monitor or compress the venipuncture site. If central access is
absolutely necessary, the most experienced individual available should perform the procedure. (See
'Coagulopathy and/or thrombocytopenia' above.)

● Central venous catheters can be inserted through the jugular, subclavian, or femoral veins, or via upper arm
peripheral veins. The type of catheter and site chosen are often determined by the clinical scenario of the
individual patient and provider preference. The optimal site is determined by operator experience, patient
anatomy, and clinical circumstances. (See 'Site selection' above.)

● Prior to the placement of central catheters, we recommend ultrasound imaging to evaluate venous patency in
patients who have a history of vascular instrumentation or prior deep vein thrombosis in the region of the
proposed access site. (See 'Use of ultrasound' above and "Catheter-related upper extremity venous
thrombosis".)

● Real-time ultrasound imaging during vessel puncture reduces time to venous cannulation and the risk of
complications. Thus, ultrasound guidance is recommended when equipment and expertise are available, and is
particularly useful in pediatric venous access and in high-risk patients, such as those with coagulopathy (See
'Use of ultrasound' above and "Principles of ultrasound-guided venous access", section on 'Summary and
recommendations'.)

● Central venous catheterization is performed through a series of well-defined steps. Venous sheaths are placed
in a similar manner. (See 'General technique' above.)

● Chest radiography is often used to confirm jugular and subclavian catheter placement prior to use in
nonemergency situations. Femoral catheters do not generally require radiological confirmation of position. The
need to confirm placement in all patients undergoing jugular venous access procedures is controversial.
Periprocedural ultrasound is an alternative aid to avoid catheter malposition and detect pneumothorax. (See
'Confirmation of catheter tip positioning' above.)

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REFERENCES

1. Ruesch S, Walder B, Tramèr MR. Complications of central venous catheters: internal jugular versus
subclavian access--a systematic review. Crit Care Med 2002; 30:454.
2. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003;
348:1123.
3. American Society of Anesthesiologists Task Force on Central Venous Access, Rupp SM, Apfelbaum JL, et al.
Practice guidelines for central venous access: a report by the American Society of Anesthesiologists Task
Force on Central Venous Access. Anesthesiology 2012; 116:539.
4. Freel AC, Shiloach M, Weigelt JA, et al. American College of Surgeons Guidelines Program: a process for
using existing guidelines to generate best practice recommendations for central venous access. J Am Coll
Surg 2008; 207:676.
5. Bodenham Chair A, Babu S, Bennett J, et al. Association of Anaesthetists of Great Britain and Ireland: Safe
vascular access 2016. Anaesthesia 2016; 71:573.
6. Frykholm P, Pikwer A, Hammarskjöld F, et al. Clinical guidelines on central venous catheterisation. Swedish
Society of Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiol Scand 2014; 58:508.
7. Patel IJ, Davidson JC, Nikolic B, et al. Consensus guidelines for periprocedural management of coagulation
status and hemostasis risk in percutaneous image-guided interventions. J Vasc Interv Radiol 2012; 23:727.
 8. Fisher NC, Mutimer DJ. Central venous cannulation in patients with liver disease and coagulopathy--a
prospective audit. Intensive Care Med 1999; 25:481.
9. Segal JB, Dzik WH, Transfusion Medicine/Hemostasis Clinical Trials Network. Paucity of studies to support
that abnormal coagulation test results predict bleeding in the setting of invasive procedures: an evidence-
based review. Transfusion 2005; 45:1413.
10. Weigand K, Encke J, Meyer FJ, et al. Low levels of prothrombin time (INR) and platelets do not increase the
risk of significant bleeding when placing central venous catheters. Med Klin (Munich) 2009; 104:331.
11. Doerfler ME, Kaufman B, Goldenberg AS. Central venous catheter placement in patients with disorders of
hemostasis. Chest 1996; 110:185.
12. Polderman KH, Girbes AJ. Central venous catheter use. Part 1: mechanical complications. Intensive Care Med
2002; 28:1.
13. Tercan F, Ozkan U, Oguzkurt L. US-guided placement of central vein catheters in patients with disorders of
hemostasis. Eur J Radiol 2008; 65:253.
14. Estcourt LJ, Desborough M, Hopewell S, et al. Comparison of different platelet transfusion thresholds prior to
insertion of central lines in patients with thrombocytopenia. Cochrane Database Syst Rev 2015; 2015.
15. Hall DP, Lone NI, Watson DM, et al. Factors associated with prophylactic plasma transfusion before vascular
catheterization in non-bleeding critically ill adults with prolonged prothrombin time: a case-control study. Br J
Anaesth 2012; 109:919.
16. Agarwal AK. Central vein stenosis: current concepts. Adv Chronic Kidney Dis 2009; 16:360.
17. Gonsalves CF, Eschelman DJ, Sullivan KL, et al. Incidence of central vein stenosis and occlusion following
upper extremity PICC and port placement. Cardiovasc Intervent Radiol 2003; 26:123.
18. Dryden MS, Samson A, Ludlam HA, et al. Infective complications associated with the use of the Quinton
'Permcath' for long-term central vascular access in haemodialysis. J Hosp Infect 1991; 19:257.
19. Niederhuber JE, Ensminger W, Gyves JW, et al. Totally implanted venous and arterial access system to
replace external catheters in cancer treatment. Surgery 1982; 92:706.
20. Gyves J, Ensminger W, Niederhuber J, et al. Totally implanted system for intravenous chemotherapy in
patients with cancer. Am J Med 1982; 73:841.
21. Barbetakis N, Asteriou C, Kleontas A, Tsilikas C. Totally implantable central venous access ports. Analysis of
700 cases. J Surg Oncol 2011; 104:654.
22. Knebel P, Lopez-Benitez R, Fischer L, et al. Insertion of totally implantable venous access devices: an
expertise-based, randomized, controlled trial (NCT00600444). Ann Surg 2011; 253:1111.
23. Pegues D, Axelrod P, McClarren C, et al. Comparison of infections in Hickman and implanted port catheters in
adult solid tumor patients. J Surg Oncol 1992; 49:156.
24. Chopra V, Flanders SA, Saint S, et al. The Michigan Appropriateness Guide for Intravenous Catheters
(MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method. Ann Intern
Med 2015; 163:S1.
25. Plumhans C, Mahnken AH, Ocklenburg C, et al. Jugular versus subclavian totally implantable access ports:
catheter position, complications and intrainterventional pain perception. Eur J Radiol 2011; 79:338.
26. Timsit JF. Central venous access in intensive care unit patients: is the subclavian vein the royal route?
Intensive Care Med 2002; 28:1006.
27. Marik PE, Flemmer M, Harrison W. The risk of catheter-related bloodstream infection with femoral venous
catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the
literature and meta-analysis. Crit Care Med 2012; 40:2479.
28. Biffi R, Pozzi S, Bonomo G, et al. Cost effectiveness of different central venous approaches for port placement
and use in adult oncology patients: evidence from a randomized three-arm trial. Ann Surg Oncol 2014;
21:3725.
29. O'Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related
infections. Am J Infect Control 2011; 39:S1.
30. Sterner S, Plummer DW, Clinton J, Ruiz E. A comparison of the supraclavicular approach and the
infraclavicular approach for subclavian vein catheterization. Ann Emerg Med 1986; 15:421.
31. Sznajder JI, Zveibil FR, Bitterman H, et al. Central vein catheterization. Failure and complication rates by three
percutaneous approaches. Arch Intern Med 1986; 146:259.
32. Arrighi DA, Farnell MB, Mucha P Jr, et al. Prospective, randomized trial of rapid venous access for patients in
hypovolemic shock. Ann Emerg Med 1989; 18:927.
33. Merrer J, De Jonghe B, Golliot F, et al. Complications of femoral and subclavian venous catheterization in
critically ill patients: a randomized controlled trial. JAMA 2001; 286:700.
34. Eisen LA, Narasimhan M, Berger JS, et al. Mechanical complications of central venous catheters. J Intensive
Care Med 2006; 21:40.
35. Mansfield PF, Hohn DC, Fornage BD, et al. Complications and failures of subclavian-vein catheterization. N
Engl J Med 1994; 331:1735.
36. Reeves ST, Roy RC, Dorman BH, et al. The incidence of complications after the double-catheter technique for
cannulation of the right internal jugular vein in a university teaching hospital. Anesth Analg 1995; 81:1073.
37. The clinical anatomy of several invasive procedures. American Association of Clinical Anatomists, Educational
Affairs Committee. Clin Anat 1999; 12:43.
38. Lorente L, Henry C, Martín MM, et al. Central venous catheter-related infection in a prospective and
observational study of 2,595 catheters. Crit Care 2005; 9:R631.
39. Biffi R, Orsi F, Pozzi S, et al. Best choice of central venous insertion site for the prevention of catheter-related
complications in adult patients who need cancer therapy: a randomized trial. Ann Oncol 2009; 20:935.
40. Ge X, Cavallazzi R, Li C, et al. Central venous access sites for the prevention of venous thrombosis, stenosis
and infection. Cochrane Database Syst Rev 2012; :CD004084.
41. Parienti JJ, Thirion M, Mégarbane B, et al. Femoral vs jugular venous catheterization and risk of nosocomial
events in adults requiring acute renal replacement therapy: a randomized controlled trial. JAMA 2008;
299:2413.
42. Parienti JJ, du Cheyron D, Timsit JF, et al. Meta-analysis of subclavian insertion and nontunneled central
venous catheter-associated infection risk reduction in critically ill adults. Crit Care Med 2012; 40:1627.
43. Parienti JJ, Mongardon N, Mégarbane B, et al. Intravascular Complications of Central Venous Catheterization
by Insertion Site. N Engl J Med 2015; 373:1220.
44. O'Grady NP, Alexander M, Burns LA, et al. Summary of recommendations: Guidelines for the Prevention of
Intravascular Catheter-related Infections. Clin Infect Dis 2011; 52:1087.
45. Joynt GM, Kew J, Gomersall CD, et al. Deep venous thrombosis caused by femoral venous catheters in
critically ill adult patients. Chest 2000; 117:178.
46. Timsit JF, Bouadma L, Mimoz O, et al. Jugular versus femoral short-term catheterization and risk of infection in
intensive care unit patients. Causal analysis of two randomized trials. Am J Respir Crit Care Med 2013;
188:1232.
47. Drew DA, Weiner DE. Peripherally Inserted Central Catheters (PICCs) in CKD: PICC'ing the Best Access for
Kidney Disease Patients. Am J Kidney Dis 2016; 67:724.
48. Greene MT, Flanders SA, Woller SC, et al. The Association Between PICC Use and Venous
Thromboembolism in Upper and Lower Extremities. Am J Med 2015; 128:986.
49. Shingarev R, Allon M. Peripherally inserted central catheters and other intravascular devices: how safe are
they for hemodialysis patients? Am J Kidney Dis 2012; 60:510.
50. Al Raiy B, Fakih MG, Bryan-Nomides N, et al. Peripherally inserted central venous catheters in the acute care
setting: A safe alternative to high-risk short-term central venous catheters. Am J Infect Control 2010; 38:149.
51. Chopra V, O'Horo JC, Rogers MA, et al. The risk of bloodstream infection associated with peripherally inserted
central catheters compared with central venous catheters in adults: a systematic review and meta-analysis.
Infect Control Hosp Epidemiol 2013; 34:908.
52. Hilty WM, Hudson PA, Levitt MA, Hall JB. Real-time ultrasound-guided femoral vein catheterization during
cardiopulmonary resuscitation. Ann Emerg Med 1997; 29:331.
53. Dronen S, Thompson B, Nowak R, Tomlanovich M. Subclavian vein catheterization during cardiopulmonary
resuscitation. A prospective comparison of the supraclavicular and infraclavicular percutaneous approaches.
JAMA 1982; 247:3227.
54. Kaye W, Bircher NG. Access for drug administration during cardiopulmonary resuscitation. Crit Care Med
1988; 16:179.
55. Emerman CL, Bellon EM, Lukens TW, et al. A prospective study of femoral versus subclavian vein
catheterization during cardiac arrest. Ann Emerg Med 1990; 19:26.
56. Ely EW, Hite RD, Baker AM, et al. Venous air embolism from central venous catheterization: a need for
increased physician awareness. Crit Care Med 1999; 27:2113.
57. Mirski MA, Lele AV, Fitzsimmons L, Toung TJ. Diagnosis and treatment of vascular air embolism.
Anesthesiology 2007; 106:164.
 58. Bellazzini MA, Rankin PM, Gangnon RE, Bjoernsen LP. Ultrasound validation of maneuvers to increase
internal jugular vein cross-sectional area and decrease compressibility. Am J Emerg Med 2009; 27:454.
59. Samy Modeliar S, Sevestre MA, de Cagny B, Slama M. Ultrasound evaluation of central veinsin the intensive
care unit:effects of dynamic manoeuvres. Intensive Care Med 2008; 34:333.
60. Parry G. Trendelenburg position, head elevation and a midline position optimize right internal jugular vein
diameter. Can J Anaesth 2004; 51:379.
61. Tanner J, Moncaster K, Woodings D. Preoperative hair removal: a systematic review. J Perioper Pract 2007;
17:118.
62. Mimoz O, Lucet JC, Kerforne T, et al. Skin antisepsis with chlorhexidine-alcohol versus povidone iodine-
alcohol, with and without skin scrubbing, for prevention of intravascular-catheter-related infection (CLEAN): an
open-label, multicentre, randomised, controlled, two-by-two factorial trial. Lancet 2015; 386:2069.
63. Geffers C, Meyer E. No reason to conclude that maximal sterile barrier precautions do not reduce catheter-
related blood stream infections. Ann Surg 2011; 253:212.
64. Kost, SI. Ultrasound-assisted venous access. In: Textbook of Pediatric Emergency Procedures, 2nd edition,
King, C, Henretig, FM (Eds), Lippincott Williams and Wilkins, Philadelphia 2008. p.1255.
65. Johnson E, Babb J, Sridhar D. Routine Antibiotic Prophylaxis for Totally Implantable Venous Access Device
Placement: Meta-Analysis of 2,154 Patients. J Vasc Interv Radiol 2016; 27:339.
66. Gornik HL, Gerhard-Herman MD, Misra S, et al. ACCF/ACR/AIUM/ASE/IAC/SCAI/SCVS/SIR/SVM/SVS/SVU
2013 appropriate use criteria for peripheral vascular ultrasound and physiological testing part II: testing for
venous disease and evaluation of hemodialysis access: a report of the american college of cardiology
foundation appropriate use criteria task force. J Am Coll Cardiol 2013; 62:649.
67. P Souza Neto E, Grousson S, Duflo F, et al. Ultrasonographic anatomic variations of the major veins in
paediatric patients. Br J Anaesth 2014; 112:879.
68. Bedel J, Vallée F, Mari A, et al. Guidewire localization by transthoracic echocardiography during central
venous catheter insertion: a periprocedural method to evaluate catheter placement. Intensive Care Med 2013;
39:1932.
69. Gillman LM, Blaivas M, Lord J, et al. Ultrasound confirmation of guidewire position may eliminate accidental
arterial dilatation during central venous cannulation. Scand J Trauma Resusc Emerg Med 2010; 18:39.
70. Gu X, Paulsen W, Tisnado J, He Y, Li Z, Nixon JV: Malposition of a central venous catheter in the right main
pulmonary artery detected by transesophageal echocardiography. J Am Soc Echocardiogr 2009; 22:1420
71. Sawchuk C, Fayad A. Confirmation of internal jugular guide wire position utilizing transesophageal
echocardiography. Can J Anaesth 2001; 48:688.
72. Lucey B, Varghese JC, Haslam P, Lee MJ. Routine chest radiographs after central line insertion: mandatory
postprocedural evaluation or unnecessary waste of resources? Cardiovasc Intervent Radiol 1999; 22:381.
73. Gebhard RE, Szmuk P, Pivalizza EG, et al. The accuracy of electrocardiogram-controlled central line
placement. Anesth Analg 2007; 104:65.
74. Abood GJ, Davis KA, Esposito TJ, et al. Comparison of routine chest radiograph versus clinician judgment to
determine adequate central line placement in critically ill patients. J Trauma 2007; 63:50.
75. Lessnau KD. Is chest radiography necessary after uncomplicated insertion of a triple-lumen catheter in the
right internal jugular vein, using the anterior approach? Chest 2005; 127:220.
76. Wirsing M, Schummer C, Neumann R, et al. Is traditional reading of the bedside chest radiograph appropriate
to detect intraatrial central venous catheter position? Chest 2008; 134:527.
77. Francis KR, Picard DL, Fajardo MA, Pizzi WF. Avoiding complications and decreasing costs of central venous
catheter placement utilizing electrocardiographic guidance. Surg Gynecol Obstet 1992; 175:208.
78. Guilbert MC, Elkouri S, Bracco D, et al. Arterial trauma during central venous catheter insertion: Case series,
review and proposed algorithm. J Vasc Surg 2008; 48:918.

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