INTENSIVE CARE
Central venous
cannulation
Peter B Williamson
C Stephanie Cattlin
Abstract
Central venous cannulation using the basic principles of the Seldinger
technique is a core skill for anaesthetists and critical care doctors in
situations where intravenous access is difficult or multiple infusions
are required. While potentially lifesaving, central venous cannulation
carries the risk of serious morbidity (or even mortality). Mitigating
these risks through aseptic technique, ultrasound guidance and timely
management of complications is vital.
Keywords Central venous line; seldinger; ultrasound
Royal College of Anaesthetists CPD Matrix: 2A04, 2C04
Central venous cannulation comprises safely introducing devices
into a large vein using the Seldinger technique. The common
sites used are the internal jugular, subclavian and femoral veins
and devices range from the most simple single lumen catheters
though to multi-lumen central lines, catheters for haemofiltra-
tion, trauma lines for rapid transfusion, and sheaths to float
pacing wires or pulmonary artery catheters. Other specialities
increasingly defer this procedure to anaesthetists and/or inten-
sivists given the potential for life threatening complications.
Indications
The common indications for central venous cannulation are for
advanced venous access (when peripheral access fails or for
multiple incompatible infusions which make multiple points of
peripheral access impractical) and for the administration of
venotoxic drugs that require high blood flow to dilute the drug
(such as concentrated electrolytes, inotropes, vasopressors,
amiodarone and total parenteral nutrition).
Less common indications include monitoring trends in central
venous pressure (although the association with filling status is
poor) and haemofiltration using a vascath to facilitate renal
replacement therapy.
Rarer situations requiring central access include large bore
access using a trauma line during massive haemorrhage, insert-
ing sheaths to facilitate floating either a pulmonary artery cath-
eter or pacing wires, or in an emergency to aspirate an air
embolism from the right atrium.
Peter B Williamson MBBS BSc FRCA is a Consultant Anaesthetist at
Imperial College Healthcare NHS Trust, London, UK. Conflicts of
interest: none declared.
C Stephanie Cattlin MBBS BSc FRCA FFICM is a Consultant in Intensive
Care Medicine at Imperial College Healthcare NHS Trust, London,
UK. Conflicts of interest: none declared.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 19:12
Learning objectives
After reading this article, you should be able to:
C list the different indications for central venous cannulation
C describe the step-by-step process of central venous line
insertion
C outline situations where line placement is awkward and
describe solutions
C list complications of central line placement and outline how to
manage them
Technique
1. Check blood test results especially platelets and clotting.
2. At the preoperative visit, take a standard medical history and
ask specifically about lying flat, claustrophobia, also check
that respiratory function is sufficient, and note any agitation
or confusion.
3. Explain the procedure and take informed consent.
4. Full monitoring should be applied during the procedure
(pulse oximetry, three lead ECG, non-invasive blood pres-
sure monitoring), peripheral access made available (if
possible).
5. Set up the ultrasound scanner (recommended by NICE1) and
consider a ‘pre-scan’ to exclude anatomical variants
requiring expert help.
6. Position the patient, scrub, don gloves and a gown, establish
aseptic field including ultrasound probe cover.
7. Prepare the central line by flushing all lumens with
saline.
8. Infiltrate local anaesthetic (usually 1% lignocaine) to target
skin insertion point.
9. Use ultrasound to scan the vein, then insert the needle or
cannula with constant aspiration.
10. On aspirating venous blood either slide the cannula over the
needle or thread the guidewire. If using a cannula, confirm
venous blood aspirates, then thread the guidewire.
11. Use ultrasound to confirm guidewire is in the vein and the
wire moves freely.
12. Position dilator ready for use, make a small incision in the
skin following the wire.
13. Railroad the dilator to create a tract from skin to vein, then
remove and apply firm pressure.
14. Railroad the central line using the distal lumen with care to
control the end of the wire.
15. Confirm guidewire removed with assistant.
16. Confirm you can aspirate venous blood from, and flush each
port.
17. Apply clips and hub, suture both in place.
18. Apply dressing, use the paper section of the dressing to
indicate the date of insertion.
19. Document the line insertion and any complications in the
patient’s notes.
20. Order post-procedure CXR (for lines placed in the internal
jugular or subclavian veins: check for line direction, depth
and pneumothorax.
For troubleshooting common problems encountered, see Table 1.
627 Ó 2018 Elsevier Ltd. All rights reserved.
 INTENSIVE CARE

Common line insertion problems Table 1 (continued )

Problem Issue Solution Problem Issue Solution

Unable to cannulate, Too medial or lateral Pull needle back to Proximal port will not Consider line not fully If still under aseptic
needle shadow angled just under skin, use aspirate on inserted in vein conditions: push line
away from vessel US to reangle towards line in further
vein If post-procedure:
Unable to cannulate, Likely double Pull need back while may need new line
needle shadow puncture aspirating to open up Other ports will not Line may be abutting Consider advancing or
directly in line with vein again aspirate on inserted vein wall withdrawing 1 cm or
vein, sufficient depth In future: avoid line rotating
obtained pressure with US Port aspirates bright Line has been Leave line in place
probe, tear through red blood with syringe inadvertently placed and do not use,2
vein wall with decisive self-filling in an artery contact vascular
jab rather than surgery urgently
smooth pressure
Cannulated, guidewire Partial cannulation Confirm needle Table 1
won’t thread beyond position on US, make
needle tip small angular and Complications of central venous cannulation
rotational
adjustments until C Due to positioning: hypoxia, discomfort, claustrophobia
good flow, then C Damage to surrounding structures: co-located arteries, lungs,
rethread wire thoracic duct, brachial plexus, thyroid, trachea, abdominal cavity
Cannulated, guidewire Distorted or Confirm most C Guidewire related: arrhythmias, pericardial tamponade, trauma to
threads beyond obstructed anatomy proximal wire vessel, retained wire
needle tip but then placement on C Exposing the vein to the atmosphere: air embolism, bleeding
meets resistance ultrasound, but do not C Malpositioned lines: arterial, intrapleural, unintended proximal
force wire. Consider direction
contacting C Length of placement: infection with or without a biofilm, throm-
interventional bosis, catheter fracture
radiology
Box 1
Cannulated, syringe Arterial puncture Remove needle/
self filling with blood, cannula, apply firm Complications
on removal of syringe pressure for 5 min
Complications of central venous cannulation occur in approxi-
small central ‘jet’ of then re-scan to assess
mately 15% of patients3 and can result in serious morbidity or
blood visualized anatomy
even mortality. They are classified either by cause or temporality
Guidewire threaded, Wire threaded too far Withdraw the wire
as listed in Box 1. If they occur, conduct a full assessment of the
ectopics on ECG and and is stimulating the until ectopics cease
patient and seek expert help from the appropriate team (anaes-
irregular pulse right atrium or
oximetry trace ventricle
thetics, vascular surgery, cardiothoracics or cardiology). A
Guidewire has Either insufficient Revise incision
threaded, unable to incision with scalpel Pull wire back to REFERENCES
dilate, wire has blade assess wire distortion, 1 NICE. Guidance on the use of ultrasound locating devices for
resistance Or kink in wire decide whether to placing central venous catheters. 2002. October 2002, https://
preventing passage of continue or www.nice.org.uk/guidance/ta49/resources/guidance-on-the-use-
dilator recannulate with a of-ultrasound-locating-devices-for-placing-central-venous-
new wire catheters-pdf-2294585518021.
Dilated, wire totally Insufficient dilation Redilate further with 2 Gibson F, Bodenham A. Misplaced central venous catheters:
free, but line won’t small twisting applied anatomy and practical management. Br J Anaesth 2013;
railroad movements 110: 333e46. https://doi.org/10.1093/bja/aes497.
None of the ports will Line is not in a vessel Transduce to confirm 3 Eisen LA. Mechanical complications of central venous catheters.
aspirate on inserted no venous trace then J Intensive Care Med 2006; 21: 40e6. https://doi.org/10.1177/
line remove and insert a 0885066605280884.
new line. Consider
FURTHER READING
pneumothorax
Association of Anaesthetists of Great Britain & Ireland Guidelines:
https://www.aagbi.org/sites/default/files/AAGBI_Safer_Vascular_
Access_2016.pdf.

ANAESTHESIA AND INTENSIVE CARE MEDICINE 19:12 628 Ó 2018 Elsevier Ltd. All rights reserved.