Central Venous Catheter (CVC)

A CVC places its tip in a great vein. Confirm venous access and tip position, and keep the site clean.

A central venous catheter (CVC) goes into a venous great vessel. ASA 2020 names these: the superior or inferior vena cava, brachiocephalic vein, internal jugular vein, subclavian vein, iliac vein or common femoral vein. This page covers non-tunneled CVCs. Tunneled and dialysis catheters, pulmonary artery catheters and PICCs are outside the ASA 2020 guideline, so they are not covered here.

How It Works

• Venous access: The needle gets into the vein. The guidewire goes in next. The dilator and catheter follow the wire.
• Tip position: Confirm the tip before use. Chest radiography is what ASA 2020 uses for OR placement. Ultrasound, fluoroscopy, continuous ECG and transesophageal echocardiography are also listed as verification methods.

Where It Fits

Start with peripheral access when it works (see IV Insertion). SSC 2021 suggests starting vasopressors peripherally instead of delaying them for central access. If the drug is still needed, move it to central infusion. Intraosseous access is on the IO Access page.

Indications

• Vasopressor still needed after the short peripheral phase: SSC 2021 suggests central infusion as soon as it is practical, if resources are available. The point is fewer complications.
• Protocol-defined need: ASA 2020 does not define indications. Use clinical judgment and local protocol. Document the specific need.

Absolute Contraindications

Do not use a site with burned or infected skin.

Relative Contraindications & Cautions

• Femoral site in adults: Pick an upper-body site when you can. ASA 2020 links the femoral site to a higher risk of thrombotic complications.
• Potentially contaminated sites: Avoid the inguinal area, a site next to a tracheostomy, or a site beside an open surgical wound when an alternative exists. ASA 2020 advises avoiding potentially contaminated sites when possible.
• Chlorhexidine allergy: Use povidone-iodine or alcohol for skin preparation per ASA 2020.
• Coagulopathy: ASA 2020 does not address coagulopathy at insertion, so set correction targets by local protocol. Note anticoagulation or coagulopathy before the puncture. Expert practice generally leans toward a compressible site, the internal jugular or femoral, with real-time ultrasound and the fewest passes. Bleeding from the subclavian cannot be compressed. That is general consensus, not ASA.
• Infants and children: See Special Populations for site and confirmation differences.

Consider an Alternative

• Peripheral IV: Short-term vasopressor infusion through a peripheral vein per SSC 2021; see IV Insertion.
• Intraosseous access: When IV access fails in shock or arrest, follow IO Access and local protocol.

Abort / Stop Criteria

• Sterility breach: Aseptic technique breaks? Any team member should be able to stop the procedure, per SHEA 2022.
• Wire will not advance or will not come out: Do not force it. Consult per local protocol. ASA 2020 lists interventional radiology or surgical consultation for a wire knot or a catheter that will not come out.
• Arterial cannulation: Stop advancing, leave the dilator or catheter in place and consult per ASA 2020.

Team Roles During the Procedure

• Operator: Selects the site, performs the puncture and places the catheter.
• Sterile assistant: Helps during placement and keeps the sterile field organized (ASA 2020 recommends an assistant).
• Ultrasound and monitor: Runs the ultrasound, watches the ECG and the patient, and reports changes.
• Recorder and checker: Runs the checklist, records the attempts, confirmation method and the wire count.

Pick the site by clinical need, infection risk and mechanical risk. ASA 2020 frames it that way.

Internal Jugular

1. Scan first: Use static ultrasound before prep to identify the vein and check patency per ASA 2020.
2. Position: Use Trendelenburg when clinically appropriate and feasible per ASA 2020. The evidence is too thin to show it improves success.
3. Puncture under real-time ultrasound: Real-time ultrasound is what ASA 2020 recommends for the puncture when you choose the internal jugular.
4. Confirm venous access: Use manometry or pressure waveform before the wire or dilator.

Pediatric

Kids' right internal jugular runs wider in Trendelenburg than supine. Observational pediatric studies say so, per ASA 2020. Get sizes from the equipment sizing page.

Subclavian

1. Choose the site: In the ICU, SHEA 2022 prefers the subclavian site to reduce infectious complications. Avoid it in patients who are or may need hemodialysis, because of stenosis risk. Choose with nephrology when dialysis is possible. In an emergency, the fastest safe route may take priority.
2. Position: Use Trendelenburg when clinically appropriate and feasible per ASA 2020.
3. Use ultrasound when feasible: Real-time ultrasound may be used for the subclavian vein, per ASA 2020. SHEA 2022 calls ultrasound guidance essential for insertion. It also notes that ultrasound use can risk a breach in aseptic technique.
4. Select the technique: ASA 2020 picks a thin-wall (Seldinger) needle for the subclavian approach.

Pediatric

Technique is the same as for adults. In neonates, infants and children, venous confirmation may come after the wire is threaded, per ASA 2020.

Femoral

1. Check for an upper-body option: In adults, use an upper-body site when possible per ASA 2020.
2. Check the groin: ASA 2020 counts the inguinal area as potentially contaminated.
3. Use ultrasound when feasible: Real-time ultrasound may be used for the femoral vein per ASA 2020.
4. Consider the thrombotic risk: RCTs show no clear difference in mechanical complications between femoral and subclavian, per ASA 2020. In adults, though, the femoral site carries the higher thrombotic risk.

Pediatric

SHEA 2022 says a femoral catheter may be considered in children and infants when upper-body sites are contraindicated. A tunneled femoral catheter with the exit site in the mid-thigh, outside the diaper area, may be safer.

Equipment

Sizing

Use the smallest outside diameter appropriate for the clinical situation per ASA 2020. Pediatric sizing by weight is on Equipment Sizing and Pediatric Vascular Access.

Patient Positioning & Preparation

• Positioning: Trendelenburg for neck or chest access when clinically appropriate and feasible per ASA 2020.
• Hand hygiene: Use alcohol-based hand rub or soap and water before insertion. Gloves do not replace hand hygiene per SHEA 2022.
• Assistant: Use an assistant during placement per ASA 2020.

These are typical adult and pediatric references. Check them against local protocol and current drug labeling. Doses vary by protocol; follow local protocols and medical direction.

Phase 1: Prepare

1. Confirm the need and the site: Document the indication. Choose a site that is not contaminated; in adults use an upper-body site when possible per ASA 2020.
2. Run the checklist: Use a checklist or protocol and assign an assistant per ASA 2020. SHEA 2022 asks each facility to have such a process in place.
3. Scan before prep: Use static ultrasound to find the vein and check patency before draping per ASA 2020.
4. Hand hygiene and barrier: Perform hand hygiene. Everyone wears a mask, cap, sterile gown and sterile gloves, and the patient gets a full-body drape per SHEA 2022.
5. Apply antiseptic: Apply alcoholic chlorhexidine of at least 2% gluconate and let it dry before the puncture per SHEA 2022.

Phase 2: Perform

6. Position the patient: Use Trendelenburg for neck or chest access when clinically appropriate and feasible per ASA 2020.
7. Anesthetize within limits: Infiltrate lidocaine within the label limits (see Medications & Settings).
8. Puncture under real-time ultrasound: Use real-time ultrasound for venipuncture when the internal jugular is chosen; use it for the subclavian or femoral vein when feasible per ASA 2020.
9. Confirm venous access: Use manometry or pressure waveform. Do not rely on blood color or absent pulsatile flow per ASA 2020.
10. Thread the wire and confirm it: With the thin-wall technique, confirm the wire is in the vein after it is threaded per ASA 2020.
11. Dilate and place the catheter: Advance the dilator and the smallest appropriate catheter over the wire per ASA 2020.
12. Remove the wire and count it: Confirm the complete guidewire is out of the field. If it is not found, order a chest radiograph per ASA 2020.

Phase 3: Confirm & Secure

14. Confirm the tip: Use continuous ECG during placement, a chest radiograph, or ultrasound, as local protocol allows per ASA 2020. See Confirmation & Monitoring.
15. Secure and dress: Fix the catheter by local practice, with as few skin punctures as possible. Apply a transparent bioocclusive dressing; a chlorhexidine-containing dressing is allowed per ASA 2020.
16. Cap the hubs: Use antiseptic-containing caps on every connector per SHEA 2022.

Alternative Technique: Catheter-over-the-Needle

1. Advance with manometry: Advance the catheter over the needle and use manometry or pressure waveform to confirm venous entry per ASA 2020.
2. Check the wire when unsure: If there is any uncertainty, confirm the wire is in the vein after threading, before the dilator per ASA 2020.
3. Choose by site: For the subclavian approach, ASA 2020 picks a thin-wall technique. For the jugular or femoral approach, the choice depends on skill and the situation.

Primary Confirmation

Confirm the tip as soon as it is clinically appropriate. Use a chest radiograph, continuous ECG during placement or ultrasound, per protocol, per ASA 2020. In RCTs, continuous ECG during placement identifies tip position better than no ECG, per ASA 2020.

Target Tip Position

In an adult upper-body CVC, the usual target sits in the lower third of the superior vena cava or the cavoatrial junction, with the tip parallel to the vessel wall. Keep it out of the right atrium and ventricle, and off the vessel wall. This target is general practice, not ASA 2020 wording. Confirm it against local protocol.

• Chest radiograph: Read the tip against the carina. Your target, the lower SVC or cavoatrial junction, sits at or just above it.
• Common malpositions: Contralateral brachiocephalic vein; ipsilateral internal jugular or azygos vein; too deep in the right atrium or ventricle (arrhythmia risk).
• ECG (general practice): Watch the P wave. It peaks near the cavoatrial junction. Biphasic or negative P waves suggest the tip has entered the right atrium.

Secondary Confirmation

• Venous pattern: Manometry or pressure waveform shows a venous pattern before the dilator.
• Wire accounted for: The complete guidewire is in the procedural field after removal per ASA 2020.
• Pneumothorax excluded: A chest radiograph or transthoracic ultrasound, per protocol; ASA 2020 cites high specificity for transthoracic ultrasound.
• Dressing intact: Transparent dressing secure and dry per SHEA 2022.

Ongoing Monitoring

• Each shift: Inspect the site for signs of infection and check the dressing per ASA 2020 and SHEA 2022.
• Daily: Assess whether the line is still needed and remove it promptly when it is not per ASA 2020.
• Before each access: Disinfect the hub, needleless connector and injection port per SHEA 2022.

Pediatrics

• Femoral site: In infants and children, a femoral catheter may be considered when upper-body sites are contraindicated, per SHEA 2022.
• Venous confirmation: In neonates, infants and children, you may confirm venous placement after the wire is threaded, per ASA 2020.
• Dressing: For CVCs in patients over 2 months of age, use a CHG-containing dressing, per SHEA 2022. Neonatal skin prep follows institutional protocol, per ASA 2020.
• Sizes and doses: See Equipment Sizing, Pediatric Vascular Access, and Weight-Based Dosing.

Dialysis Patients

• Scope: Tunneled lines, dialysis catheters included, sit outside the ASA 2020 guideline. Follow the hemodialysis page and nephrology protocol.
• Site care: For hemodialysis catheters, SHEA 2022 recommends an antimicrobial ointment at the insertion site.
• Subclavian for CVCs: SHEA 2022 says the subclavian site is avoided in patients receiving or likely to need hemodialysis, because of stenosis risk. Choose the site with nephrology and protect the AV-fistula arm. In an emergency, the fastest safe route may take priority.

Pregnancy

• Positioning: Use left lateral tilt when feasible (general practice, protocol-dependent).
• Site: Prefer an upper-body site with ultrasound guidance, such as the internal jugular (general practice, protocol-dependent).

Physiologically Difficult

• Shock: SSC 2021 suggests starting vasopressors peripherally, rather than waiting until central access is secured.
• Fluid decisions: SSC 2021 says heart rate, CVP and systolic blood pressure alone are poor indicators of fluid status. Reach for dynamic measures instead.

Immediate Aftercare

• Tip confirmation: Confirm the final tip position as soon as clinically appropriate per ASA 2020.
• Site check: Inspect the site and dressing; the dressing must be intact and dry per SHEA 2022.

Ongoing Maintenance

• Dressing: Transparent every 7 days or at once if soiled, loose or damp; gauze every 2 days per SHEA 2022.
• Hubs: Disinfect hubs and connectors before each access; keep caps on per SHEA 2022 and ASA 2020.
• Administration sets: Replace at intervals up to every 7 days, except for blood, blood products or lipid formulations per SHEA 2022.
• Daily bathing: Bathe ICU patients older than 2 months with a chlorhexidine preparation every day per SHEA 2022.
• Need: Assess daily and remove the catheter promptly when it is not needed per ASA 2020.
• Removal: At removal, use Trendelenburg, Valsalva, direct pressure and an air-occlusive dressing, and monitor for a period after removal per ASA 2020.

Transport Considerations

• Site check after each move: Check the dressing and site; change the dressing if soiled, loose or damp per SHEA 2022.
• Existing line (general practice): Verify blood return and a free flush before use, scrub the hub before each access, keep air out of the line, and secure the line and tubing for transfer. Do not infuse through a line you cannot verify.

Handoff & Documentation

Pearls

• Ultrasound first: The meta-analyses ASA 2020 cites favor real-time ultrasound at the internal jugular. First-attempt and overall success both go up, compared with the landmark approach.
• ECG for the tip: In RCTs, continuous ECG finds proper tip placement better than no ECG, per ASA 2020.
• Chlorhexidine for skin and dressing: Alcoholic chlorhexidine goes on the skin. CHG dressings are for patients over 2 months, per SHEA 2022.
• Ask every day: Is the line still needed? If not, take it out, per ASA 2020.

Common Pitfalls

• Dark blood taken as proof → confirm with manometry or pressure waveform per ASA 2020.
• Dilating before venous confirmation → confirm first, then dilate per ASA 2020.
• Losing track of the wire → count it; chest radiograph if it is missing per ASA 2020.
• Routine replacement to prevent infection → do not routinely replace CVCs per SHEA 2022.
• Femoral site in adults → use an upper-body site when possible per ASA 2020.
• CVP alone for fluids → use dynamic measures per SSC 2021.

Skill Maintenance

• Sequence rehearsal: Rehearse the ASA 2020 sequence: static scan, real-time puncture, venous confirmation, wire count.
• Checklist: Use the checklist or protocol at every practice run per ASA 2020.
• Competency: SHEA 2022 recommends education and competency assessment. It covers everyone who inserts, cares for or maintains CVCs.