Primary Authors: Satchel Genobaga and Jonathan Cleek; Co-Author: Victor Lee. Oversight, Review, and Final Edits by Vi Dinh (POCUS 101 Editor).
Central line placement is an essential tool health providers must learn to care for critically ill patients. Using ultrasound to guide your central line placement can reduce the time needed to complete the procedure, the number of mechanical complications, and the number of catheter misplacements (McGee, D., Gould, M.). So why doesn’t every central line placement include ultrasound guidance? Well, often, beginners or those needing a refresher find it challenging to find a relevant, descriptive, yet concise step-by-step guide on how to perform an ultrasound-guided central line placement. Luckily, you have come to the right place!
At the end of this article, you will be able to:
- Perform a preparatory scan before the central line placement.
- Cannulate the internal jugular, subclavian, and femoral vein central line under ultrasound guidance.
- Confirm the placement of the needle, guidewire, and catheter.
Indications and Contraindications
Some of the indications for central venous line placement include (Smith, R., Nolan, J.):
- Poor peripheral access
- Vasopressor requirements
- Parenteral nutrition
- Infusion of irritant drugs
- Dialysis (renal replacement therapy)
- Plasma exchange
- Frequent lab draws
- Hemodynamic monitoring
What Central Vein Site Should You Choose?
You will be cannulating the internal jugular vein the vast majority of the time. However, there are a couple of other options. This post will primarily cover the right internal jugular vein, but we will cover the other options briefly later. You should use an alternative vein if there is the presence of a thrombus, infection, distorted anatomy, or extensive scarring at the internal jugular vein (Schmidt, G., et al.).
Here are some of the contraindications to central line placement:
- Local infection
- Coagulopathy (relative contraindication)
*Ultrasound provides the advantage of viewing the vessel to rule out thrombosis or stenosis prior to initiating the procedure.
The patient should be placed in Trendelenburg position: Supine and tilted 15-20º with their feet elevated above their head. Tilt the patient’s head slightly opposite of the side that you want to scan.
Ultrasound Machine Preparation
- Transducer: Linear Ultrasound Probe
- Preset: Vascular Access or Venous Preset
- Ultrasound Machine Placement: Place the ultrasound machine on the same side of the patient you are going to cannulate. Face the machine when you are behind the patient. This way, your eyes, hand, patient landmark, ultrasound probe, and ultrasound screen are all on the same axis.
- The ultrasound probe marker should be facing your left. This ensures that moving the probe to the left will shift the ultrasound image to the left on the screen.
- Hold the probe with your left hand. Your right hand will be free to grab equipment or change settings on the ultrasound machine.
Central Line Equipment List
Here is a list of materials you will need. If you are busy, you can ask the nurse or tech to help obtain these:
- Procedure table
- Trash bin
- 3 claves
- 3 vials of 10 cc’s of saline
- Sterile ultrasound probe cover kit
- Cap, mask, gloves
- Sterile gown
- ChloraPrep/chlorhexidine (If CVL kit does not have)
- Biopatch (If CVL kit does not have)
- Lidocaine (If CVL kit does not have)
- Sterile dressing/Tegaderm dressing (If CVL kit does not have)
- Central Line Kit (should contain the following):
- Sterile drape
- 1% lidocaine without epinephrine
- 5 mL syringe
- 18-ga needle
- Scalpel with 11-blade
- Triple-lumen catheter* (or introducer catheter/Cordis)
- Silk suture
- Needle driver
- Tegaderm dressing
*The correct catheter length will be based on which anatomical site you are using. The best length for the right internal jugular vein (the site mainly discussed in this post) is the 16 cm catheter.
Complete Pre-Procedure Setup
Place the table between yourself and the ultrasound machine so you can quickly and comfortably access its contents. Do not open the central line kit until the sterile field has been set up. Make sure you have all of the other equipment ready for use.
For internal vein cannulation, the ultrasound machine goes on the same side of the patient you will be cannulating. That way, when you are facing the machine, your eyes, hand, patient landmark, ultrasound probe, and ultrasound screen are all on the same side.
Ultrasound Pre-scan Technique:
- Prepare the ultrasound transducer by applying gel to its end.
- Place the transducer on the skin using the general landmark of the area between the sternal and clavicular heads of the sternocleidomastoid muscle (SCM) above the clavicle. The boundaries of the sternal head of the SCM, clavicular head of the SCM, and clavicle form what is called Sidellot’s Triangle, which is the landmark we are aiming for here.
- Approach the neck with the probe as superiorly as possible while maintaining perpendicular contact with the skin. This would equate to placing the transducer at the “top” or “apex” of Sidellot’s Triangle.
- Align the transducer along an axis that is perpendicular to the vessels. This alignment will produce a transverse view of the vessels. This view is known as the short axis. You should see two darker, nearly round structures on the screen. These are the internal jugular vein and the common carotid artery.
When you are pre-scanning a patient before performing the ultrasound procedure, you want to ensure you have an ideal vessel to cannulate. The three things you should evaluate for in the vein are size/collapsibility, position, and the presence of a thrombus.
Internal Jugular Vein Size and Collapsibility
The first thing you should do when looking at the internal jugular vein (IJ) site is to evaluate its size and collapsibility. Sometimes a very dehydrated patient may have a small and collapsible internal jugular vein, making it difficult to cannulate.
Sometimes placing the patient in Trendelenburg or giving a fluid bolus will help increase the size of the internal jugular vein.
Also, some patients may have had multiple central line procedures in the past, causing their IJ to be sclerotic and stenosed. If this is the case, you may want to choose an alternative site.
Optimize Internal Jugular Vein Position
The best position of the internal jugular vein is when it is laterally displaced from the common carotid artery. If the vein is directly over the artery, it increases the risk of an arterial puncture because the needle can accidentally puncture the posterior wall of the vein. If the patient’s head is turned too far to the contralateral side, it can cause the vein to come directly over the artery (Maecken, T., et. al.; Lamperti, M., et. al.).
Usually, the vein will be anterior and lateral to the artery. However, that is not always the case. Scan up and down the neck to find that optimal view. If you cannot find it, the patient may have an anatomical variation, and it is worth considering a different anatomical site (Maecken, T., et. al.; Lamperti, M., et. al.).
Rule Out Internal Jugular Vein Thrombus
It is essential to confirm the vein’s patency and rule out the presence of a thrombus in the vein. First, the lumen of a patent vessel will appear “black” (anechoic) versus a thrombus that will have some echogenicity. Second, the thrombus will also prevent or alter the vein’s ability to be compressed. Lastly, it is possible to detect thrombi using the color doppler view on the ultrasound. If a thrombus is identified, always use a different site, whether it be the contralateral side or a different central vein.
Ultrasound-Guided Central Line Placement Steps
Step 1: Procedural Preparation
Before you start the procedure, we have found the following actions are crucial to performing an ultrasound-guided central line:
- Put on cap, mask, and non-sterile gloves.
- Turn patient’s head to the contralateral side and apply ChloraPrep.
- Open procedure kit and place all sterile items that do not come with kit inside: Biopatch, dressing, claves, and probe cover.
- Remove non-sterile gloves.
- Put on sterile gown and sterile gloves.
- Place sterile drape on top of the patient.
Step 2: Central Line Equipment Setup
Now that the patient is draped and you are sterile, let’s work on setting up our central line equipment on the table. We have found that arranging your equipment from left to right in a sequential organization allows for the safest, quickest, and most efficient placement of a central line once you begin.
Here is how you should set up your Central Line Equipment from Left to Right:
- Sterile ultrasound probe cover with sterile gel
- Lidocaine with needle and syringe
- 18 gauge Introducer needle attached to 5 mL syringe
- Gauze (very important to control bleeding after the guidewire is placed)
- Scalpel (11 blade)
- Tissue dilator
- Central line (triple lumen in this post)
- Sterile flushes
- Catheter clamp
- Suture and needle driver
- Tegaderm dressing
Here is how you, the CVL kit, and the patient should be set up. (Note: This is a demo image so the operator is not sterile, make sure to put on sterile gown, cap, and gloves prior to initiation of the procedure.)
Step 3: Put Ultrasound Probe Cover On
- Open up the sterile ultrasound sheath.
- Place your non-dominant hand in the open end and invert the sheath over your dominant hand.
- With the dominant hand covered with the sheath, grab the ultrasound probe from the top.
- With the other hand, unfurl the rest of the sheath down the probe wire like a sock.
- Smoothen out any air bubbles present between the sheath and the probe tip.
- Secure the sheath over the probe using the rubber bands. Secure one rubber band around the neck of the probe and the other around the probe’s base where it meets the wire. The second rubber band keeps the sheath from slipping around.
After all of these steps, the setup should look like this:
Step 4: Mapping the Vein
- Apply the sterile gel (usually in a silver packet) onto the patient’s skin where you are about to scan.
- Once again, locate the vessels that you identified in the pre-procedure scan.
- Re-familiarize yourself with the patient’s anatomy and differentiate the artery and vein using compression.
- Slide the probe up and down to map out the trajectory of the vein. Be sure that the vein is always in the center of the screen. This is important to ensure that your probe is oriented correctly (whether in short or long axis) and that your needle’s path is actually in line with the vein.
ALERT: If you don’t have the correct trajectory of the vein, scanning up and down will look something like the image below.
Step 5: Insert Introducer Needle Under Ultrasound Guidance
First, anesthetize the area with the provided lidocaine using the smaller syringe and the smaller needle.
After you anesthetize the area but before you start the cannulation, you will need to properly hold the larger syringe.
- Take the large bore cannulation needle and attach it to the larger syringe.
- Have the open side of the bevel aligned with the numbers on the syringe. This way, once the needle is in the vessel, you know where the bevel opening is pointing.
- Hold the syringe between your index and middle finger.
- Have your thumb in between these fingers ready to push the base of the syringe as your fingers pull the plunger away from the syringe to aspirate.
- As you enter the needle into the skin, you will continue to aspirate until you see a flash of blood.
Next you will use either the short axis or long axis approach:
|Short Axis||Center of vessel easily visible|
Easier hand-eye coordination
Better lateral field of view
|Difficult to see the tip of the needle|
|Long Axis||Able to see the whole length of the needle|
|May be technically challenging for beginners|
While a long axis approach can be used to cannulate the vessel, it is technically more challenging. We recommend using the short axis approach when starting out. However, after both are mastered, the long axis view may be more efficient and may lead to fewer needle redirections than the short axis view for internal jugular vein cannulation (Vogel, J., et. al., Stone, M., et. al.).
Step 5a: Short (Transverse) Axis Approach
- Locate the vein entry site using ultrasound. Find a place along the vessel that you would like the needle to penetrate. Measure the depth of the vessel.
- Locate the skin puncture site. Use the depth of the vessel you just measured and track that same distance away from the center of the probe. For example, if the vein is 2 cm deep, the best skin puncture site is 2 cm away from the probe.
- Angle the needle 45º.
- Slide the probe back to the skin puncture site.
- Puncture the skin right underneath the center of the ultrasound probe.
- Advance the needle using “Creep Method” (see below for illustration). For this view, you must never lose sight of the tip of the needle. The tip of the needle will appear as a bright hyperechoic (white) dot. Because this view gives a cross-sectional view of the needle, the shaft will look just like the tip. After you advance the needle slightly, fan the probe away from the needle until the dot disappears. This is how you can confirm that the dot is actually the tip. Only after you see the tip can you advance the needle farther. Each time you advance the needle, repeat this process of fanning the probe away from the needle tip then back towards it until you find the tip. If fanning the probe does not cause the dot the disappear, then instead slide the probe away from the needle until the dot disappears and resume fanning to find the needle tip.
- Look for anterior wall “tenting.” Once you advance the needle far enough, the needle will push into the anterior wall of the vessel, as shown to the right. Once you see this, move on to the next step. You are on the right track!
- Change the angle of the needle to 20-30º. This decreases the chance of penetrating the posterior wall of the vein.
- Advance the needle until you see a flash of blood.
- Make sure the tip of the needle is in the center of the lumen. This will ensure that the guidewire goes in smoothly.
…never lose sight of the tip of the needle.
Step 5b: Longitudinal Axis Approach
- For this approach, turn the probe 90º clockwise so that the probe indicator is pointing toward the syringe.
- Insert the needle directly under the probe at a 45º angle.
- Keep the probe still and never lose sight of the needle.
- Advance the needle slowly and stop if the needle tip is lost from view.
- Advance the needle until a flash of blood is seen in the syringe.
- Make sure the tip of the needle is in the center of the lumen.
Pitfall: Inserting the guidewire when the needle bevel has only partially penetrated the vessel. This can happen even after a flash of blood in the syringe and can lead to hematoma.
Tip: To avoid this, use ultrasound to confirm the tip of the needle is in the center of the vessel lumen.
Step 6: Insert the Guidewire and Confirm its Position
Keep a tight hold on the needle. Put down the ultrasound probe in the sterile field. With the same hand you used to hold the probe, grab the base of the needle with your thumb and index finger while anchoring your hand against the patient with your pinky. Twist off the syringe with the other hand while keeping the needle secure.
Insert the guidewire into the base of the needle and feed it through slowly. It should enter the vessel smoothly with no resistance.
Pitfall: Entering the guidewire too far can irritate the heart and potentially cause arrhythmias.
Pick the probe back up and confirm the position of the guidewire in the lumen of the vein (Saugel, B., et. al.). This should be done using both the short and longitudinal axis approach.
Pitfall: Losing the guidewire.
Tip: During the entire central line placement, always have one hand holding and securing the guidewire.
Step 7: Dilate the Vessel
- Take the scalpel and nick the skin approximately 0.5 cm adjacent to the guidewire. Have gauze ready for subsequent bleeding.
- Feed the dilator over the guidewire at approximately 5-10º relative to the skin. (Decreasing the angle will prevent guidewire kinking).
- Drive it through the skin and vessel by twisting it in a clockwise motion. It should go in smoothly with minimal resistance.
- Feed the dilator through approximately 2/3rds of its length. Remove the dilator.
Tip: Have gauze ready during this whole step to manage bleeding.
Step 8: Insert the Central Line
- Insert the central line catheter over the guidewire, making sure not to allow the guidewire to slip.
- If using a triple-lumen catheter, clamp the proximal and medial ports. The guidewire should go through the distal port.
- Feed the catheter through up to the desired length. A common principle is to feed it through up to the “15” mark on the catheter when using the right internal jugular vein, indicating that the catheter has been fed 15 cm into the vessel.
- Pull out the guidewire, attach the claves, and flush all three lines with sterile saline.
Step 9: Secure and Dress the Central Line
- Place the clip over the catheter where it inserts the skin.
- Suture the clip in place.
- Put the Biopatch over the site.
- Finally, put the Tegaderm over the site.
Step 10: Confirm Proper Central Line Placement
The common practice is to get a chest x-ray after the catheter insertion to confirm that the tip is in the correct location.
An alternative to a chest x-ray which has been shown to be effective, efficient, safe, and specific, is to confirm catheter tip placement with ultrasound. Because of the sterile field, this will need to be done by a second operator. If one is unavailable, use a chest x-ray and move on to step 11.
- With the phased array probe, obtain a subxiphoid or apical 4-chamber view of the heart (details of how to obtain these views are explained in another post here: subxiphoid or apical 4-chamber).
- Push 5cc of non-agitated normal saline through the brown port of the catheter. If the catheter is placed correctly, there will be hyperechoic, turbulent flow in the right atrium (Wilson, S., et. al.).
Step 11: Check for Pneumothorax
It is important as a final step to check for pneumothorax. A detailed explanation of how to look for pneumothorax can be found here.
- In between the 2nd and 3rd intercostal space, check for lung sliding. The hyperechoic pleural line will resemble “ants crawling on a log.”
- For extra assurance that pneumothorax is not present, you can turn on M mode in the same view.
- In healthy patients, you will see the “seashore sign.”
Complete Step by step video demonstration:
Here is a video we made for you going over all of the steps to place a central line:
Central Line Complications
Other complications besides pneumothorax include mechanical complications, such as arterial puncture, hematoma, pneumothorax, hemothorax, and mechanical irritation of the heart (Ortega, R., et. al.). There is also the potential for infection, air embolism, and thrombosis. The use of ultrasound reduces the risk of these complications (McGee, D., Gould, M.).
Identification of the vein and figuring out the patient’s unique anatomy helps prevent accidental cannulation of the common carotid artery, which can lead to serious complications such as a hematoma that can obstruct the airway, pseudoaneurysm, or stroke (Guilbert, M., et. al.).
The subclavian and femoral veins are possible alternative sites to the internal jugular vein. The subclavian vein is advantageous because it has a lower risk of catheter-associated DVT compared to the other two sites. In some ways, it is anatomically favorable because it remains patent, and its position is relatively constant. However, the disadvantage of the subclavian vein is its proximity to the pleura. Pneumothorax rates are higher in subclavian vein cannulation than in the internal jugular or femoral vein (Parienti, J., et. al.).
Compared to the subclavian and internal jugular vein, femoral vein cannulation carries a higher risk of mechanical complications, infections, and thrombosis (McGee, D., Gould, M.; Deshpande, K., et. al.). All of these factors should be considered in deciding where to put a central line.
Other Central Line Sites:
The infraclavicular approach refers to viewing and cannulating the subclavian vein from under the clavicle. First, estimate the area underneath the distal half of the clavicle, which is the approximate area where the subclavian vessels course.
Use the linear transducer to identify the subclavian vessels. For this site, it is best to use a long axis approach, which is when the transducer is parallel to the vessel. The long axis approach can identify the vein using compression with the ultrasound probe, just like with the short axis in the internal jugular vein. The short axis can also be used, but it may be more challenging to find a clean image because of the clavicle. The clavicle will cast a dark shadow occluding anything underneath it, so slide and fan the probe as needed to trace the course of the vein (Davies, T., et. al.).
The supraclavicular approach refers to viewing and cannulating the subclavian vein from above the clavicle. Scan the area lateral to the clavicular head of the sternocleidomastoid but superior to the clavicle.
The supraclavicular fossa is small. Therefore, if the linear transducer cannot capture the desired image, a standard endocavitary probe can be used instead (Mallin, M., et. al.). The subclavian vein tends to be more superficial and caudal than the subclavian artery, but like the previous approaches, use compression and color doppler to be sure which vessel is which. In addition to vessel identification, identify the pleural line, which will be deep to the vessels. It is very important to avoid this structure when cannulating.
Scan the approximate area inferior to the middle of the inguinal ligament. The femoral vein can be found medial and inferior to the femoral artery. The smaller great saphenous vein may also be found medial to the femoral vein, and the bifurcation of the femoral artery may be seen laterally. Like the above approaches, find the appropriate vessels using compression and color doppler. You can use either the short or long axis approaches.
- McGee, D., Gould, M. (2003). Preventing Complications of Central Venous Catheterization New England Journal of Medicine 348(12), 1123-1133. https://dx.doi.org/10.1056/nejmra011883
- Saugel, B., Scheeren, T., Teboul, J. (2017). Ultrasound-guided central venous catheter placement: a structured review and recommendations for clinical practice Critical Care 21(1), 225. https://dx.doi.org/10.1186/s13054-017-1814-y
- Jenssen, C., Brkljacic, B., Hocke, M., Ignee, A., Piscaglia, F., Radzina, M., Sidhu, P., Dietrich, C. (2015). EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part VI – Ultrasound-Guided Vascular Interventions Ultraschall in der Medizin – European Journal of Ultrasound 37(05), 473-476. https://dx.doi.org/10.1055/s-0035-1553450
- Smit, J., Raadsen, R., Blans, M., Petjak, M., Ven, P., Tuinman, P. (2018). Bedside ultrasound to detect central venous catheter misplacement and associated iatrogenic complications: a systematic review and meta-analysis Critical Care 22(1), 65. https://dx.doi.org/10.1186/s13054-018-1989-x
- Brass, P., Hellmich, M., Kolodziej, L., Schick, G., Smith, A. (2015). Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterization Cochrane Database of Systematic Reviews 1(1), CD006962. https://dx.doi.org/10.1002/14651858.cd006962.pub2
- Denys, B., Uretsky, B., Reddy, P. (1993). Ultrasound-assisted cannulation of the internal jugular vein. A prospective comparison to the external landmark-guided technique. Circulation 87(5), 1557-1562. https://dx.doi.org/10.1161/01.cir.87.5.1557
- Smith, R., Nolan, J. (2013). Central venous catheters BMJ 347(nov11 4), f6570-f6570. https://dx.doi.org/10.1136/bmj.f6570
- Schmidt, G., Blaivas, M., Conrad, S., Corradi, F., Koenig, S., Lamperti, M., Saugel, B., Schummer, W., Slama, M. (2019). Ultrasound-guided vascular access in critical illness. Intensive care medicine 45(4), 434-446. https://dx.doi.org/10.1007/s00134-019-05564-7
- Maecken, T., Marcon, C., Bomas, S., Zenz, M., Grau, T. (2011). Relationship of the internal jugular vein to the common carotid artery: implications for ultrasound-guided vascular access European Journal of Anaesthesiology 28(5), 351-355. https://dx.doi.org/10.1097/eja.0b013e328341a492
- Lamperti, M., Biasucci, D., Disma, N., Pittiruti, M., Breschan, C., Vailati, D., Subert, M., Traškaitė, V., Macas, A., Estebe, J., Fuzier, R., Boselli, E., Hopkins, P. (2020). European Society of Anaesthesiology guidelines on peri-operative use of ultrasound-guided for vascular access (PERSEUS vascular access) European Journal of Anaesthesiology 37(5), 344-376. https://dx.doi.org/10.1097/eja.0000000000001180
- Vogel, J., Haukoos, J., Erickson, C., Liao, M., Theoret, J., Sanz, G., Kendall, J. (2015). Is long-axis view superior to short-axis view in ultrasound-guided central venous catheterization? Critical care medicine 43(4), 832-9. https://dx.doi.org/10.1097/ccm.0000000000000823
- Stone, M., Moon, C., Sutijono, D., Blaivas, M. (2010). Needle tip visualization during ultrasound-guided vascular access: short-axis vs long-axis approach The American Journal of Emergency Medicine 28(3), 343-347. https://dx.doi.org/10.1016/j.ajem.2008.11.02
- Wilson, S., Assaf, S., Lahham, S., Subeh, M., Chiem, A., Anderson, C., Shwe, S., Nguyen, R., Fox, J. (2017). Simplified point-of-care ultrasound protocol to confirm central venous catheter placement: A prospective study World Journal of Emergency Medicine 8(1), 25. https://dx.doi.org/10.5847/wjem.j.1920-8642.2017.01.004
- Ortega, R., Song, M., Hansen, C., Barash, P. (2010). Ultrasound-Guided Internal Jugular Vein Cannulation New England Journal of Medicine 362(16), e57. https://dx.doi.org/10.1056/nejmvcm0810156
- Guilbert, M., Elkouri, S., Bracco, D., Corriveau, M., Beaudoin, N., Dubois, M., Bruneau, L., Blair, J. (2008). Arterial trauma during central venous catheter insertion: Case series, review and proposed algorithm Journal of Vascular Surgery 48(4), 918-925. https://dx.doi.org/10.1016/j.jvs.2008.04.046
- Parienti, J., Mongardon, N., Mégarbane, B., Mira, J., Kalfon, P., Gros, A., Marqué, S., Thuong, M., Pottier, V., Ramakers, M., Savary, B., Seguin, A., Valette, X., Terzi, N., Sauneuf, B., Cattoir, V., Mermel, L., Cheyron, D., Group, 3. (2015). Intravascular Complications of Central Venous Catheterization by Insertion Site New England Journal of Medicine 373(13), 1220-1229. https://dx.doi.org/10.1056/nejmoa1500964
- Deshpande, K., Hatem, C., Ulrich, H., Currie, B., Aldrich, T., Bryan-Brown, C., Kvetan, V. (2005). The incidence of infectious complications of central venous catheters at the subclavian, internal jugular, and femoral sites in an intensive care unit population* Critical Care Medicine 33(1), 13-20. https://dx.doi.org/10.1097/01.ccm.0000149838.47048.60
- Davies, T., Montgomery, H., Gilbert-Kawai, E. (2020). Cannulation of the subclavian vein using real-time ultrasound guidance Journal of the Intensive Care Society https://dx.doi.org/10.1177/1751143720901403
- Mallin, M., Louis, H., Madsen, T. (2010). A novel technique for ultrasound-guided supraclavicular subclavian cannulation The American Journal of Emergency Medicine 28(8), 966-969. https://dx.doi.org/10.1016/j.ajem.2009.07.019
- Duran-Gehring, P. E. et al. The bubble study: ultrasound confirmation of central venous catheter placement. Am J Emerg Medicine 33, 315–319 (2015).