Indications
- Invasive monitoring — central venous pressure, central venous oxygen saturation.
- Vasoactive drug delivery — vasopressors and inotropes ideally given via a secure central line rather than peripherally where practical, particularly for anticipated prolonged use.
- No peripheral access despite escalation (see the difficult IV access page) and urgent access is needed.
- Delivery of hyperosmolar fluids, parenteral nutrition, or repeated blood sampling in the critically unwell patient.
Contraindications & cautions
Relative contraindications
- Coagulopathy or anticoagulation — correct where urgency allows; ultrasound guidance reduces bleeding risk further.
- Local infection over the insertion site.
- Contralateral pneumothorax, or known ipsilateral vascular abnormality/thrombosis.
Cautions
- No absolute contraindication in a genuine emergency; balance risk against the urgency of access.
- Uncooperative or agitated patient — consider sedation or an alternative site.
- Distorted neck anatomy (previous surgery, radiotherapy).
Consent & preparation
- Written consent where time allows; verbal/best-interests documented in emergencies. Discuss bleeding, infection, pneumothorax, arterial puncture and arrhythmia.
- Continuous ECG monitoring throughout — the guidewire can provoke transient atrial or ventricular arrhythmia if advanced too far.
- Position: Trendelenburg (head-down) tilt distends the internal jugular vein and reduces air embolism risk; head turned slightly away from the site.
- Full maximal sterile barrier precautions — cap, mask, sterile gown, sterile gloves, large sterile drape — as part of a line-insertion bundle (the "Matching Michigan" central line bundle approach).
Equipment
Ultrasound view — IJV and carotid
Step-by-step technique
Position and prepare
Head-down tilt, head turned slightly away from the side chosen. Full maximal sterile barrier precautions; chlorhexidine skin prep with adequate drying time.
Scan and mark
Identify the IJV in short-axis, confirm compressibility, and note its relationship to the carotid artery and its depth from skin.
Local anaesthesia
Infiltrate skin and the needle track in the conscious patient.
LAST rescue — AAGBI algorithm ↗Needle puncture under direct vision
Advance the introducer needle under real-time ultrasound guidance, tracking the tip continuously, aspirating until free dark venous blood returns. Avoid advancing beyond the point needed to confirm entry.
Guidewire — watch the monitor
Remove the syringe and feed the wire smoothly; watch the ECG continuously as the wire is advanced — ectopy or arrhythmia signals the wire has reached the right atrium and should be withdrawn slightly. Never let go of the wire.
Dilate and insert catheter
Small skin nick, dilate along the wire track, then thread the catheter to the appropriate depth (commonly ~15 cm on the right, deeper on the left, adjusted to patient size), remove the wire.
Confirm venous placement
Confirm free, non-pulsatile, dark blood return and easy aspiration from every lumen. Ultrasound can confirm the wire or catheter tip lies within the vein before dilation, and a venous blood gas trace or pressure transduction can confirm venous (not arterial) placement if there is any doubt.
Secure and image
Suture, dress, flush all lumens. Obtain a chest X-ray to confirm catheter tip position (ideally at the cavoatrial junction) and exclude pneumothorax before using the line for infusions, unless the clinical urgency mandates immediate use with a clear risk discussion.
Complications
Early
- Arterial puncture — carotid lies posteromedial to the IJV; apply firm pressure if this occurs.
- Pneumothorax — more associated with subclavian approach, but possible with a low or medial IJV puncture.
- Arrhythmia from wire advanced too far into the right atrium/ventricle.
- Air embolism — minimised by head-down positioning and covering the needle hub promptly.
- Guidewire loss — always maintain control of the wire.
Late
- Catheter-related bloodstream infection — reduced by full barrier precautions and chlorhexidine prep.
- Thrombosis of the vein.
- Catheter malposition found on chest X-ray.
- Line fracture or blockage with prolonged use.
Aftercare & documentation
- Post-insertion chest X-ray before use for infusions where time allows; confirm tip position and exclude pneumothorax.
- Document: indication, consent, site, ultrasound use, number of attempts, complications, depth at skin, X-ray confirmation.
- Daily review of ongoing need — remove as soon as no longer required, as part of standard line-care bundles to reduce bloodstream infection.
- Dressing checks per local infection-control policy; label clearly with insertion date.
Pitfalls & pearls
- Never let go of the wire — a lost wire migrating centrally is a recognised, serious, avoidable error.
- Watch the ECG trace continuously as the wire advances — arrhythmia is your cue to withdraw slightly.
- Ultrasound throughout, not just for the initial puncture — confirm the needle tip, wire and (where practical) catheter position dynamically.
- Don't rely on blood colour alone to exclude arterial placement in a hypoxaemic or shocked patient — use pressure transduction or a blood gas if there is any doubt before dilating.
DOPS pointers
RCEM curriculum: establish invasive monitoring — central venous pressure. What assessors look for at each entrustment level:
| 1 | Observed only — can describe indications, IJV/carotid ultrasound anatomy, and the barrier-precautions bundle. |
| 2a | Performs with supervisor scrubbed alongside: correct ultrasound identification, controlled needle and wire technique, ECG monitoring. |
| 2b | Performs with supervisor in the department: full sequence including confirmation of venous placement and securing. |
| 3 | Indirect supervision: manages arterial puncture, arrhythmia during wire passage, difficult anatomy; interprets post-procedure imaging. |
| 4 | Independent; can teach and supervise, including troubleshooting and complication management. |
References
- NICE. Guidance on the use of ultrasound locating devices for placing central venous catheters. Technology Appraisal Guidance 49 (TA49).
- Faculty of Intensive Care Medicine / GPICS. Guidelines for the Provision of Intensive Care Services — vascular access standards.
- Pronovost P, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:2725–2732 (Keystone/"Matching Michigan" central line bundle).
- RCEM Curriculum 2021 — Emergency Medicine Specialty Learning Outcomes: establishing invasive monitoring.