Central Venous Catheterisation

CVC Opener

This module describes how to perform central venous catheterisation (CVC) via the subclavian route.


  1. Monitoring central venous pressure (CVP)

  2. Delivering caustic medications

  3. Emergency resuscitation

  4. Haemodialysis

  5. Pulmonary artery catheterisation


  1. Infection of the overlying skin

  2. Thrombosis of the vein to be catheterised

  3. Trauma to, and distortion of the site

  4. Weigh up the risks and benefits in patients with coagulopathy

  5. Weigh up the risks and benefits in patients with only one functioning lung


Always verify your patient’s identity and obtain informed consent before proceeding.

How do I explain this procedure?

“I need to place a thin tube in one of the large veins in your chest. The tube is called a central venous catheter.”

What can my patient expect?

“I will give you an injection that will stop you from feeling pain at the puncture site. The procedure will take a few minutes. The catheter may need to stay in place for a few days and we will stitch it in place to make sure it doesn't fall out by accident.”

What is my patient’s role?

“Let me know if you have any allergies or a bleeding tendency, or use blood thinners. Fearing blood or needles is normal, but tell me if you have fainted from it. Keep as still as possible. If you feel strange sensations or severe pain, tell me immediately. Do not fiddle with the stitches or tubing.”


Prepare a trolley with equipment. It is useful to have

and a sterile probe sleeve available, as its use decreases the risk of complications. An assistant is required for this procedure. The patient should have ECG, BP and sats monitoring attached.

CVC Equipment

Documentation

  1. Patient notes

Equipment

  1. Alcohol-based hand rub

  2. A central venous catheter pack containing at least:

    1. A central venous catheter
    2. A guidewire
    3. A dilator
  3. A suture pack containing:

    1. Sterile drapes
    2. Gauze
    3. A well for skin disinfectant
    4. Forceps and needle holders
  4. Three 10 ml syringes

  5. An 18 G needle, a blunt fill needle, and one needle of the smallest gauge available

  6. 2% lignocaine & an alcohol swab

  7. Sterile normal saline

  8. A 3-0 non-absorbable suture

  9. A scalpel blade

  10. An IV giving set and bag of fluid

  11. A transparent film dressing


The CVC may be inserted into the internal jugular, subclavian, or femoral vein. The femoral route is unfavourable due to a high incidence of infections, thrombosis, and arterial puncture. The subclavian route has the lowest risk of infections and arterial puncture, though its rate of haemo-/pneumothorax and thrombosis is higher than that of the internal jugular vein. The subclavian route is preferred in patients who are awake as the approach is not affected by head movement, and in patients in cervical collars. This module will focus on the subclavian route.

Position the patient in the Trendelenburg position. Contrary to popular practice, do not turn the face away from the site of the procedure, and do not place an object between the shoulder blades to retract them.

When inserting a CVC, insert the needle at the junction between the medial and middle thirds of the clavicle, a fingerbreadth away from the clavicle. Aim under the clavicle towards the suprasternal notch—place the index finger of the non-dominant hand here, and the thumb on top of the clavicle at the entry point to keep track of these landmarks.

CVC anatomy


Follow medical asepsis with sterile gloves.

  1. Perform hand hygiene.

  2. Open the suture pack and create a sterile field. Rearrange the items in the suture pack with sterile gauze or spare forceps if necessary. Fill the well with skin disinfectant. Open the needles, syringes, suture, dressing, and blade onto the sterile field. Open the CVC pack.

  3. Draw up 5 ml lignocaine in the first syringe with the blunt fill needle. An assistant should clean and hold the vial for you. Remove and discard the blunt fill needle and attach the small gauge needle.

  4. Draw up 10 ml normal saline with the second syringe. An assistant should open and hold the vials for you.

    the CVC ports.

  5. Check that the guidewire runs forward in the sheath and retracts smoothly.

  6. Attach the 18 G needle to the third syringe.

  7. the skin and allow it to dry. Drape the patient.

  8. the target site, including the skin and the subclavicular area. Wait 5-10 minutes.

  9. While maintaining gentle suction with the plunger, insert the 18 G needle into the target site aiming at the suprasternal notch. Keep the needle parallel to the ground—do not point it downwards. Once you hit the clavicle, withdraw slightly, depress the syringe and needle as a whole, and advance under the clavicle.

    CVC insertion

  10. Advance until you get flashback of blood into the syringe. The blood should flow freely into the syringe and should be dark in colour i.e. the colour of venous blood.

  11. and thread the guidewire into the back of the needle, watching the ECG monitor for any disturbances of rhythm.

  12. on to the guidewire, withdraw the needle over the guidewire and dispose.

  13. Make a 2 mm incision at the insertion site. Thread the

    over the guidewire and insert it with a corkscrew movement. Retract it over the guidewire.

  14. Thread the catheter over the guidewire into place to the required

    .

  15. Remove the guidewire.

  16. Connect the catheter to the intravenous line and lower the vaculitre bag slightly to observe the drainage of blood into the tubing. Hang the bag up immediately.

  17. Flush each port to confirm good flow.

  18. Suture the CVC into place by the two wings.

  19. Apply the transparent film dressing.

  20. Dispose of medical waste safely.

  21. Record completion of the procedure in patient notes.

  22. Order a chest X-ray to confirm positioning.


The wire does not advance smoothly.

Do not force it. Withdraw a few cm, turn it, then advance again. If it still does not advance, withdraw and see if there is still good backflow through the hub of the needle. If not, you’re probably outside the subclavian vein. Connect the syringe again and reposition your needle until you are back in the vein.

The patient has a lot of body hair.

Try to avoid shaving as the skin disruption increases the risk of infection.

The patient is developing an arrhythmia.

Withdraw the tip of the guidewire. You’re probably in the right atrium, irritating the myocardium.

The patient has become unstable.

An air embolism might have occurred, presenting as sudden, acute cardiac output failure. Check for a drop in blood pressure and clinical signs of decreased peripheral and cerebral perfusion. A continuous murmur may be heard over the heart and the jugular veins may be distended. Turn the patient onto their left side, administer 100% oxygen and aspirate the air from the right atrium with the same central line.

The patient is obese.

Consider using ultrasound guidance, or call a senior for assistance.


  1. Local hematoma, pain, or excessive bleeding at the site

  2. Arterial puncture with massive haematoma, and/or thrombosis and embolism

  3. Haemo/chylo/hydro/

  4. Injury to nerves, including the phrenic nerve, brachial plexus, and vagus

  5. of major vessels or heart with cardiac tamponade

  6. Target vein

  7. Malpositioned catheter tip (often in the internal jugular vein)

  8. Central Line-associated Bloodstream Infection

  9. Catheter embolisation

  10. Sharps injury to healthcare personnel

  11. Vasovagal response (fainting)


  1. Boon JM, van Schoor AN, Abrahams PH, Meiring JH, Welch T, Shanahan D. Central venous catheterization -- an anatomical review of a clinical skill -- Part 1: subclavian vein via the infraclavicular approach. Clin Anat. 2007;20(6):602-611. doi:10.1002/ca.20486

  2. Leib AD, England BS, Kiel J. Central Line. [Updated 2021 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519511/

  3. Graham AS, Ozment C, Tegtmeyer K, Lai S, Braner DA. Central Venous Catheterization. N Engl J Med. 2007;356:e21. DOI: 10.1056/NEJMvcm055053.

  4. Nicol A, Steyn E. Emergency Procedures. Chapter 6. Handbook of Trauma for Southern Africa. 2009. 4th ed. 71-75

  5. Department of Health, Republic of South Africa. Practical Manual for Implementation of the National Infection Prevention and Control Strategic Framework. 2020. Available from: https://www.health.gov.za/wp-content/uploads/2020/11/practical-manual-for-implementation-of-the-national-ipc-strategic-framework-march-2020.pdf