This document provides information about a central venous catheter (CVC) insertion workshop focusing on the right internal jugular vein. It discusses indications and contraindications for CVC placement, possible complications, common sites for insertion, and summarizes a study comparing infection rates between sites. It also reviews surface anatomy of insertion sites, ultrasound basics including machine settings and imaging planes. The document outlines the Seldinger technique for CVC insertion and provides an equipment list with images of required supplies.

1. CVC Workshop

2. Right Internal Jugular Central Venous
Catheter Insertion Workshop
Pre-reading

3. Introduction
• The placement of central venous catheters (CVC) is an essential skill
for any clinician working with critically ill patients.
• The widespread access to ultrasound (USS) and multiple studies
showing the superiority of real time ultrasound in CVC placement
compared to landmarks alone has meant that the use of realtime USS
in CVC placement is now the gold standard.

4. Indications
• IV access (especially if difficult peripheral access)
• CVP monitoring
• Central venous oxygen saturation (ScvO2 ) monitoring/sampling
• Infusions of irritant substances (e.g. vasoactive agents, calcium,
chemotherapy or TPN administration)
• Renal replacement therapy, plasmapheresis and apheresis
• Transvenous pacing

5. Contra-indications
• coagulopathy
• respiratory failure (patient positioning and ability to tolerate procedure)
• raised ICP (cannot tilt head down)
• can use femoral approach in all the situations above
• obstructed vein (e.g. thrombus, tumour etc)
• overlying skin infection, burn or other disease process
• hemorrhage from target vessel
• uncooperative patient

6. Complications
• Infectious Complications
• Catheter related bloodstream infections
• approximately 1.5% in Jugular CVC (3SITES Study1)
• Vascular Complications
• Carotid puncture/cannulation
• Haematoma from multiple attempts
• Equipment
• Catheter related thrombosis
• Pulmonary
• Pneumothorax
• Venous air embolism
See the attached paper “Preventing Complications of Central Venous Catheterisation”
(alternatively double click on icon to the right)
1 Parienti, J., et al. (2015). Intravascular Complications of Central Venous Catheterization by Insertion Site. New England Journal of Medicine N Engl J Med, 373(13), 1220-1229. doi:10.1056/nejmoa1500964

7. Sites for CVC placement
• 3 main sites are used for CVC placement
• Internal jugular, subclavian and femoral
• All have the option for either left or right sided placement
• All are associated with infectious, thrombotic, and mechanical complications.
• The rate of total complications is similar for all three sites although the exact
composition of the complications may differ

8. 3SITES1 Study Summary
•Randomised Multicenter Trial with 3471 CVC inserted
•Compared Catheter Related infections in Femoral,
Internal Jugular(IJ) and Subclavian lines.
•Subclavian was shown to have significant less infections.
While the Femoral and IJ had comparable infection rates
with no significant statistical difference
To Read full article click on icon to the right
1 Parienti, J., et al. (2015). Intravascular Complications of Central Venous Catheterization by Insertion Site. New England Journal of Medicine N Engl J Med,
373(13), 1220-1229. doi:10.1056/nejmoa1500964
To read full article double click on icon to the right (optional)

9. • Now lets review the surface anatomy of the 3 sites for CVC placement

10. Subclavian vein
Anatomy
• CVC insertion to this vein is
usually done using land mark
technique as it is not easy to
ultrasound
• The infra clavicular approach is
most commonly used

11. Femoral Vein
Anatomy Ultrasound Image
SV= saphenous vein, CFV = Common Femoral Vein, CFA = Common
Femoral Artery
N
A
V
Y
NAVY pneumonic – used to remember the
structures going from lateral to medial
(Y=y-fronts i.e. midline)

12. Right Internal Jugular
• This site has been selected for this workshop because:
• Most commonly used site in this institution
• Why the right side?
• Convenient for right handed operators – as they can palpate artery/hold ultrasound probe in
their non-dominant hand.
• Less likely to slide into brachiocephalic vein in comparison to left
• Amenable to real time USS guidance especially compared to subclavian
• Less likely to become obstructed when patient sits up or mobilises in comparison to femoral

13. Right Internal Jugular
Landmarks: Surface Anatomy

14. • Surface Anatomy
• How internal structures relate to
surface anatomy
• Lies between two heads of
sternocleidomastoid muscles
• Lateral (occasionally posterior) to
carotid.

15. Summary
• Review Of Indications and Contra-indications
• Possible complications of central line insertion
• 3 common sites for CVC insertion

16. Ultrasound Basics

17. Ultrasound (USS)
• Realtime USS in CVC placement is recognised as the gold standard as
opposed to using the landmark technique alone .
• Guidelines highlightening this:
• NICE guidelines – Guidance on the use of ultrasound locating devices for placing central
venous catheter 1
• International evidence-based recommendations on ultrasound-guided vascular access 2
• Proficiency with the use of ultrasound is essential to becoming competent at
placing real-time USS guided CVCs.
1 Guidance on the use of ultrasound locating devices for placing central venous catheters. (n.d.). October 4 2002, from https://www.nice.org.uk/guidance/ta49
2 Lamperti M, Bodenham A, Pittiruti M, Blaivas M, Augoustides J, Elbarbary M, et al. International evidence-based recommendations on ultrasound-guided vascular
access. Intensive Care Med. 2012 2012/07/01;38(7):1105-17.

18. Basics of USS Physics

19. Basic USS physics
•A pulse of sound is
sent out by a
transducer, hits an
object and then
bounces back

20. Basic USS physics
• Ultrasound waves show up on
the screen anywhere from black
to white in color. Why?
• Different tissues attenuate the
sound waves differently
• Fluid has low attenuation, fat has
high attenuation and bone has
very high attenuation
Fluid
Fat
Bone

21. Basic USS physics
• Importantly the quality of the
image is degraded as the sound
waves pass through areas of
high attenuation
• The image to the right
demonstrates how below the
bone no further objects can be
seen
Bone

22. 3 Ps of Ultrasound

23. 3 Ps of VASCULAR Ultrasound
• Patient
• Enter patient details
• Ensure patient is positioned adequately
and comfortable as possible
• Probe
• Choose the high frequency linear probe
for vascular ultrasound (6-13mhz)
• Preset
• Each probe can be used for multiple
tissues i.e. muscle, nerves, blood vessels
• Choose the vascular setting (The location
of the preset menu will vary on each
machine)

24. Other Settings

25. Depth
• Depth determines how deep
from the skin that you can
visualise
• Ideally get the object you want
in the center of the screen as
demonstrated by the 4cm image
to the right
• This way structures below can
been seen and avoided when
inserting a needle

26. Depth
• Too much depth as
demonstrated by these images
results in decrease resolution
• This will result in increased
difficulty in trying to needle the
object of interest

27. Gain
• This function is very similar to a brightness control
• Too much or too little gain will make visualisation of objects
difficult (too bright or too dark)
• Most ultrasound have an auto gain function that will attempt to
calibrate the ideal gain

28. Gain
Gain too high can result in
blurring of the walls of the
structure. This may impact
visualisation of the needle going
through the vessel wall.
Gain too low can result in
structures not being seen

29. Color
• This mode can be activated to
visualise flow through the blood
vessels
• Blue indicates flow away from
the probe and red indicates flow
towards the probe (BART: BLUE
AWAY, RED TOWARDS)
• Arterial blood (red in this picture)
will be pulsatile
• Venous Blood (blue in this picture)
will be laminar

30. Now lets look at an Ultrasound
of the Neck Structures

31. Nomenclature for imaging vascular structures
• Longitudinal
• Transverse

32. Transverse view of the right neck vessels
Medial Lateral
Legend:
• SCM = Sternocleidomastoid
• CA = Carotid artery
• IJV = Internal jugular vein
• Notice the different shades
• Complete black is fluid (blood in
this instance)
• Muscle has a grainy appearance

33. Different ways of imaging the needle

34. Different ways of imaging the needle
• Both in-plane and out-of-plane are used for CVC placement
• Locally the out-of-plane approach is favoured and that is what will be
taught in the workshop
• The greatest benefit with out-of-plane imaging is it gives a better view
of adjacent structures
• One of the biggest risks in this procedure is puncture of the adjacent
carotid artery - this is best avoided whilst using an out-of-plane
approach

35. Out-of-plane approach

36. Out-of-plane approach gives this view
The arrow is
pointing
to the needle

37. Out-of-plane approach
• The biggest downside to the out-of-plane approach is that the white
dot on the screen representing the needle could represent anywhere
along the needle.
• Therefore the technique is to advance the needle into the plane, see
the needle on the ultrasound screen then fan the ultrasound probe
until the needle is lost and then advance the needle again until it
breaks the plane and is then seen on the screen.
• Repeat this until the needle is where you want it to be

38. Video on in-plane versus out-of-plane imaging

39. Equipment List For CVC
insertion

40. Personal Protective Equipment
Hat and Glasses Face Shield

41. Personal Protective Equipment
Surgical Mask Gown

42. Personal Protective Equipment
Gloves
Get to know your glove size as
appropriately fitting gloves are
important when undertaking
surgical skills

43. Major Anaethesia Pack

44. Major Anaesthesia Pack

45. Major Anaesthesia Pack Contents
Gown

46. Major Anaesthesia Pack Contents
Aperture Drape used to isolate surgical
field

47. Major Anaesthesia Pack Contents
Gallipot: Good for emptying
Chlorhexidine in when prepping surgcial
area (to be thrown away after patient
Kidney Bowels: Good Place to put sharps on your
tray.
Galipot: Good for emptying
normal saline vials in if needed

48. Major Anaesthesia Pack Contents
Tube Clamp
Straight Scissors
Rampley Forceps: Used to dip gauze in
chlorhexidine and prepare surgical area

49. Major Anaesthesia Pack Contents
Gauze: Pick up with forceps and soaked
in chlorhexidine then used to prepare
surgical field Huck Wipes

50. Items for Preparing surgical Field
Rampley Forceps: Used to dip gauze in
chlorhexidine and prepare surgical area
Aperture Drape used to isolate surgical field
Gauze: Pick up
with forceps
and soaked in
chlorhexidine
then used to
prepare
surgical field
Chlorhexidine 2%
(tinted red)

51. Items for Preparing Surgical field
Place Chlorhexidine
in one Gallipot and
Saline in the other.
Chlorhexidine is
tinted red
(sometimes blue)

52. Various kits: main difference is number
size of lumens

53. This Course will use 3 lumen 7Fr CVCs
Note the lumen gauges
and their expected flow
rates

54. Back of Central Venous Catheter (CVC) Kit
Note: You will need to replace the
injection caps (needle) that come with
the kit with needleless injection cap
connectors
Needle injection caps

55. CVC Kit Contents
Spring-Wire Guide (Marked)
with Arrow Advancer ™
Multi-
lumen CVC
Fastener: Catheter Clamp
From Left to Right:
• Tissue Dilator
• Spring-Wire
introducer syringe
(5cc)
• Introducer Needle
(18Ga x 2.5 inch)
Catheter
18Ga 2.5
inch
Radiopaqu
e over
20Ga
Needle
(Not
Generally
Used)

56. CVC Kit Contents
Arrow Advancer ™ for Spring -Wire
Spring-Wire with ‘J’ Tip

57. CVC Kit Contents
Spring-Wire: Note gradation markers every 10 cm

58. CVC Kit Contents
Spring-Wire introducer syringe (5cc) attached to
Introducer Needle (18Ga x 2.5 inch)

59. CVC Kit Contents
• Hole through introducer
Syringe plunger for
Spring-wire to be
inserted

60. CVC Kit Contents
You may choose to insert Spring-Wire directly
through introducer syringe when vein puncture
confirmed (shown)
OR
You may remove introducer syringe and insert
spring wire directly through introducer needle
hub (as will be demonstrated in course)

61. Triple Lumen CVC
CVC Clamp to as additional
point to suture in place

62. Triple Lumen CVC
Needleless Injection Caps
needle injection cap
connectors that come pre-
connected

63. Triple Lumen CVC
Remove old caps and replace with new needless caps

64. Triple Lumen CVC

65. Triple Lumen CVC
Connect 10ml Syringe with Normal
Saline and flush each port to ensure
patency

66. Triple Lumen CVC
Ensure catheter
flushes from each port

67. Anaesthetic Equipment
IMPORTANT NOTE: Using a 5ml syringe prevents mix up
with normal saline syringe (10ml) and other syringes
Drawing up needle
2 – 5ml Lignocaine
1% vials
5ml Syringe
1 – 23G Needle
1 – 25G Needle

68. Retractable blade for insertion of tissue
dilator preparing dilation

69. Suture Set
Many will use a 0 silk suture (pictured above) which does not usually require
the equipment in the suture set and can be done by hand alone. If using 3-0
prolene you will need a suture set (fine forceps, needle holder forceps and
scissors)

70. Materials for suturing CVC in place
From suture set
Anaesthesia equipment

71. Suture Kit
0 Silk Suture
Suture Set

72. Normal Saline (Flush)
1 – Draw Needle
3 – 10ml vial normal
saline
1 - 10 ml Syringe

73. Ultrasound Probe Cover
1 – Probe Cover Kit
a) Probe cover sleeve
b) Sterile ultrasound gel
c) Elastics

74. 1 – Probe Cover Kit
a) Probe cover sleeve
b) Sterile ultrasound gel
c) Elastics
Ultrasound Probe Cover Opened
1 – Sterile Gel
1 – Elastics
1 – Probe cover sleeve

75. Chlorhexidine (Skin Preparation)
1 – 2 pack 10 cm2 Gauze
1 – 30ml bottle
chlorhexidine 2%

76. Anaesthetic equipment
1 – Drawing-up needle
1 – 3ml Syringe
2 – 5ml Lignocaine
1% vials
1 – 25G Needle
IMPORTANT NOTE: Using a 3-5ml syringe prevents mix up
with normal saline syringe (10ml) and other syringes

77. Dressings for CVC exit site
1 – Fixomull
1 – Transparent Film Dressing
1 – Biopatch
Apply
print side
up
around
exit site
of
catheter

78. Dressings for CVC exit site
• NB – ICU has started using
chlorhexidine patch dressings
which have replaved the IV 3000
and biopatch

79. Seldinger Technique

80. • The Seldinger technique, also
known as Seldinger wire
technique, is a procedure to
obtain safe access to blood
vessels and other hollow organs.
• It is named after Dr.Sven-Ivar
Seldinger, a Swedish radiologist
who introduced the procedure
in 1953

81. Steps
• Needle inserted into blood
vessel while aspirating on the
syringe

82. • Syringe is removed and
guidewire is inserted through
the needle hub

83. • Needle is removed

84. • Dilator is inserted over
guidewire to make the tract
larger
• Dilator is then removed.

85. • Catheter is inserted over
guidewire
• Note that the guidewire comes
out of the brown port

86. • Catheter is inserted to
appropriate length

87. Uses
• The Seldinger technique is used for:
• Angiography
• insertion of chest drains and central venous catheters
• insertion of the leads for an pacemaker/implantable defibrillator
• …and numerous other interventional medical procedures.

88. CVC Insertion Technique

89. • NOTE:
• Images in this PPT are using an older CVC kit which ARROW has modified
recently.

90. Equipment Preparation

91. Equipment Preparation

92. Equipment Preparation

93. Equipment Preparation

94. Equipment Preparation

95. Equipment Preparation

96. Equipment Preparation

97. Equipment Preparation

98. Equipment Preparation

99. Equipment Preparation

100. Equipment Preparation

101. Equipment Preparation

102. Equipment Preparation

103. Equipment Preparation

104. Equipment Preparation

105. Surface Anatomy Review

106. Preparing the Patient

107. Preparing the Patient

108. Preparing the Patient
Drape the patient, leaving the area of insertion exposed

109. Preparing the Ultrasound

110. Preparing the Ultrasound

111. Preparing the Ultrasound

112. Preparing the Ultrasound

113. Preparing the Ultrasound

114. Preparing the Ultrasound

115. Pre-needle Ultrasound

116. Pre-needle Ultrasound
Image of right internal jugular. Colour can be
applied to confirm internal jugular vein (IJV ) and
common carotid artery (CCA)

117. Local Anaesthetic
Anesthetize the area with Lignocaine. This can be
guided using the ultrasound.

118. Needling the Internal Jugular (IJV)
Using the ultrasound to locate the IJV the
needle is inserted aspirating as you advance
(note the probe here is in the in-plane
position. The course will focus on out-of-plane
insertion of needle)

119. Needling the Internal Jugular (IJV)
Ultrasound confirmation of needle in the IJV is
an essential step

120. Needling the Internal Jugular (IJV)

121. Guidewire Insertion

122. Guidewire Insertion

123. Guidewire Insertion

124. Guidewire Insertion

125. Guidewire Insertion

126. Guidewire Insertion

127. Guidewire Insertion
Ultrasound confirmation of guidewire in the
IJV must be performed prior to proceeding
Out of plane image In plane image

128. Dilator Insertion
Make a small incision using
the scalpel at the
guidewire entry point

129. Dilator insertion

130. Dilator insertion

131. Catheter Insertion

132. Catheter Insertion

133. Catheter Insertion

134. Catheter Insertion

135. Catheter Insertion

136. Catheter Insertion

137. Catheter Insertion

138. Catheter Insertion

139. Catheter Insertion

140. Securing the Central Line

141. Securing the Central Line

142. Securing the Central Line

143. Securing the Central Line
• The traditional way that most
people have been shown to fix a
line is shown to the left
• This is problematic in that the
line often kinks, resulting in
occlusion of the lumen, failure to
deliver drugs or sudden purges
when it unblocks, see arrow

144. Securing the Central Line
• Use at least O nylon, deep 1 cm
bite of skin
• Secure the clip, and then sandal
tie the hub so that it is secured
to the skin via the clip
Sutured to patientNot sutured to
patient

145. After Care
• Following insertion of CVC:
• CXR to check for complications (eg.pneumothorax) and adequate position of
CVC – tip of CVC should be in the lower Superior Vena CAVA
• Documentation of CVC insertion – including number of needle passes and any
other complications

146. After Care
• CVC need to be changed between 10 – 14 days due to increasing risk
of catheter related sepsis and thrombus formation around the
catheter.
• Daily review of the CVC should be implemented to check for signs of
sepsis or thrombus formation and CVC not being used should be
removed to reduce these risks

147. CVC insertion Video
(Click below to start video)