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Central Line Insertion: Current controversies and best practices in 2019

Avery Tung, M.D. FCCM Wilmette, IL

Introduction:
Anesthesiologists are inserting fewer central lines. Since 2007, Medicare claims for non-tunnelled line
insertions by anesthesiologists have fallen by 35%. Paradoxically, however, the safety of central line insertion has
never been greater. Widespread use of dynamic ultrasound, organization improvements in the insertion process,
better training methods, and a belief that lower complication rates are possible have dramatically improved the
avoidance, detection, and treatment of central line complications including failed insertion, pneumothorax, air
embolism, arterial cannulation, catheter related bloodstream infections, and retained guide wire.

The development of high fidelity 2-dimensional ultrasound stands out as a major advance in central line
insertion. These devices have not only enabled clinicians to define central vein anatomy with greater accuracy than
previously, but also allowed inserters to visualize vein cannulation in real time, verify wire and catheter tip position,
and troubleshoot potential complications such as pneumothorax (2). Existing literature is nearly unanimous that
ultrasound reduces line insertion complications (3), and a 2015 Cochrane review (4) lists advantages of ultrasound
including increased first stick success, fewer arterial puncture and hematomas, and shorter time to successful line
insertion. Experience with ultrasound has also led to the development of ultrasound guided subclavian (5), axillary
and supraclavicular insertion locations. (6,7)

Another major advance in line insertion safety has been the increased use of high-fidelity simulation. In
many large teaching hospitals, historic “see one do one” approaches have been supplanted by multidimensional
training programs including video, computer-based training programs, hands on simulation (8), and “live”
insertions. With these advanced educational approaches, novices can become familiar with insertion hardware,
patient anatomy, ultrasound visualization, sterile technique, and rescue or troubleshooting strategies with far less
risk to actual patients. Existing evidence suggests that such simulation approaches can increase learner confidence
(9) and reduce complications (10).

Finally, improvements in the process of line insertion have made line insertion easier and reduced
complications. In particular, checklists, supply carts and electronic medical record pathways have increased the ease
of complying with insertion bundles and other empirically derived benefits to line placement. Considerable
evidence suggests that such pragmatic, operational approaches are working. In addition to the 2006 report of
reduced central line infections with checklist use (11), large national databases also suggest dramatic reductions in
central line infections (12) when specific processes are used. Of the checklist items commonly used, avoiding the
femoral site and removing unnecessary lines have the greatest impact on-line infection rates (13).

Partly as a result of the above advances, numerous medical specialty societies have created line insertion
guidelines. The American Society of Anesthesiologists (ASA) (14), American College of Surgeons (15), British
National Institute of Clinical Excellence (16), Australian Clinical Excellence Commission (CEC) (17), Swedish
Society of Anaesthesiology and Intensive Care (18), Asia Pacific Society for Infection Control (19), and the Centers
for Disease Control (20) have all issued guidelines. This talk will review existing literature (including these
guidelines where relevant) with respect to central line insertion, identify best practice where applicable, and briefly
address specific complications of line insertion.

Pre-insertion
a. Indications
A full discussion of indications (and contraindications) for central line placement are beyond the scope of this talk.
Two trends in clinical practice are worth noting. The first is a decreasing emphasis on central venous access for
hemodynamic monitoring purposes in intraoperative and acute care settings. Neither central venous pressure
measurement nor Swan Ganz catheterization clearly improve outcomes when used for hemodynamic monitoring
(21,22). PA catheter use is declining (23) in all areas except for heart failure (24). The second is the increasing use

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publication contains material copyrighted by others. Individual refresher course lectures are reprinted by ASA with permission.
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of peripherally inserted central access (PICC) lines and tunneled lines for intravenous infusions. In fact, radiologists
now place most of the central lines in the United States (25).

b. Location and resource preparation:

If time permits, surveying the anticipated site of central line insertion with ultrasound can identify anatomical issues
that may complicate placement. “Pre-scanning” can be particularly useful in patients with other venous hardware,
previous central lines, prior neck surgery and/or venous thrombosis. Unanticipated abnormalities in the
size/location of the target vein, hematomas or clot, and/or foreign bodies may all be identifiable with ultrasound. In
one study of ultrasound surveillance, the internal jugular vein could not be visualized in up to 2.5% of patients (26).
For the internal jugular site, prescanning may permit positioning the head to maximize lateral separation of the
carotid and internal jugular vein. Increased head rotation frequently increases carotid/internal jugular overlap (27),
raising the risk of inadvertent carotid puncture.

Although not evidence-based, both ASA and CEC guidelines recommend basic levels of ancillary support for
central line insertion. An environment that permits use of aseptic techniques, a trained assistant, monitoring
equipment, and immediate access to resuscitation equipment and drugs are considered basic support requirements
for line insertion.

c. Site Selection:
Historically, femoral insertion sites have been considered at higher risk for infection than either IJ or subclavian
sites (11). However, more recent data suggest that any difference in infectious risk between sites is shrinking (28).
A 2012 Cochrane review (29) likewise found no site-specific difference in catheter-related blood stream infections
or colonization and also observed “no overall differences in catheter-related complications between the subclavian
and internal jugular sites”. Improved management and more prompt removal may partly explain this narrowing in
infection risk among central cannulation sites (30).

The Cochrane review also found more thrombotic and mechanical complications with the femoral (vs subclavian)
site but fewer mechanical complications than the internal jugular site and no difference between subclavian and
internal jugular insertion sites with respect to mechanical or thrombotic complications.

The largest randomized analysis of line sites and complications is the 2015 “3Sites” study (31). This multicenter
trial randomized 3,471 insertions to the subclavian, femoral, or internal jugular sites and found the lowest incidence
of their composite outcome (vein thrombosis & CLABSI) at the subclavian site but a higher incidence of mechanical
complications…primarily pneumothorax…in the subclavian group. Variation in ultrasound use (twice as many IJ
lines were inserted under ultrasound than subclavian or femoral), a failure rate for subclavian use twice that for IJ,
and an unusually high CLABSI rate (>1:1000 catheter days) make the study difficult to generalize.

With respect to other aspects of line site selection, anatomy favors the right vs the left internal jugular insertion site,
due to the larger diameter and straighter course of the right IJ, the lower right pleural dome, absence of the thoracic
duct, and ease of access for the right handed operator (32, 33). Although existing evidence does not clearly favor
internal jugular over subclavian approaches, multiple case reports describe aortic injury, hemothorax, and
tamponade with subclavian central venous catheterization. In addition, literature reviews suggest slightly higher risk
for arterial puncture with the right subclavian approach, possibly due to kinking of the guidewire during vessel
dilation (30). One 2002 (pre-ultrasound) meta-analysis included >2000 internal jugular and subclavian catheters and
found more arterial punctures with the jugular approach, more malpositions with the subclavian approach, and no
difference in hemo or pneumothoraces (34). Post-ultrasound era data largely confirm these risk factors (35)

Ultrasound use may also affect line site selection. Because of anatomical considerations, ultrasound imaging is
more effective for internal jugular than for subclavian insertion. This slight advantage to internal jugular line
placement may be particularly relevant in patients who are anticoagulated or have a history of difficult line insertion.
The incidence of subclavian stenosis with insertion of large bore subclavian lines (36) has caused current CDC
guidelines and the National Kidney Foundation to recommend against subclavian dialysis access (36). The use of
small -footprint phased array probes with nonzero elevation may change this preference, as they increase the
likelihood of visualizing the tip of the needle and thus decrease the chance of pneumothorax.

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Taken together, these data and guidelines suggest the following “best practice” approach to line site selection:
1. Identify available sites. If possible, avoid sites with prior surgery, known thrombotic complications,
broken/infected skin, or existing hardware (such as transvenous pacemakers). Be aware that case reports identify
the left IJ site as more complication prone than the right IJ, suggest a higher likelihood of aortic injury/tamponade
with subclavian vs internal jugular approaches, and imply that the more tortuous path of the right subclavian
approach may predispose to aortic injury due to guidewire kinking.
2. Prioritize the femoral site LAST for thrombosis and infectious control reasons, particularly if the duration
of the line is expected to be long. If access requirements are emergent, femoral access followed by relocation to a
less infection prone site after stabilization is a reasonable approach.
3. Scan available sites to identify potential barriers to site insertion
4. If placing a large-bore introducer, consider the smaller size and more variable location of the left IJ, and
risk of subclavian stenosis with large bore indwelling catheters as potential decision factors.
5. Recognize that the risk of pneumothorax during ultrasound guided subclavian insertion is higher due to an
inability to visualize the entire needle tip.

e. Aseptic technique
Although the mechanism by which “bundles” of activities performed together reduce central line infections is
unclear (11), the effect is robust. Elements of such bundles include cap, mask, sterile gown and gloves, and
handwashing prior to performing the procedure (37). The drop in central line infections triggered by revamping
organizational aspects of line insertion has been highlighted in a US Morbidity.Mortality Weekly Report in March
of 2011 (38). Among bundle components, avoiding the femoral site and removing unneeded lines have the greatest
impact on-line infection (13). But even partial bundle compliance reduces infection rates (39, 40). These data
suggest that specific elements of a line insertion “bundle” may not be as important as whether a bundle is used at all.

With respect to skin preparation, chlorhexidine and alcohol have largely supplanted Povidine-Iodine due to
controversial guideline pressure (41). The largest trial to date comparing the two strategies finds Chlorhexidine
superior for CLABSI prevention, but also that it caused more skin reactions (42). A 2016 Cochrane review found
weak evidence for the superiority of Chlorhexidine when compared to Povidine Iodine (43). Note that the package
insert for chlorhexidine/alcohol recommends a, “back and forth” scrubbing application pattern for 30 seconds rather
than the “inside to outside’ circular pattern used for Povidine Iodine to adequately penetrate skin layers (44).

An emerging concern is chlorhexidine allergy. Because chlorhexidine may be present in hospital products such as
shampoo, rectal and gynecological gel, mouthwash and toothpaste, exposure to chlorhexidine in the healthcare
setting is common. A 2017 FDA warning noted that of the 43 cases of chlorhexidine allergy reported since June
2015, more than half occurred after 2010 (45). A classical pattern is severe, persistent hypotension on exposure to
topical skin preparation, and in one 2016 study the most common mechanism of repeat allergic reaction was central
line insertion (46).

With respect to antibiotic-impregnated central lines, a 2013 Cochrane review (47) found a reduction in catheter
colonization and related bloodstream infections only in the ICU and no effect on mortality. A 2016 trial of
chlorhexidine impregnated lines also found no reduction in CLABSI with chlorhexidine impregnated lines (48)
CDC guidelines recommend use of impregnated catheters only for prolonged use, or if a comprehensive strategy to
reduce infection rates does not work.

Insertion
a. Patient position
Although the effect is variable, abdominal compression, increased intrathoracic pressure, and Trendelenburg
position all increase internal jugular (49) but not subclavian (50) vein size. Nevertheless, using the Trendelenburg
position where clinically feasible for both access sites reduces the risk of air embolism. When targeting the internal
jugular site, head rotation should be limited as increasing head rotation increases overlap between the internal
jugular vein and carotid artery (32). Evidence suggests modest improvements in subclavian vein size with the head
in the neutral position (50).

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publication contains material copyrighted by others. Individual refresher course lectures are reprinted by ASA with permission.
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Observational studies from the pre-ultrasound era find that central venous access complication rates increase with
the number of needle passes (51), and that more experienced operators have higher success rates (52). Based on
these data, practitioners should consider changing operators or techniques if multiple passes by a single operator are
unsuccessful.

All guidelines listed on page 1 of this handout recommend the use of ultrasound to facilitate central line insertion.
One important caveat to ultrasound use is verifying visualization of the needle tip. In short axis scanning, the tip
and shaft of the needle will appear identical and inexperienced operators failing to scan distally may miss the needle
tip and increase the risk of carotid puncture or pneumothorax. Long axis visualization may lower (but not eliminate)
that risk but current data comparing long and short axis views are mixed (53, 54) Focusing on the ultrasound image
instead of the patient during insertion may also lead to overadvancing the needle (55). CDC guidelines for consider
training a category 1B recommendation and CEC guidelines explicitly state that “previous training or experience is
required to use this technology (US) effectively”. Two “clinical pearls” that may help with needle and wire
visualization is tilting the probe to target a 90 angle between ultrasound beam and needle and aiming the beam into
the chest to follow the wire below the clavicle.

Complications of wire insertion include dislodgement and ensnarement of vena caval filters (56), entanglement in
the tricuspid valve (57), and complete heart block (58). This literature suggests that best practice should avoid
inserting the wire too deeply. Once the wire is inserted, a verification step is strongly recommended to verify wire
location in the target vein. Strategies to distinguish venous from arterial location with equivocal evidence include
pressure waveform analysis, color of blood, blood gas analysis, or absence of pulsatile flow. Other strategies such
as fluoroscopy, continuous electrocardiography, transesophageal echo, or chest XRay have little comparative
evidence, but considerable face validity. The “bicaval” TEE view of the right atrium is widely considered the most
reliable guide to verifying wire location in the right atrium. Transthoracic ultrasound may also be helpful for wire
visualization (59)

The strongest published evidence for verifying catheterization of the vein is manometry. With this technique, a
length of IV tubing is attached to an IV catheter or needle located inside the vessel in question. The pressure in the
vessel is then measured either by the height of the column of blood, or by pressure transduction. In a 2009
retrospective review (60), 9,348 central venous catheters were placed during a 15 year period using manometry and
no cases of dilator placement into adjacent arteries were noted. The authors concluded that manometry prevented up
to 56 possible arterial dilations.

The choice of verification technique depends on cannulation technique. With the Seldinger technique, use of
manometry to verify wire placement must be performed with the needle tip manually stabilized. It is easy to see that
this approach requires a high degree of manual dexterity, particularly when access is difficult or the patient is
breathing spontaneously or moving. In contrast, with the modified Seldinger technique the inserter threads a plastic
catheter over the hollow needle into the vein. Manometry can then be performed via this catheter.

Overall, existing evidence is insufficient to dictate a ‘best practice” for insertion. Nevertheless, case reports,
observational trials, clinical experience, and expert opinion can be integrated to recommend a reasonable practice
with respect to the insertion process:
1. Because the consequences of arterial puncture are significant, verification that the target vein has been cannulated
(vs the artery) is strongly recommended by ASA and CEC guidelines
2. Blood color, waveform analysis, and/or pulsatility are NOT recommended due to high error rates
3. Case reports and observational trials support the use of fluoroscopy, catheter tip electrocardiography, or TEE/TEE
4. The two verification strategies with the greatest degree of overall support are pressure transduction of the target
vessel (manometry) and ultrasound imaging of the catheter inside the target vessel.
5. Choice of verification technique should depend on operator experience, technical issues, and verification strategy.

Some controversy exists with respect to catheter tip position. While tip location in the right atrium predisposes to
perforation and tamponade (61), cadaver studies suggest that the pericardial reflection can reach as high as the
middle third of the superior vena cava (62). In addition, a “high” catheter tip from the left subclavian or IJ site is
prone to thrombosis/malfunction (63) and may form an acute angle to the SVC and predispose to perforation (64).
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Verifying that the tip of the line does not protrude below the bottom border of the right mainstem bronchus is
helpful in preventing atrial location (65). CEC guidelines provide a table to specify insertion depth as a function of
patient height and insertion site.

Complications and aftercare

The list of complications referable to central line insertion is large. These include arterial puncture, hematoma,
hemothorax, pneumothorax, aortic injury, vena caval or atrial perforation, tamponade, intrathecal insertion, guide
wire loss, thoracic duct damage, arrhythmia, and catheter-related infection. A 2003 New England Journal review
estimated the incidence of arterial puncture as 6-9% for the IJ site and 3-5% for the subclavian site, and the
incidence of pneumothorax as 0.1-0.2% for IJ and 6 to 11% for subclavian sites (66). With ultrasound, the incidence
of arterial puncture is now ~1% for the IJ site.

A 1970- 2004 closed claims analysis of central line complications found 110 claims for injuries related to central
lines (67). The most common were wire/catheter embolus (N=20), followed by tamponade, carotid artery
puncture/cannulation, and hemothorax/pneumothorax. Post-insertion best practice should thus include maintaining a
high degree of suspicion for the possibility of injury. Other elements of central line aftercare include daily attention
to the ongoing need for central access, and prompt removal if the line is no longer necessary can clearly shorten line
duration and reduce infectious complications. Existing literature recommends against routine replacement of central
venous catheters (68), against routine antibiotic ointments (63), and against routine wire guided line exchange (68).

The 2019 ASA guideline revision:

2019 marks the first revision of the original 2012 ASA guidelines for central line insertion. Although most
guideline recommendations are the same, some subtle changes have occurred:
1. The 2019 version now excludes central line removal, management of peri-insertion coagulopathy, and
competency assessment as covered topics. None have adequate data for a firm recommendation. Although
few data inform central line removal, most protocols include Trendelenburg position, application of an
occlusive dressing, and positive intrathoracic pressure as steps to prevent air entrainment. No platelet count or
INR/FFP transfusion threshold establishes safe management of peri-insertion coagulopathy. And, although
simulator training improves trainee performance, no consensus process for competency assessment exists.
2. The 2019 version no longer recommends a trained assistant (although an assistant is still recommended)
3. In line with near universal acceptance of insertion bundles as an empiric strategy for reducing complications,
survey results are no longer broken out by % for separate bundle elements
4. In the 2012 guidelines, consultants recommended the subclavian site rather than the IJ to minimize catheter
related infection. The 2019 version recommends only an upper body insertion site (vs femoral). These
changes are consistent with newer data finding a smaller effect of insertion site on infection risk.
5. The 2019 version recommends that chlorhexidine containing dressings be observed daily for signs of
irritation/allergy/necrosis
6. Where as the 2012 version recommended the IJ site to minimize catheter related risk of thrombotic
complications, the 2019 version suggests only an upper body site (vs femoral).
7. The 2019 version responds to new data finding inconsistent enlargement of the IJ with Trendelenburg position
8. The 2019 version reviews data comparing thin wall vs catheter over needle cannulation techniques. For the
subclavian approach, one study finds benefit to a thin wall approach.
9. The 2019 guidelines emphasize dynamic (vs static) use of ultrasound for line insertion
10. The 2019 guidelines widen wire localization strategies to include transthoracic ultrasound
11. The 2019 guidelines state that, if using catheter over needle, wire confirmation is not neded if the catheter
enters the vein easily and manometry verifies venous location
Summary

Advances in central line insertion techniques, increased attention to central line complications, and improved
training strategies have dramatically improved the safety of central line insertion. Best practices likely include an
organized, systematic approach to inserter training, line insertion, use of static and dynamic ultrasound when
feasible, evidence-based site selection, verification of wire position, localization of the catheter tip, and post-
insertion maintenance.

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Refresher Course Lectures Anesthesiology 2019 © American Society of Anesthesiologists. All rights reserved. Note: This
publication contains material copyrighted by others. Individual refresher course lectures are reprinted by ASA with permission.
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