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Possessing the ability to safely insert central venous catheters (CVCs) for the care of critically ill patients is a potentially life saving skill.   Performing this procedure poorly can result in unecessary patient harm.

Completing this guide can provide you with the nonclinical knowledge and preparation necessary for a solid procedural foundation.

Making the most of your training

This guide will increase your knowledge and comfort with obtaining central venous access.  This guide is not intended to replace the hands-on simulation and clinical practice necessary to become a skilled practitioner.  

Steps of Safe Central Line Insertion Include:


When and when not to insert a central line

We want to insert central lines only in patients in whom they are indicated. 


How to choose the right insertion site for each patient

Choosing the correct insertion site can prevent subsequent infections and complications 


How deep to insert a central line

Getting the depth correct and a perfect first central line dressing are required steps. 

How much do you really know about central line placement?

Central line insertion is a fundamental skill for all residents, fellows, and attendings.   Do you really have the knowledge to be a central line professional? 

Types of Central Venous Catheters.

There are two main types of central venous catheters: multi-lumen catheters and introducer sheaths.    

Multi-lumen catheters are the workhorse of the hospital and are used for many different purposes.  Introducer sheaths are often used in the ICU and procedure labs to “introduce” another catheter, such as a Swan Ganz Cather or a transvenous pacemaker. 

Central lines can also be categorized by: 

  • Site of insertion
  • Tunneling
  • Antibacterial coating
  • Length
  • Number of lumens
  • Total and luminal gauge

Complications of Central Venous Catheter Insertion.

CVCs are also associated with life-threatening complications. To minimize these complications, each CVC insertion must be carefully planned concerning indication, type, site, insertion procedure, and subsequent management.

When to Seek Help.

As with most medical procedures, experienced operators have fewer complications. (1)  The actual number varies by provider, but the incidence of mechanical complications after three or more failed insertion attempts is six times the rate after a single attempt. (2) 

High-risk catheterizations should be recognized ahead of time and performed by experienced staff. 

If you are having trouble, seek help. 

Chapter 1

Principles of Central Venous Catheter Insertion

  • Central Line insertion is a complex procedure that has immediate and delayed complications.   Insertions should only be done in areas with adequate physical conditions, equipment, monitoring, and trained assistance. 

  • Untrained clinicians should be supervised when inserting central venous catheters. Clinicians without experience in central venous catheterization should complete a training program consistent with your institution’s central line medical education department.  If your institution does not have education, can direct you to other training programs. 

  • The level of supervision required by a clinician for a particular central venous catheterization should be appropriate for the operator’s experience and the patient’s clinical condition. Patient factors must be considered before beginning central venous catheterization. An escalation procedure should be in place to minimize patient harm when difficulties arise (e.g., multiple passes and complications).


  • A central venous catheter should only be inserted when there is a clear indication for its use and when the benefits obtained from central venous access outweigh the insertion risks. Central venous catheters are associated with several complications and should be removed as soon as practical. 

  • The site of central venous catheterization and type of catheter should be determined based on patient/situational factors and the risks inherent in the sites considered. The number of lumens and the catheter diameter should be minimized to reduce the risk of catheter-related infection and thrombosis. 
  • Clinicians should be aware of and take appropriate steps to minimize the risks of guide wire embolization and damage.


  • Dilators should not be inserted into a vessel until it is determined to be a vein, not an artery. 

  • All connections, ports, and stopcocks attached to a central venous catheter should be cleaned before injecting fluids/drugs or aspiration of blood.


  • The routine replacement of central venous catheters (i.e., weekly changes) and antibiotic prophylaxis is NOT recommended to reduce CLABSI.

  • Tunneled central venous catheters have a lower infection rate and may be more suitable when long-term (greater than 30 days) access is required. 

  • Appropriate post-insertion care is vital to minimize short and long-term complications. A perfect dressing at the time of insertion, as well as proper ongoing care and maintenance of the line, is vital for preventing CLABSI.  

  • Ultrasound guidance aids the insertion of central venous catheters and should be used in most central venous catheterization.


  • Strict asepsis is required for all central venous catheterizations to reduce the risk of local and/or systemic infection.

A central venous catheter is an intravascular catheter placed so that the tip lies near the center of circulation in one of the vena cava.

These large veins have a large luminal diameter and high blood flow that makes them suitable for:


  • Administration of sclerosing infusions
  • High blood flow access for dialysis or plasmapheresis
  • Hemodynamic monitoring
  • Venous access when peripheral access is unavailable
  • Long-term venous access.


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