LRH · EMERGENCY DEPARTMENT

Central Venous Catheter (CVC)

INDICATIONCentral venous access for drugs / monitoring / volume resuscitation / dialysis when peripheral access is inadequate — ultrasound-guided Seldinger technique, full sterile barrier precautions.

EQUIPMENT
RESUS BAY · CVC KIT + ULTRASOUND
  • Catheter choice: triple-lumen 7 Fr 15–20 cm (drugs/monitoring) · 8.5 Fr introducer sheath/Cordis/MAC (volume resuscitation) · 12 Fr dialysis catheter where needed
  • Kit includes: 18g introducer needle + syringe, J-tip guidewire, dilator
  • Ultrasound + high-frequency linear probe, sterile probe cover and gel
  • Full barrier: sterile gown/gloves/cap/mask, large drape, dressing tray, 600 mL bowl + 150 mL gallipot for flush
  • Skin prep: chlorhexidine 2% in 70% alcohol or povidone-iodine, 2× 15 cm foam applicators
  • Disposable 10/11 scalpel; syringes (2×10 mL + 1×5 mL Luer-lock); needles 18g blunt/21g/25g; lidocaine 1%
  • To finish: suture kit with 3/0 non-absorbable, gauze, Biopatch, Tegaderm 10×12 (large) + 6×7 (small), non-return caps ×4 (one per lumen), saline flushes
FIG 1 · RIGHT IJ ACCESS UNDER ULTRASOUND
STEPS
  1. Site: right IJ preferred (straight run to SVC, ultrasound-friendly); subclavian has lowest infection rate but highest pneumothorax risk; femoral fastest in arrest. If the IJ attempt fails, next attempt stays ipsilateral — never risk bilateral pneumothorax.
  2. Position: supine, head neutral (cervical collar on if trauma); Trendelenburg for IJ/subclavian, head rotated slightly away. Pre-scan the vein: compressible, adequate calibre.
  3. Full sterile prep and drape; sheath the probe; flush all lumens; anesthetize skin and track.
  4. Puncture under real-time ultrasound at ~45° (shallower for subclavian), tracking the needle tip, aspirating until dark venous flash.
  5. Drop the angle, stabilize, remove the syringe (occlude the hub) and thread the J-wire — never force it, stop at ~15 cm. Ectopy on monitor → withdraw wire a few cm.
  6. NEVER let go of the wire — remove the needle over it.
  7. Confirm the wire in the vein in transverse AND longitudinal planes before dilating.
  8. Nick the skin ~0.5 cm beside the wire; dilate — only the first 1/3–1/2 of the dilator is needed.
  9. Advance the catheter over the wire to target depth (see key numbers); withdraw the wire out of the distal port, check the whole wire is out.
  10. Aspirate then flush every lumen, non-return cap on each; secure with two sutures + Biopatch + Tegaderm; CXR to confirm tip at cavoatrial junction, no pneumothorax.
Losing the guidewire intravascularly is the classic disaster — one hand on the wire at all times, count it out at the end. Dilating before two-plane wire confirmation risks arterial dilation, the injury that matters.
~15 cm
WIRE IN
0.5 cm
SKIN NICK
13–17 cm
DEPTH R/L IJ & SC (±2)
INR >3 / PLT <20K
CAUTION
2 PLANES
CONFIRM WIRE B4 DILATE