Read this Review of Vascular Complications of CVC Placement
(J Cardiothoracic and Vascular Anesthesia 2014;28(2):358)
When to Confirm
I prefer to confirm all non-crash introducers and especially HD caths prior to dilation. There are times I will place a triple lumen and then confirm the line after insertion (do the latter at your own risk)
Confirming Venous Placement (Choose at least 1)
- Observation of the intravascular pressure waveform using an electronic transducer and pressure tubing
- Determination of the of the intravascular pressure using sterile tubing as a venous manometer
- Analysis of the PO2 of a blood specimen drawn from the needle/catheter compared to simultaneously drawn arterial blood (this is stupid!)
- Bubble Test-when saline is rapidly injected through the catheter, there is opacification of the echocardiographic view of the right heart structures.
- Using real-time fluoroscopic or echocardiographic confirmation of venous catheterization (e.g., visualizing the guide wire or catheter within the superior vena cava)
- Using a contrast study to opacify the venous structures.
Less Desirable
- Guidewire Visualization in the Vein
The Methods in Depth
Pressure Transduction
Easiest way to do this is use the casing of the wire was packaged in–this tip thanks to my friend Taku Taira, MD.
How to Use Wire Casing to Transduce Pressure
- [cite source='pubmed']19377052[/cite]
- [cite source='pubmed']9412883[/cite]
- Numerous other studies cited here: (J Cardiothoracic and Vascular Anesthesia 2014;28(2):358)
Study specifically on using tube transduction (Anesth Analg 2009;109:130)
Or if doing IJ, Just use the Catheter-Over-Needle from the Get-go (but I will lose all respect for you)
thankfully Reub provided the study showing the needle technique is superior [cite source='doi']10.1097/CCM.0000000000001167[/cite]
Or Using a Commercial Device
Compass Single Use Manometers with or without guidewire slot
Bubble Test, Flush Test, Rapid Atrial Swirl Sign (RASS)
Inject 10 ml of saline and observe Right Atrium/Right Ventricle
- [cite source='doi']doi:10.1016/j.ajem.2014.10.010[/cite]
- [cite source='pubmed']24552526[/cite]
- [cite source='pubmed']25624649[/cite]
- [cite source='pubmed']17006130[/cite]
- [cite source='pubmed']19829102[/cite]
- [cite source='pubmed']23242559[/cite]
- Should appear in <2 seconds for properly placed neck line [cite source='pubmed']25550065[/cite]
- Saline Flush and Pneumo Exclusion obviates immediate chest radiography [cite source='pubmed']26112633[/cite]
- For Hemodialysis Caths (Kidney International Reports 2017;2:952
- Crit Care Med 2017;45(7):1192
- SR DOI 10.1097/CCM.0000000000002188
- Ultrasound to Detect Central Venous Catheter Placement Associated Complications: A Multicenter Diagnostic Accuracy Study. Anesthesiology. 2020 Jan 21. doi: 10.1097/ALN.0000000000003126. [Epub ahead of print]
bubble confirm of central lines
Video from Sinai EM Ultrasound
and
from Prekker et al. Rapid Confirmation of Central Venous Catheter Placement Using an Ultrasonographic “Bubble Test” DOI: 10.1111/j.1553-2712.2010.00785.x
Guidewire Visualization
[cite source='pubmed']20006207[/cite]
but…
This series should scare the hell out of you [cite source='pubmed']19531950[/cite]
so, strongly recommend visualizing down to clavicle [cite source='pubmed']20626896[/cite]
Make it Easier to see
- Push just caudad to the entry of the wire at the skin to improve wire visualization
- GIF from Canadian Journal of Anesthesia , Volume 62, Issue 7, pp 839-840
- People who think they can see the guidewire probably can’t (American Journal of Emergency Medicine 2011;29:432)
Confirming the Subclavian went down instead of up
[cite source='pubmed']19244259[/cite] and [cite source='pubmed']11748395[/cite]
So Do We Need a Chest Radiograph?
I would say eventually, but certainly use the line way before the x-ray. And–Non-contrast radiographic examination should NOT be used to confirm that a central venous catheter is located in a vein. Radiologic examination is useful for determining the depth of insertion and the presence or absence of complications related to the central line placement, such as pneumothorax or hemothorax.
Recent study says, we do not need one at all1
Do we need to turn off the Ventilator?
No!!! (Anesthesia & Analgesia September 2016 – Volume 123 – Issue 3 – p 636–640)
Influence of Mechanical Ventilation on the Incidence of Pneumothorax During Infraclavicular Subclavian Vein Catheterization: A Prospective Randomized Noninferiority Trial
For More on the Above, Please Read PulmCrit's Post on Central Line Positioning
Update: More Support for Ultrasound Confirmation (Emerg Med J doi:10.1136/emermed-2015-205000)
Treatment of Inadvertent Arterial Cannulation
‘If in doubt, don't take it out!' from the excellent review: [cite source='doi']10.1093/bja/aes497[/cite]
If there is a placement of a catheter into an artery, please follow the following procedures:
Introducer or Dialysis Catheter
- Leave line in situ, clamp, and cap it
- Call vascular consult
- Vascular should not being pulling carotid introducer catheters in the ED, unless it is discussed with the vascular attending.
- These patients usually need direct visualization of the injury in the OR or endovascular techniques
Triple Lumen
- Go by local guidelines
Guilbert et al.'s series should explain why pull & pray may not be the best move [cite source='doi']10.1016/j.jvs.2008.04.046[/cite]
Injection of Meds into Unrecognized Arterial Lines
The article on arterial injection of medications was Mayo Clin Proc. 2005;80(6):783-795
The Lost Guidewire
Review [cite source='doi']10.1097/CCM.0000000000001012[/cite]
Additional New Information
More on EMCrit
- PulmCrit Post
- EMCrit 157 – Central Lines II – Placement Tips(Opens in a new browser tab)
- Doubling down: ultrasound confirms central line position(Opens in a new browser tab)
- PulmCrit- Shrug Technique for US-guided subclavian lines(Opens in a new browser tab)
- Line infection(Opens in a new browser tab)
Additional Resources
You Need an EMCrit Membership to see this content. Login here if you already have one.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
- EMCrit 396 – Some Philosophy of Surgical Airways (Crics) and What to Do When the Doom is Lower Down (Central Airway Obstruction) - March 7, 2025
- EMCrit 395 – Stellate Ganglion Block – Not Whether, but When? - February 23, 2025
- EMCrit 394 – CV-EMCrit – Inotrope Basics Part 2 – Specific Scenarios - February 7, 2025
Hi Scott – Great podcast! Long time listener but first time commentor. I am one of the ICU residents/ED registrars from a metropolitan hospital Down Under in Australia. Thank you for doing this fortnightly podcast! You’ve greatly contributed to my education so far. My tip in order to avoid losing the guidewire from a central line: As soon as I withdraw the guidewire through the central line and the distal part of the guidewire comes through the brown port, I use an artery forceps to clamp down on the guidewire, thus securing it (and the guidewire can never be sucked… Read more »
great stuff, Gavin. I will say, once the wire has popped out of the brown, you are already in the clear–you won’t lose your wire. Wires get lost because people do not push them all the way back through the line.
First, my disclaimer: I am the Director of Clinical & Medical Affairs in Europe, Africa & the Middle East for Teleflex (Arrow CVCs, EZ-IO, LMA, MAD Nasal, etc). My clinical background is ED nursing in South Texas. I just wanted to mention that there is a transduction probe which can be inserted through the back of the Raulerson syringe (using the same port the wire would go through). On the protruding end of the probe there is a luer lock which can be use for any of the methods you discussed in verifying placement. It basically creates an open pathway… Read more »
I use arrow and have the probe. Find the set-up unwieldy. Would love to see a 60 mm Hg non-electric, purely mechanical, strain gauge that pops up red between needle and syringe with a one-way valve
Such a mechanical valve (Turkey thermometer!) would be amazing.
Great podcast Scott, I think this is an incredibly important topic as it is one of the most common ICU and ED procedures out there and the consequences can be devastating if you botch this procedure. I’ve seen horrible outcomes from very senior anesthesia providers cannulating the carotid pre-CV surgery and it was a sobering sight to behold. I am an Acute Care Nurse Practitioner and my practice in three different ICU’s over the years has always been to have a sterile pressure transducer ready to go before I start the line so the nurse can hand me the transducer… Read more »
Hi scott, cool talk. ( regular listener and thanks for mail bag on emrap in AUG) I am an ED reg in Dublin. Just want to mention that one the most difficult bit I find is the dilatation. Especially with not dilating far enough, the cath then ends up kinking over the wire, some cases actually ripping the tip. But if going too far, end up causing lots of bleeding and further damage. At times not enough local so the patient in pain so I hold back and not advance far enough.. Just wanna know whether you have any tricks… Read more »
Pun, I find that the scalpel nick is important. If it is too small you can have issues with dilation. I will also use a bit of a twisting motion when advancing the dilator. Another issue that you can run into is when the angle of entrance into the neck or groin is to abrupt. IE the dilator has to bend a bit to stay inline with the wire. I run into this more with those with a very large neck. The issue with subclavian dilation is that if the needle passed just barely pass the periostium of the bone,… Read more »
Hi,
I am a Nephrology / rheumatology resident from Germany. I think that for triple lumen catheters the skin nick with the scalpel is not necessary if you are not in an emergent situation. Try to gently twist and push the dilator and it will go deeper eventually. You need a little patience for this but you might avoid some of those small bleeders from the incision site that take you like half an hour to stop.
– Peter
Great point Peter, I find this to be a valuable alternative when a patient has a bleeding issue…ex from uremia, on blood thinners etc. When I teach residents and fellows, I urge the operator to use some dilation. I think that it allows for ease of placement and in larger necks, you might run into difficulty driving a catheter. I have seen numerous residents and even fellows struggle with placement of the catheter if they are trying to force a very flexible line to go through skin. Typically once the wire is in the vessel the hurdle of advancing over… Read more »
Hi Scott, awesome talk and great tips. I am cardiologist in Bulgaria with interest in pacemaker implantation (permanent and temporary). The method that I am using for verifying that I am in vein and not in artery (with approach from the IJ and SC) is to sink down the guidewire in the inferior vena cava before insertion of the catheter. This is very reliable method to confirm the venous access. There is no way to be in artery and the wire will pass below the diaphragm on the right side of the spine. Of course it`s a little bit confusing… Read more »
Hi Scott, We don’t have the pressure transducer set up where I work (large community ER near Seattle). My preferred technique is simply to have an IV set up hanging and ready. As soon as I have placed my line I attach it to the IV. If it’s arterial, the blood will back up the line quite a way, even in a hypotensive patient (60 mmHg=80cm H2O), even allowing for the resistance of the tubing. Obviously this is after dilation, but if I access the vessel and am worried that it might be arterial I can attach it to the… Read more »
Liam, Unfortunately this method will not work at all in the circumstances where differentiation is most critical and difficult. Almost all infusion sets have built in anti-reflux valves to allow injection without having to pinch tubing. These can be seen as little disks on the line. I would be very surprised if your standard infusion sets did not have them. If you want to use the method you describe , you need blood tubing, which lacks these valves. Even then, it is fraught with potential for misinterpretation in the setting of hypotension. An easy estimate of whether there will be… Read more »
HI Scott, I really liked the post. Some thoughts: First, I think the Bubble test really obviates the need of for a CXR. Where else should the catheter be if not (somewhere) in the svc? It’s not even necessary for the exclusion of a pneumothorax, which can be excluded using ultrasound, as you mentioned. How sure are you that the patient does not have a pneumothorax when you immediately scan the ipsilateral lung using ultrasound? Most pneumothoraces do not develop immediately with the exception of a tension pneumothorax. How do you deal with ‘misplaced’ cvc personally? For example, if it… Read more »
Keep hearing no chest x ray is needed. I argree that this is data supported but I have a few concerns. Have you guys not seen the IJ catheter go toward the skull before? My understanding is that the risk of thrombosis increases as the vessel lumen becomes smaller, so a caudal pathway may lead to venous thrombosis. Can this complication be discovered by anything other than CXR? If not what is the issue if any of infusion of epi, levo and the like toward the venous sinus? I dont get chest x rays in the ICU on my patient… Read more »
“I do not get the CXR to see if the line is in a vein at initial placement” needs to be clearer. I get a film but the reason is not to see if the line is in a vessel lumen its to see where the line is anatomically
sorry for the repost.. just forgot how to edit my post.
Hi Craig,
Getting a chest x-ray is still standard of care at my institution,too, to look for displaced catheters (especially those going cephalad). But with a negative flush test you already know that the line has been incorrectly placed or moved and you can correct it during the procedure and start scanning the vessels and find the cath. Sometimes this gets easier when you reintroduce the wire and scan subclavian, IJ, contralateral and so on.
– Peter
I am assuming that fluroscopy is not being used for placement mind you… as that is adequate, but I rarely see the fluro machine come out for a good ole fashion central line…..
Great podcast again, particularly the section on managing inadvertent arterial placement. I’m currently updating our local guideline in response to some complications. We’re emphasizing that it really should be a 2 person job (at least), where possible. The second person’s main role is to audit the process, in our case on a single page checklist that also serves as the procedure note. On it is standard stuff plus the IN/OUT check: this ensures that 2 people are convinced, by whichever method, that the line is IN the vein, and that the guidewire is OUT. Both sign the form and take… Read more »
Hi Scott! Long time listener first time commenter. I’m a first year EM Resident at Morristown Medical Center in Morristown, NJ. While listening to podcast 156, you discussed the only way to lose sight of the guidewire is to get interrupted by someone entering the room and asking a question. I know it may sound simple, but while I was on SICU my first month before any other part of prep was done for a CVC, we ALWAYS closed the door/curtains and used that STOP sign in the kits (instead of throwing them away like I’ve seen done in the… Read more »
same thing when I was in the unit. It is the ED that is a chaotic disaster
Scott,
Two things
You don’t get it both ways buddy. Either there are gremlins or not.
Having trained in Detroit in the mid 90’s in a busy ED, remember YOU and only YOU as the proceduralist are responsible for your sharps!
Amen to the sharps!
There are definitively gremlins, but they don’t grab the wire during central lines–they drink my 3rd and 4th beers and then hit me in the head with a hammer while I am sleeping.
Scott, Thanks for posting, I think I will pass all my residents to this podcast before coming to the unit with me. A few things, do you really do confirm most of your central lines before dilation? I gown up with residents and after they get flash and pass wire successfully I look in longitudinal and short axis view at the entry point, and as far distally as my sterile field will go. In the neck or subclavian this is pretty easy, and if the resident back-walled the vessel its ALMOST ALWAYS at the site of puncture, which makes it… Read more »
Dave, great comments!
Great episode Scott! I’ve gotten to demonstrate a number of these techniques at the bedside to the SICU and ED residents…they love em.
Just wanted to see if you’d seen the 3SITES study just published in NEJM that prospectively confirmed the old biases of central line infection (Subclavian cleanest, IJ=Femoral for infection rates, IJ/Fem have higher thrombosis rates than SC). I’d be interested in seeing what your take is given podcast 80…
Luke Duncan, MD
Albany Medical Center
yes, of course. it only confirmed my biases–so obviously i loved the study
Hello Scott, thank you for those great resources.I look at them regularly myself and can only recommend them to anyone. Regarding pausing ventilation briefly or not: I just read an article that contradicts with the one mentioned by you. Maybe you should take a short pause in ventilation if you: – use, landmark technique for the subclavian approach AND the patient has a low BMI or COPD “The pneumothorax rate was significantly higher in the mechanical ventilation group (2.2% vs. 0.4%; p = 0.012) with an odds ratio (OR) of 5.63 (95% confidence interval, CI: 1.17–27.2; p = 0.031). A lower body mass index… Read more »