ICU Procedure Guide

Ultrasound-Guided Central Venous Catheter Insertion

Central venous access using real-time ultrasound, maximal sterile barrier precautions, wire safety and reliable confirmation before high-risk use.

Competency & safety: For trained operators with immediate access to supervision/rescue when difficult anatomy or complications occur.

AI-generated ICU Knowledge Map summary infographic for central venous catheter placement, covering indications, site selection, sterile preparation, Seldinger insertion, confirmation, and complications. — AI-generated educational illustration reviewed for alignment with the accompanying ICU Knowledge Map topic. The topic text and cited references remain the source of truth for clinical decisions. Tap or click the image to open it full size.

Educational ICU procedure visual: Ultrasound-Guided Central Venous Access — Safety Checkpoints. — AI-generated educational illustration reviewed for alignment with the accompanying ICU Knowledge Map topic. The topic text and cited references remain the source of truth for clinical decisions. Tap or click the image to open it full size.

Post-procedure imaging

Verify it on ICU Imaging

Practice recognizing correct device position, malposition and imaging complications after this procedure.

🩻 CXR Case 004 →🩻 CXR Case 026 →

Decide first

Indications & contraindications

Indications

Vasoactive infusions
Reliable central access for selected irritant/hyperosmolar therapies
Difficult peripheral access
Hemodynamic monitoring when clinically useful
Large-bore access or dialysis when an appropriate catheter is selected

Contraindications / reasons to change strategy

Infection or burn at the insertion site
Known thrombosis/occlusion of target vessel
Uncorrected severe coagulopathy when a safer site/strategy exists
Anatomy that cannot be safely visualized

Before starting

Equipment checklist

□01Full sterile barrier: cap, mask, sterile gown/gloves and full-body drape

□02Chlorhexidine-alcohol skin prep unless contraindicated

□03Ultrasound with sterile cover and gel

□04Central line kit: needle, guidewire, dilator, catheter, scalpel

□05Local anesthetic

□06Pressure transducer/manometry or other venous confirmation method when needed

□07Suture or approved securement device and sterile dressing

Know what you should see

Ultrasound vessel view

Landmarks

Target vein and adjacent artery
Compressibility and respiratory variation
Needle tip entering the lumen
Guidewire visualized within the vein before dilation

Ultrasound / visual target

Use real-time needle-tip visualization
Scan for thrombosis before puncture
Confirm the wire remains intravascular before dilating

Danger zones

Carotid/subclavian/femoral artery
Pleura/lung apex for thoracic approaches
Excessive wire insertion causing arrhythmia
Dilating an unconfirmed vessel

Watch the technique

Procedure video

External educational video

Central Venous Catheter Insertion

Pre-insertion

Preparation, positioning, ultrasound assessment, sterile setup and equipment review (0:00–6:33).

0:00–6:33

Central Venous Catheter Insertion — Pre-insertion

Insertion

Needle/wire/catheter insertion and completion from 6:33 to the end.

6:33–end

Central Venous Catheter Insertion — Insertion

Clinical-use note: Embedded from TeachIM. The source is licensed for noncommercial reuse; do not rehost or republish it as commercial content without permission.

Source: TeachIM ↗Creator: TeachIM procedural curriculumLicense: CC BY-NC 4.0 ↗Noncommercial / restricted use

Set up for success

Preparation

Choose the site by balancing infection, mechanical-complication, thrombosis, bleeding and future dialysis-access risks. In adults, CDC guidance advises avoiding femoral CVC access when suitable alternatives exist; for a nontunneled CVC, subclavian access has lower infection risk than jugular/femoral access but must be balanced against pneumothorax/bleeding risk.
Avoid subclavian access in hemodialysis patients and patients with advanced kidney disease when possible because central venous stenosis can compromise future permanent dialysis access.
Use the minimum number of catheter lumens required for the clinical indication.
Perform hand hygiene and maximal sterile barrier precautions: cap, mask, sterile gown, sterile gloves and a full-body sterile drape.
Prepare clean skin with >0.5% chlorhexidine in alcohol unless contraindicated, and allow the antiseptic to dry according to the product instructions before puncture.
Flush and prepare all lumens, caps and clamps before insertion.
For adults undergoing CVC placement at a compressible site, the 2025 AABB/ICTMG platelet guideline recommends prophylactic platelet transfusion when the platelet count is <10 × 10^3/µL (conditional recommendation). Do not extrapolate this single threshold to noncompressible, large-bore or otherwise higher-risk access; individualize with the procedural context and local policy.

Technique

Step-by-step technique

Identify vein and artery with ultrasound and confirm patency

Infiltrate local anesthetic

Advance needle under real-time ultrasound until tip is clearly in the vein

Confirm venous blood/pressure when uncertainty exists

Advance guidewire without force and visualize it in the vessel

Make a small skin nick, then dilate only after wire position is certain

Advance catheter over the wire while maintaining control of the wire at all times

Remove wire, aspirate and flush every lumen

Secure catheter, apply sterile dressing and document depth

Hard stop points

Never dilate without confident venous wire position
Stop if resistance is encountered
Treat sudden hypoxemia/hypotension after thoracic insertion as a possible procedural complication until excluded

Never assume

How to confirm success

Confirm venous placement before dilation when doubt exists
Confirm final catheter tip/absence of pneumothorax using the locally accepted method: ultrasound, intracavitary ECG and/or chest radiography depending on site and circumstances
Do not use for high-risk infusion if location remains uncertain

When it does not go to plan

Complications & troubleshooting

Complications to watch for

Arterial puncture/cannulationHematomaPneumothorax/hemothoraxAir embolismGuidewire lossArrhythmiaThrombosisMalpositionCLABSI

Wire will not advance

Stop. Do not force it. Reconfirm needle tip position and vessel anatomy; withdraw and repuncture if necessary.

Large-bore catheter/dilator placed in an artery

Leave it in place and obtain vascular/endovascular consultation rather than removing it blindly.

No blood return from a lumen

Check clamp/kink/position, withdraw slightly if safe, and confirm catheter position before use.

Procedure is not finished when the device is in

Aftercare & documentation

Daily line-necessity review
Inspect site and dressing
Use meticulous hub disinfection
Remove promptly when no longer required

Procedure competency mode

Test yourself before the bedside

Sequence recognition, hard-stop recall and complication response for Central Line. This is an educational self-check, not credentialing.

1. Sequence challenge

Score 0/5

Current step