INTRODUCTION — Central venous access is a commonly performed procedure to place central venous catheters that also facilitates other venous interventions and device insertions, including the following: pulmonary artery catheters, plasmapheresis catheters, hemodialysis catheters, extracorporeal life support cannulas, inferior vena cava filters, and intracardiac pacing wire and defibrillator leads. The central venous access site and techniques by which access is achieved depend upon the indication for placement, patient vascular anatomy, and other patient-related factors.
The general principles of central venous access, including indications, contraindications, and general issues of preparation and placement, will be reviewed here. The role of catheters and devices for monitoring cardiac parameters or administering chemotherapy or parenteral nutrition are discussed in separate topic reviews.
The general principles of ultrasound-guided placement and placement of jugular, subclavian, and femoral catheters; issues specific to these anatomic sites; routine maintenance and care of catheters and port devices; and complications of central venous catheters and related devices are reviewed in more detail elsewhere.
●(See "Principles of ultrasound-guided venous access" and "Placement of jugular venous catheters" and "Placement of subclavian venous catheters" and "Placement of femoral venous catheters".)
●(See "Routine care and maintenance of intravenous devices".)
●(See "Overview of complications of central venous catheters and their prevention in adults".)
CENTRAL VENOUS ACCESS — A central venous access device is defined as a catheter placed into a thoracic central vein (eg, superior vena cava, brachiocephalic vein, subclavian vein, internal jugular vein) or the iliocaval venous system (eg, inferior vena cava, iliac vein, common femoral vein).
Central venous access is obtained at specific anatomic sites by percutaneous puncture to cannulate the vein, often using ultrasound guidance. (See 'Device and site selection' below.)
A wide range of central venous catheters and devices are available and are classified based on clinical category (ie, acute, subacute, chronic), duration of catheter use (ie, dwell time: short-term, mid-term, long-term) (algorithm 1), type of insertion (ie, central, peripheral), location of insertion (ie, jugular, subclavian, femoral, brachial), number of lumens (ie, single, double, triple), as well as whether the catheter is implanted or not and to what extent (ie, tunneled [ie, hemodialysis], totally implanted [ie, port]) (figure 1). The basic features of the various types of catheters and the way these features influence catheter selection are discussed separately. (See "Central venous access: Device and site selection in adults", section on 'Types of central venous catheters'.)
Several other medical devices also require central venous access for placement (eg, pulmonary artery catheter, extracorporeal life support cannula, inferior vena cava filter, and intracardiac pacing wire and defibrillator leads), often using an introducer sheath for vein access.
Indications — Indications for the placement of central venous catheters include [1-4]:
●Inadequate peripheral venous access (unable to obtain, or complex infusion regimen).
●Peripherally incompatible infusions – Long-term intermittent or continuous administration of medications such as vasopressors, hyperosmolar solutions, chemotherapy agents, and parenteral nutrition are typically administered into a central vein, as they can cause vein inflammation (phlebitis) when given through a peripheral intravenous catheter.
●Hemodynamic monitoring – Central venous access permits measurement of central venous pressure, venous oxyhemoglobin saturation (ScvO2), and cardiac parameters (via pulmonary artery catheter).
●Extracorporeal therapies – Large-bore venous access is required to support high-volume flow required for many extracorporeal therapies, including renal replacement therapy (ie, hemodialysis, hemofiltration), plasmapheresis, and extracorporeal membrane oxygenation.
●Venous access for placement of:
•Vena cava filters (image 1) (see "Placement of vena cava filters and their complications")
•Venous thrombolytic therapy/venous angioplasty/venous stenting (see "Endovenous intervention for thoracic central venous obstruction" and "Endovenous intervention for iliocaval venous obstruction")
•Pulmonary artery catheters (figure 2) (see "Pulmonary artery catheters: Insertion technique in adults")
•Pacemakers/defibrillators (figure 3) (see "Temporary cardiac pacing" and "Permanent cardiac pacing: Overview of devices and indications" and "Implantable cardioverter-defibrillators: Overview of indications, components, and functions")
Relative contraindications — Contraindications to central venous catheterization are relative and depend upon the urgency and alternatives for venous access.
Coagulopathy and/or thrombocytopenia — Moderate-to-severe coagulopathy is a relative contraindication to central venous catheterization, although major bleeding is uncommon. A systematic review of central line placement in coagulopathic patients documented a bleeding incidence of 0 to 32 percent, with major bleeding in <1 percent. Importantly, the risk of bleeding was not predicted by severity of coagulopathy [5].
The need for urgent and emergency venous access may require cannulation despite coagulopathy, and the safety of standard and large-bore nontunneled catheter insertion in this circumstance has been documented [6-10]. In general, nontunneled catheterization at sites that are easy to monitor for bleeding is preferred in patients with documented coagulopathy. As an example, the subclavian approach must be avoided due to limitations in monitoring or compressing the venipuncture site, unless an alternative site is not suitable. (See "Central venous access: Device and site selection in adults", section on 'Benefits/risk for specific sites'.)
For patients with severe coagulopathy who require immediate central venous access, we recommend ultrasound-guided cannulation, whenever possible, performed by an experienced provider [11]. Ultrasound guidance decreases the number of attempts required for successful cannulation and reduces complication rates, including bleeding. (See 'Use of ultrasound' below.)
The platelet count, international normalized ratio (INR), and partial thromboplastin time thresholds for which central venous catheterization can safely be performed remain unclear. Thrombocytopenia, especially when coupled with platelet dysfunction, appears to pose greater risk compared with prolonged clotting times [12,13]. Despite common concern and practice, there is limited evidence supporting routine correction of coagulopathy prior to central venous cannulation [5,10,14,15]. Retrospective studies suggest that no preprocedure reversal is warranted for platelet count >20 x 109/L and INR <3 [5]. For severe coagulopathy (eg, platelet count <20 x 109/L and INR >3), we advocate consideration of administration of a preprocedure blood product (eg, platelets, fresh frozen plasma) when time allows and based on the clinical decision that the benefit of preprocedure replacement outweighs the risk. The indications for correcting coagulopathy in patients undergoing invasive procedures and dosing are discussed in detail elsewhere. (See "Platelet transfusion: Indications, ordering, and associated risks", section on 'Preparation for an invasive procedure' and "Clinical use of plasma components", section on 'Overview of indications'.)
Site-specific considerations — Cannulation is generally avoided at sites with anatomic distortion or other indwelling intravascular hardware, such as a pacemaker or hemodialysis catheter. Contaminated or potentially contaminated sites such as local skin infection or proximity to a wound, burn, or tracheostomy are avoided. Vascular injury proximal to the insertion site represents another relative contraindication. Relative contraindications for specific sites are discussed separately. (See "Central venous access: Device and site selection in adults", section on 'Access site' and "Overview of acute and emergency central venous access in adults", section on 'Site selection' and "Central venous catheters for acute and chronic hemodialysis access and their management", section on 'Access site'.)
GENERAL PREPARATION — Nontunneled percutaneous central catheters are usually placed at the bedside, while tunneled catheters, catheters with subcutaneous ports (ie, totally implantable central venous devices), and other devices are generally placed in an interventional suite or operating room using fluoroscopic guidance. The equipment needed for central venous catheterization is given in the table (table 1).
Device and site selection — The most appropriate site and approach for central venous cannulation should be individualized based on the clinical situation. Operator skill, ultrasound availability and precannulation vein assessment, patient anatomy (eg, recognizable landmarks, patient tolerance for access positioning, known venous occlusion, presence of lymphedema), risks associated with placement (eg, coagulopathy, pulmonary disease), and access needs (eg, patient needs and duration of catheter use) are important considerations [16-20].
●(See "Central venous access: Device and site selection in adults", section on 'Access site'.)
●(See "Overview of acute and emergency central venous access in adults", section on 'Site selection'.)
The anatomic site chosen for central catheter placement also influences the risk for and type of complications, including catheter-associated infection [21]. Complications associated with catheters may be minimized with experienced clinician insertion of catheters, strict sterile technique, proper catheter positioning, and appropriate routine care and monitoring after placement [22]. (See "Overview of complications of central venous catheters and their prevention in adults".)
Specific veins (jugular, subclavian, femoral) and access approaches have inherent advantages and disadvantages. These issues are reviewed separately.
●Jugular venous catheters. (See "Placement of jugular venous catheters", section on 'Specific approaches'.)
●Subclavian venous catheters. (See "Placement of subclavian venous catheters", section on 'Approaches to the subclavian vein'.)
●Femoral venous catheters. (See "Placement of femoral venous catheters", section on 'Femoral vein cannulation'.)
●Peripherally inserted central catheters are typically placed into a superficial vein (basilic vein, cephalic vein) in the upper extremity.
Informed consent — Central venous access is an invasive procedure and informed consent should be obtained for any patient regardless of the type of device (eg, central venous catheter, port) or approach (percutaneous, cutdown). (See "Informed procedural consent".)
All patients should be monitored during central venous access procedures, including continuous cardiac rhythm and pulse oximetry. Supplemental oxygen should be immediately available, and, for some patients, it may be prudent to administer oxygen by nasal cannula prior to covering the patient's head with sterile drapes.
Central venous devices are typically placed using local anesthesia; however, patients at risk for respiratory compromise with supine or Trendelenburg positioning (obstructive pulmonary disease, patient with obesity), which facilitates venous filling (jugular, subclavian), may require anesthesia with a controlled airway to safely place a central venous catheter or device. (See "Considerations for non-operating room anesthesia (NORA)".)
Aseptic technique — To reduce infectious complications, all central venous access procedures, including emergency procedures, should be performed in a location that permits the use of aseptic technique.
●Barrier precautions – This includes sterile drapes large enough to cover the entire patient, sterile cover for ultrasound probe, surgical antiseptic hand wash, long-sleeved sterile gown, surgical mask, gloves, and head covering [2,23-28]. Other measures to prevent access site infection should also be used (eg, hair clipping rather than shaving, skin antisepsis). (See "Overview of control measures for prevention of surgical site infection in adults", section on 'Infection control'.)
●Skin antisepsis – Preinsertion application of antiseptic solution for skin disinfection at the catheter insertion site reduces catheter colonization and aims to reduce risk of infection. Chlorhexidine gluconate (CHG)-based solutions (>0.5% chlorhexidine preparation with alcohol) are superior to both aqueous and alcohol-based povidone-iodine (PI) solutions [29-35]. In a large trial (2547 catheters), the incidence of catheter-related infection was lower for CHG-alcohol compared with PI (0.28 versus 1.77 per 1000 catheter-days; hazard ratio 0.15, 95% CI 0.05-0.41). If there is a contraindication to CHG, PI, an iodophor, or 70% alcohol can be used as alternatives [36]. CHG antiseptic is often applied via swab stick and should be applied at the access site and surrounding skin for 30 to 60 seconds. The solution should be allowed to air dry completely prior to draping the patient [31,33].
●No role for systemic antimicrobial prophylaxis – Antimicrobial prophylaxis prior to percutaneous central venous catheter placement is not standard practice. A meta-analysis comparing antibiotics versus no antibiotics for totally implanted venous access devices also showed no significant difference in infection rate [37].
USE OF ULTRASOUND
Precannulation vein assessment — Before cannulation, routine bedside ultrasound by the provider placing the access can evaluate venous patency and aid in selecting the most appropriate site of access, and is particularly useful in patients who have a history of prior instrumentation or deep vein thrombosis in the region of the proposed access site [38]. (See "Principles of ultrasound-guided venous access", section on 'Global use of ultrasound' and "Catheter-related upper extremity venous thrombosis in adults", section on 'Duplex ultrasonography'.)
Preprocedure ultrasound also identifies anatomic variations, which is particularly useful for reducing trauma associated with line placement in children. In a study of 140 children, anatomic variations occurred in approximately 7 percent [39].
Real-time ultrasound guidance — We recommend the use of real-time ultrasound guidance during central venous cannulation at any site when it is available and practical to use. Familiarity with ultrasound-guided access is an important aspect for the practitioner performing central venous catheterization. Ultrasound guidance reduces the number of access attempts and time to cannulation. The principles of ultrasound and techniques to identify venous structures for venous access are discussed in detail elsewhere. (See "Principles of ultrasound-guided venous access".)
When ultrasound is not available, landmark techniques are used to guide access. (See "Placement of jugular venous catheters" and "Placement of subclavian venous catheters" and "Placement of femoral venous catheters".)
Detection of complications — Proper use of ultrasound aims to reduce major complications. Ultrasound also assists with early detection of arterial and venous guidewire malposition and identification of procedure-related pneumothorax [40,41]. An important caveat to studies of ultrasound for this purpose is that accuracy of diagnosis was dependent upon ultrasound operator skill. (See 'Confirming catheter tip position' below and "Bedside pleural ultrasonography: Equipment, technique, and the identification of pleural effusion and pneumothorax".)
GENERAL ASPECTS OF PLACEMENT — Venous access for the placement of central venous devices follows a series of standard steps that adhere to common safety principles. This step-wise approach is outlined in the table for acute and emergency venous access (eg, nontunneled catheters, venous sheaths) (table 2); placement of other central venous devices follows a similar approach.
The Seldinger guidewire method is the preferred approach [42]. This method gains access to a central vein via an introducer needle through which a matched guidewire is threaded to maintain venous access after needle withdrawal. The catheter is advanced into position over the intravascular guidewire, which is subsequently removed from the catheter.
Specific details of central venous catheter placement at various anatomic locations (jugular, subclavian, femoral) and other devices are presented separately. (See "Placement of jugular venous catheters" and "Placement of subclavian venous catheters" and "Placement of femoral venous catheters".)
Acute or emergency access — Acute or emergency central venous access includes the placement of nontunneled central venous catheters, which may be needed for a variety of reasons (eg, fluid therapy, hemodialysis, plasmapheresis). Details of acute or emergency central venous access are provided separately (table 2). (See "Overview of acute and emergency central venous access in adults".)
In the acute setting, a venous sheath can be used for large volume intravenous infusion or for the placement of pulmonary artery catheters. (See 'Venous sheath' below and "Pulmonary artery catheters: Insertion technique in adults".)
Other venous devices — The basic principles for placing other central venous devices starts with the general steps outlined in the table for acute or emergency central venous access (table 2). Other aspects of placement are described below for each device.
Venous sheath — A venous (introducer) sheath is a combined tissue dilator and sheath assembly that is sized according to the intended device. Venous sheaths are commonly used to introduce a variety of venous devices including some tunneled catheters (which may use a peel-away sheath), pulmonary artery catheters, pacing leads, inferior vena cava filters, intravascular ultrasound, and venous interventional devices, including venous angioplasty balloons and stents.
A venous sheath is typically placed using a guidewire technique. After the guidewire is in place and the vein is dilated, the tissue dilator and sheath are advanced over the guidewire together. The tissue dilator and guidewire are then removed, leaving the sheath in place through which to introduce any venous devices. The attached side port is then aspirated and irrigated to check function, and the sheath is secured to the skin at its exit site.
Tunneled catheters — Venous access for tunneled catheters is obtained in a manner like nontunneled catheters. The exit site of the catheter on the skin is chosen, which determines the length of catheter that will be needed for proper catheter tip positioning. For some tunneled catheters, the excess length of catheter provided is trimmed before the catheter is tunneled; for others, it can be trimmed afterward. Other types of catheters come in fixed lengths (eg, dialysis catheters), and the position of the exit site is chosen to accommodate the predetermined length of the catheter. For subclavian and jugular tunneled catheters, the exit site on the chest wall should be located below the mid-clavicle in a position that does not interfere with clothing or upper extremity mobility.
Percutaneous access is performed as outlined in the table (table 2). Once the guidewire is in position, the skin at the guidewire exit site is incised to accommodate at least the diameter of the catheter. Following administration of local anesthesia to the catheter exit site and planned subcutaneous tunnel, an incision is made at the planned catheter exit site. A tunneling device is usually included in the catheter kit and is attached to the distal catheter lumen orifice (ie, catheter tip lumen hole rather than a more proximal port). The catheter is advanced subcutaneously from the catheter exit site to the guidewire exit site (antegrade), and the tunneler is removed. Some catheters will need to be tunneled retrograde. Care is taken to ensure that the tunnel provides a gentle curve in the catheter from the catheter exit site to the guidewire site. Acute angulation may lead to poor flow rates and catheter malfunction. After dilating the vein, the tissue dilator/sheath combination is placed over the wire using fluoroscopic guidance. The tissue dilator is removed, and the catheter is advanced through the sheath and the sheath peeled away. The position of the tip of the catheter is checked and adjusted, as needed. The cuff of the tunneled catheter is ideally located 2 cm from the skin exit site of the catheter. The catheter is sutured to the skin to prevent malposition until the cuff is incorporated in the subcutaneous tissue.
Subcutaneous ports — Percutaneous venous access is obtained as outlined in the table (table 2). Once the guidewire is in place, local anesthetic is administered into the skin and subcutaneous tissue in the region of the planned pocket. An incision is made through the skin and, using electrocautery, the pocket is created to accommodate the device by undermining the subcutaneous tissue to the level of the fascia. Prior to placing the port, its function should be checked by inserting a needle and irrigating with saline, which should flow freely through the port hub. The device is placed into the pocket, and the size of the pocket and orientation of the device is adjusted as needed.
Once the pocket is completed, the catheter is tunneled from the pocket to the guidewire exit site, if needed (eg, jugular venous access). Care is taken to avoid catheter angulation, which will lead to mechanical dysfunction. After dilating the vein, the tissue dilator/sheath combination is placed over the wire. The tissue dilator is removed, the catheter is placed through the sheath, and the sheath is peeled away. The catheter is positioned and adjusted as needed. The excess catheter is trimmed and attached to the hub of the port device, which is placed into the pocket and sutured into place. Placing sutures at three points of fixation into fascial tissue is important to prevent port rotation, which can transpose the access hub away from the skin surface, making access difficult. The subcutaneous tissues and skin are sutured closed. Prior to dressing the wound, the port should be accessed through the skin, and the port aspirated and irrigated to confirm its proper functioning. Ports are typically loaded with heparinized saline according to the manufacturer's recommendation if they are not accessed for immediate use.
Confirming catheter tip position — Catheter tip positioning can be confirmed with one or more of the following methods: chest radiography, fluoroscopy, ultrasound, transesophageal echocardiography (typically intraoperative), and intracavitary electrocardiography (IC-ECG) [41,43-51]. Chest radiography and fluoroscopy are the most used methods in the United States.
Radiography — In nonemergency situations, a postprocedure chest radiograph is recommended to confirm catheter course and tip position prior to use of jugular and subclavian catheters. Femoral catheters do not require radiologic confirmation of position. The need for routine radiography confirmation of apparently uncomplicated right internal jugular catheter placement has been questioned [45,47,48].
Ultrasound and echocardiography — Alternative imaging modalities to radiography to confirm catheter tip position include ultrasound and transesophageal echocardiography, which are particularly useful in critical care settings and in the operating room. Real-time ultrasound can also be used to assess for proper positioning of the catheter tip as well as identification of postprocedure pneumothorax [52-54]. A meta-analysis that pooled 20 studies showed sensitivity of 88 percent and specificity of 99 percent for ultrasound detection of pneumothorax, compared with 52 and 100 percent for chest radiography [53,55]. (See "Clinical presentation and diagnosis of pneumothorax", section on 'Pleural ultrasonography'.)
Intracavitary electrocardiography — IC-ECG is another technique that relies on detection of intracardiac P wave patterns obtained during catheter positioning. The rationale for this approach is that the sinoatrial node is located at the junction of the right atrium and superior vena cava (cavoatrial junction). Thus, mapping the catheter tip to the sinoatrial node internally identifies the biologically correct catheter tip position. Following catheter insertion, an electromagnetic guidewire is threaded through an introducer needle and connected to an electrocardiograph monitor lead. On the IC-ECG tracing:
●A normally shaped P wave identifies the mid-to-upper superior vena cava.
●The widest P wave indicates the central catheter tip is at the superior vena cava-right atrium junction.
●A biphasic P wave identifies the location of the right atrium.
●Superimposition of the intracavitary ECG with a surface ECG at the point of maximal P wave deflection indicates appropriate positioning of the catheter tip.
Several reviews in pediatric and hemodialysis populations have confirmed the utility of this technique [56-59]. In the largest review of over 1000 cases, the technique was successfully applied in 98 percent. The presence of preexisting cardiac arrhythmias that affect P wave generation and propagation (eg, atrial flutter and fibrillation) constitutes a main technique limitation, and in these cases, IC-ECG may not be helpful [59]. A meta-analysis and large registry review have found improved tip positioning for IC-ECG compared with plain radiography for placement of peripherally inserted central catheters [60,61].
Optimal catheter tip positioning — The optimal positioning of the catheter tip depends on the specific access site. In general, catheters function well with the tip situated in any major vein. However, suboptimal tip position may be related to delayed complications. As an example, catheter tip position within the subclavian vein is associated with thrombosis. If a catheter is malpositioned within the venous system, it may be used under emergency circumstances but should be repositioned when feasible. By contrast, inadvertent placement of a catheter into the arterial system mandates immediate attention [62]. Inadvertent arterial placement is prevented by using ultrasound guidance during placement. (See "Vascular complications of central venous access and their management in adults".)
Common access sites, catheter tip positioning, and management of malpositioned catheters are reviewed separately.
●(See "Placement of jugular venous catheters", section on 'Confirmation of jugular catheter position'.)
●(See "Placement of femoral venous catheters", section on 'Confirmation of femoral catheter position'.)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Venous access".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Central line infections (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Indications for central venous access – Common indications for central venous access include inadequate intravenous access, medication and fluid administration, hemodynamic monitoring, and extracorporeal therapy (eg, hemodialysis, plasmapheresis). Central venous access is also used to facilitate insertion of venous devices, including pulmonary artery catheters, pacemakers/defibrillators, inferior vena cava filters, and to perform venous intervention. (See 'Indications' above.)
●Contraindications – Moderate-to-severe coagulopathy (platelet count <20 x 109/L and international normalized ratio >3) is a relative contraindication to central venous access, with thrombocytopenia posing a greater risk than prolonged clotting time. In this circumstance, the subclavian vein approach is avoided, provided an alternative access is available. (See 'Coagulopathy and/or thrombocytopenia' above.)
●Catheter type and site selection – Central venous catheters can be inserted through the jugular, subclavian, or femoral veins, or peripherally inserted via upper arm peripheral veins. The type of catheter and site chosen are often determined by the clinical scenario of the individual patient and provider preference. The optimal site is determined by operator experience, patient anatomy, and clinical circumstances. (See 'Device and site selection' above and "Central venous access: Device and site selection in adults", section on 'Access site'.)
●Use of ultrasound
•Prior to the placement of central catheters, precannulation ultrasound should be performed by the provider placing the access to evaluate venous patency and aid in selecting most appropriate site of access. (See 'Use of ultrasound' above.)
•Ultrasound guidance is recommended during venous cannulation, whenever available, and is particularly useful in pediatric venous access and in high-risk patients, such as those with coagulopathy. Ultrasound guidance reduces the number of access attempts and time to venous cannulation and inadvertent arterial cannulation. (See 'Use of ultrasound' above and "Principles of ultrasound-guided venous access", section on 'Summary and recommendations'.)
●Aseptic technique – To reduce infectious complications, all central venous access procedures, including emergency procedures, should be performed using aseptic technique, which includes full barrier precautions and skin antisepsis. We recommend using a chlorhexidine gluconate (CHG)-based solution (>0.5% chlorhexidine preparation with alcohol), rather than a povidone iodine solution (Grade 1B). If a CHG-based solution is not available, alternative agents can be used (eg, povidone iodine, an iodophor, or 70% alcohol). Systemic antimicrobial prophylaxis prior to percutaneous central venous catheter placement is not necessary. (See 'Aseptic technique' above.)
●General access techniques – Central venous catheterization is performed through a series of well-defined steps as outlined in the table (table 2) for acute or emergency access. Central venous access for venous sheaths and other venous devices is performed in a similar manner. (See 'General aspects of placement' above.)
●Confirming catheter tip positioning – Catheter tip positioning can be confirmed with one or more of the following methods: chest radiography, fluoroscopy, ultrasound, transesophageal echocardiography (typically intraoperative), and intracavitary electrocardiography (IC-ECG). To detect catheter malposition and pneumothorax, chest radiography is typically used, but periprocedural ultrasound or IC-ECG are alternative techniques. (See 'Confirming catheter tip position' above.)
•Chest radiography is often used to confirm jugular and subclavian catheter placement prior to use in nonemergency situations. (See "Placement of subclavian venous catheters", section on 'Confirmation of subclavian catheter position'.)
•Femoral catheters do not require radiologic confirmation of position. (See "Placement of femoral venous catheters", section on 'Confirmation of femoral catheter position'.)
•The need to confirm placement in all patients undergoing jugular venous access procedures is controversial. (See "Placement of jugular venous catheters", section on 'Confirmation of jugular catheter position'.)
