UUCI Health · Department of Neurology
APP Class II · Procedural Competency Series · 2026
● Procedure 01·Neurocritical Care·High-risk tier
01.
Central Venous Line
Placement.
Internal jugular · Subclavian · Femoral.
Chadwycke R. Smith, MSN, NP, AGACNP-BC
APP Education · Department of Neurology
Approving authority: Claire Henchcliffe, MD, DPhil · Chair, Department of Neurology
APP Education · Department of Neurology
Approving authority: Claire Henchcliffe, MD, DPhil · Chair, Department of Neurology
Version 2.0 · 2026-05-11
CVL Placement · UCI Neurology APP Class II
01 / 21
UUCI · APP Class II
Procedure 01 · CVL Placement
Mechanical complication rate · unstandardized
5–19%
drops substantially with ultrasound guidance and bundle adherence —
and yet CLABSI is still NHSN-reportable, with CMS penalties attached.
- Central access is the backbone of neuro-ICU care — pressors, monitoring, dialysis, TPN.
- Baseline CLABSI rates of 0.8–2.0 per 1,000 catheter-days are achievable only with rigorous bundle adherence.
- Subclavian pneumothorax rate is 0.5–5% even with experienced operators.
- CMS classifies a retained guidewire as a Never Event — zero tolerance, mandatory reporting.
O'Grady NP et al. Clin Infect Dis. 2011;52(9):e162–e193 · PMID 21460264
Takeshita J et al. BMC Infect Dis. 2022;22(1):772 · PMID 36195853
Takeshita J et al. BMC Infect Dis. 2022;22(1):772 · PMID 36195853
CVL Placement · Why this matters
02 / 21
UUCI · APP Class II
Procedure 01 · CVL Placement
01 · Cognitive
Anatomy & site selection.
Describe vascular anatomy at IJ, SC, and femoral; differentiate sites by infection, mechanical, and DVT risk.
02 · Psychomotor
Ultrasound-guided access.
Perform US pre-scan, vein-vs-artery discrimination, dynamic needle-tip tracking under real-time guidance.
03 · Psychomotor
Seldinger mastery.
Execute puncture, wire, confirmation, dilation, catheter — with wire-never-lost control through every step.
04 · Cognitive
Complication recognition.
Recognize immediate and delayed events; escalate arterial dilation, pneumothorax, retained wire appropriately.
05 · Affective
Bundle adherence.
Execute the CDC / AHRQ insertion bundle: maximal barrier, CHG antisepsis, site selection, daily review.
06 · Affective
Confirmation & documentation.
Confirm tip at SVC/RA on CXR; document fully; lead a TJC-compliant time-out before every case.
CVL Placement · Course objectives
03 / 21
UUCI · APP Class II
Section I of IV
I.
Section one
Anatomy & site selection.
The three access sites are not interchangeable. Each has a personality —
a risk profile, a contraindication list, an operative posture. Pick the site before you pick the kit.
Dailey & Schroeder 1994 (Mosby) · redrawn from Daily, Griepp & Shumway, Arch Surg 1970 · educational fair use
Objectives C-1 · C-2 · C-4 — slides 5–7
CVL Placement · Section I
04 / 21
UUCI · APP Class II
Procedure 01 · CVL Placement
Right IJ — workhorse
The straight path
to the SVC.
- Lateral & anterior to carotid · compressible, non-pulsatile on US
- Trendelenburg + slight contralateral head turn
- Lowest mechanical risk under US guidance
Subclavian — clean & risky
Lowest infection,
highest pneumothorax.
- Pleural dome lies immediately inferior & posterior
- Pneumothorax rate 0.5–5% with experienced hands
- Avoid in coagulopathic patients — non-compressible
Femoral — fast, code-ready
No lung at risk —
review at 72 h.
- Vein medial & deep to femoral artery (NAVEL)
- Highest historical DVT risk for long dwell
- Preferred for emergency / code access
CVL Placement · Three-site comparison
05 / 21
UUCI · APP Class II
Procedure 01 · CVL Placement
| Clinical context | IJ | Subclavian | Femoral | Why |
|---|---|---|---|---|
| Stable neuro-ICU workhorse | Preferred | Acceptable | Avoid | US-guided IJ has lowest combined complication rate in NCC populations. |
| Coagulopathy / on anticoag | OK | Avoid | OK | Subclavian is non-compressible; IJ and femoral are compressible if bleeding. |
| Emergency / code access | OK | Avoid | Preferred | Fastest access, no airway competition, zero pneumothorax risk. |
| Long-term dwell (> 7 days) | Acceptable | Preferred | Avoid | CDC 2011: lowest infection rate at subclavian for prolonged dwell. |
| Contralateral pneumothorax | OK | Absolute contra | OK | Bilateral pneumothorax converts a complication into a code. |
CDC / O'Grady 2011 recommends subclavian first when mechanical risk and coagulation status are acceptable.
Practice nuance: many intensivists prefer IJ given pneumothorax risk — document your reasoning.
CVL Placement · Site decision
06 / 21
UUCI · APP Class II
Procedure 01 · CVL Placement
Indications
- Vasopressor / inotrope administration
- Hemodynamic monitoring (CVP, ScvO2)
- Hemodialysis access
- Total parenteral nutrition (TPN)
- Poor peripheral access in critically ill patient
- Rapid volume resuscitation — Cordis or large-bore PIV outperforms triple-lumen CVC
Low-dose pressor (e.g., norepi < 10 mcg/min for < 24 h) is acceptable through a peripheral IV — a CVC is not mandatory.
Contraindications & thresholds
- Absolute: infection at insertion site
- Absolute for SC: uncorrected coagulopathy · contralateral pneumothorax
- Absolute: ipsilateral venous thrombus · distorted anatomy
- PLT < 20k urgent / < 50k elective — 1U platelets pre-procedure as needed
- INR > 1.8 urgent / > 1.4 elective
O'Grady NP et al. Clin Infect Dis. 2011;52(9):e162–e193 · PMID 21460264
CVL Placement · Indications & contraindications
07 / 21
UUCI · APP Class II
Procedure 01 · CVL Placement
- 01Consent documented. Indication, risks, alternatives, right to decline — teach-back confirmed. Surrogate decision-maker engaged if patient lacks capacity.
- 02Labs reviewed. PLT ≥ 50k urgent / ≥ 100k elective · INR ≤ 1.8 urgent / ≤ 1.4 elective. Imaging reviewed (prior CXR, relevant CT).
- 03Site decision made. Communicated to team — bedside RN and any assistant know the plan and the why.
- 04Patient positioned. IJ — Trendelenburg, contralateral head turn. SC — Trendelenburg + shoulder roll. Fem — supine, slight reverse-T, leg abducted.
- 05Time-out called. Per TJC UP.01.03.01 — correct patient, procedure, site / side, equipment, consent confirmed aloud.
TJC standard
UP.01.03.01
Pre-procedure verification, site marking, formal time-out — the three-part protocol that exists because someone, somewhere, operated on the wrong side.
The Joint Commission. Universal Protocol UP.01.03.01.
TJC Hospital Accreditation Standards · 2024.
TJC Hospital Accreditation Standards · 2024.
CVL Placement · Pre-procedure verification
08 / 21
UUCI · APP Class II
Key fact · CLABSI bundle
Pronovost · Keystone ICU study · 2006
66%
reduction in CLABSI rates with full insertion-bundle adherence.
Five elements. One discipline. Mortality outcomes that are rare in modern medicine.
01
Hand
hygiene.
hygiene.
02
Maximal
barrier.
barrier.
03
CHG-alcohol
prep.
prep.
04
Optimal site
selection.
selection.
05
Daily
review.
review.
Pronovost P et al. N Engl J Med. 2006;355:2725–32 · PMID 17192537
09 / 21
UUCI · APP Class II
Procedure 01 · CVL Placement
Kit checklist
- CHG-alcohol prep (2% CHG / 70% IPA)
- Cap, mask, sterile gown, gloves
- Large full-body fenestrated drape
- Sterile probe sleeve + sterile gel
- 1% lidocaine + 25g needle
- Finder needle (22g) · introducer 18g
- 0.035-inch J-tip guidewire
- #11 scalpel blade
- Tissue dilator
- Triple-lumen catheter (7 Fr UCI standard)
- Sterile pressure transducer tubing
- 3-0 suture · CHG occlusive dressing
Pre-scan rules
- Linear high-frequency probe (10–12 MHz)
- Short-axis confirms compressibility (vein) vs pulsatility (artery)
- IJ lies lateral to carotid, compressible, non-pulsatile
- Map vessel — note depth, diameter, any thrombus
- Identify variants (small IJ, overlapping vessels)
- Mark skin entry with probe footprint
Takeshita J et al. BMC Infect Dis. 2022;22(1):772 · Zawadka M et al. Crit Care Med. 2023;51(5):642–652
CVL Placement · Kit & ultrasound
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UUCI · APP Class II
Section II of IV
II.
Section two
The Seldinger
sequence.
Seven decades old. Nine numbered steps. Every step is a verification gate.
Skip a gate, inherit the consequence.
Dctrzl · Wikimedia · CC BY-SA 4.0
Objectives P-2 · P-3 · P-4 · P-5 · P-6 · P-7 · P-8 — slides 12–15
CVL Placement · Section II
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UUCI · APP Class II
Procedure 01 · CVL Placement
01
Skin prep ·
maximal barrier.
- CHG-alcohol, concentric circles, center out
- ≥ 30 s dry time — do not blot, do not fan
- Full barrier: cap, mask, gown, gloves, drape
- Sterile probe sleeve + sterile gel
02
Probe orientation ·
needle trajectory.
- Short-axis (out-of-plane): bee-sting tip view
- Long-axis (in-plane): full shaft visible
- IJ — ~45° angle, 1 cm above probe edge
- SC — 10–15° posterior to clavicle midpoint
- Fem — ~45°, short-axis over vein
03
Venous puncture ·
dark, non-pulsatile.
- Dynamic tip tracking, small increments
- Aspirate on advance — flash of dark blood
- Disconnect syringe: blood drips, doesn't spurt
- Pulsatile / bright red — withdraw, hold pressure
Takeshita J et al. BMC Infect Dis. 2022;22(1):772 · Lin MR et al. J Clin Med. 2022;11(8):2242
CVL Placement · Steps 1–3
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UUCI · APP Class II
Procedure 01 · CVL Placement · Critical checkpoint
Critical safety checkpoint · mandatory before dilation
Confirm wire in vein
before you dilate.
Method 01 · ultrasound re-scan
Wire appears as a bright echogenic line inside the vein. Sweep short-axis, confirm artery is clean.
Method 02 · pressure transduction
Sterile tubing on wire shows a venous waveform — low pressure, respiratory variation — not a pulsatile arterial trace.
Wire in artery
STOP. Do not dilate. Hold pressure.
Consult vascular surgery.
Consult vascular surgery.
Dilating an artery is the most catastrophic CVL complication.
Takeshita J et al. BMC Infect Dis. 2022;22(1):772
Takeshita J et al. BMC Infect Dis. 2022;22(1):772
CVL Placement · Wire-in-vein checkpoint
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UUCI · APP Class II
Procedure 01 · CVL Placement
04
Wire ·
tip-first.
- J-tip first — vessel-friendly
- Monitor ECG · PVC → wire too deep
- Pull back 2–3 cm if ectopy
- WIRE-NEVER-LOST · one hand always.
05
Skin nick ·
parallel to wire.
- #11 blade, superficial only
- Blade parallel to wire, never across
- Just enough to pass dilator
06
Dilator ·
fascia only.
- Gentle twist over wire
- Never advance to the hub — back-wall injury
- Opens fascia · does not enter vessel
- Withdraw dilator, wire stays seated
07
Catheter ·
depth by site.
- Right IJ ≈ 15 cm · Left IJ ≈ 17 cm
- Subclavian ≈ 15 cm · Femoral ≈ 20 cm
- Peres 1990: right IJ ≈ heightcm/10
- Wire exits brown port before final seating
CVL Placement · Steps 4–7
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UUCI · APP Class II
Procedure 01 · CVL Placement
Step 08 — wire out, lumens flushed
- Withdraw wire in one smooth motion · do not re-advance
- Cap each lumen immediately after wire removal
- Aspirate each port: dark blood return on all lumens
- Flush each with 10 mL NS · clamp unused lumens
- Confirm no air aspirated or flushed
Step 09 — secure & dress
- 3-0 non-absorbable suture at wing clamps · two-point fixation
- CHG-impregnated transparent occlusive dressing (BioPatch)
- Document depth marker (cm at skin) on chart
- Date and initial the dressing per nursing protocol
IJ
CXR required
Subclavian
CXR required
Femoral
No routine CXR
CVL Placement · Confirmation
15 / 21
UUCI · APP Class II
Procedure 01 · CVL Placement
01 · Immediate
Arterial puncture.
Bright pulsatile blood. Withdraw, hold pressure 10–15 min. If dilated — emergent vascular surgery.
02 · Immediate
Pneumothorax.
SC > IJ > Fem (zero). Post-CXR diagnosis. Chest tube if symptomatic; observe small apical.
03 · Immediate
Arrhythmia.
PVCs / atrial ectopy from deep wire. Pull wire back 2–3 cm. Self-resolves if recognized early.
04 · Immediate
Air embolism.
Cap lumens promptly. Trendelenburg + left lateral decubitus if suspected. Prevention > treatment.
05 · Delayed
CLABSI.
0.8–2.0 / 1,000 catheter-days baseline. Bundle adherence is primary prevention. NHSN-reportable.
06 · Delayed
Catheter-related DVT.
Highest with femoral. Daily review for line necessity. Remove as soon as clinically feasible.
07 · Delayed
Catheter malposition.
Tip in contralateral brachiocephalic or azygos. Diagnosed on CXR. Reposition or replace.
08 · Never event
Retained guidewire.
CMS Never Event. 100% preventable with wire-never-lost principle. IR retrieval if it occurs.
CVL Placement · Complications
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UUCI · APP Class II
Procedure 01 · CVL Placement
01
Dilating without wire-in-vein confirmation.
The single most dangerous error in this procedure. Always confirm position by US re-scan or pressure transduction before dilation.
02
Losing the wire.
A retained guidewire is a CMS Never Event. One hand on the wire from insertion through final catheter seating.
03
Skipping Trendelenburg for IJ / SC.
Flat positioning reduces venous distension and raises air-embolism risk. Always Trendelenburg for IJ and SC access.
04
Femoral lines · no 72-hour review.
Review at 72 h is mandatory; routine removal is not evidence-based. Pull only on infection or DVT signs — but pull early when you see them.
CVL Placement · Pitfalls
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UUCI · APP Class II
Procedure 01 · CVL Placement
| Stage | Trigger | Scope |
|---|---|---|
| FPPE | Board approval of CVL privilege | First 5 independent cases · ≥1 each IJ / SC / Fem · within 6 months |
| OPPE | Continuous baseline | Every 6 mo · 10% sample (min 2, max 10) · 100% review on complication or CLABSI |
| Reinstatement | < 6 cases over 24 mo | 2 proctored cases · directly observed bundle adherence |
| Renewal | Biennial · 22 CCR §70703 (CA) | OPPE indicators aggregate · Chair sign-off |
Tracked OPPE indicators
- Successful placement ≥ 95%
- US used for every IJ attempt 100%
- Wire-in-vein confirmation documented 100%
- CLABSI rate ≤ institutional target
- Post-procedure CXR before use (IJ/SC) 100%
- Daily line-necessity review documented 100%
High-risk tier
Departures require written justification.
CVL Placement · FPPE / OPPE pathway
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UUCI · APP Class II
Procedure 01 · CVL Placement
- 01O'Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis. 2011;52(9):e162–e193. PMID 21460264.
- 02Takeshita J, Tachibana K, Nakajima Y, Shime N. Incidence of catheter-related bloodstream infections following ultrasound-guided central venous catheterization: a systematic review and meta-analysis. BMC Infect Dis. 2022;22(1):772. PMID 36195853.
- 03Zawadka M, La Via L, Wong A, et al. Real-time ultrasound guidance as compared with landmark technique for subclavian central venous cannulation: a systematic review and meta-analysis with trial sequential analysis. Crit Care Med. 2023;51(5):642–652. PMID 36861982.
- 04Pronovost P, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725–32. PMID 17192537.
- 05AHRQ. CLABSI toolkit. AHRQ Safety Program for Intensive Care Units. Rockville, MD; 2020.
- 06The Joint Commission. Universal Protocol UP.01.03.01. TJC Hospital Accreditation Standards; 2024.
- 06aThe Joint Commission. Universal Protocol UP.01.01.01 — preprocedure verification; use a standardized list (H&P, signed consent, nursing & preanesthesia assessment, labeled imaging, required equipment/devices). National Patient Safety Goals (HAP); effective January 2025.
- 06bThe Joint Commission. NPSG.01.01.01 EP 1 — use at least two patient identifiers (room number is not an identifier) before any treatment or procedure. National Patient Safety Goals (HAP); effective January 2025.
- 06cThe Joint Commission. NPSG.07.01.01 EP 1 — implement CDC and/or WHO hand-hygiene categories IA, IB, IC. National Patient Safety Goals (HAP); effective January 2025.
- 06dThe Joint Commission. Universal Protocol UP.01.02.01 — mark the procedure site; mark by the accountable licensed practitioner (APRN/PA delegation permitted per institutional policy); unambiguous, visible after prep & drape. National Patient Safety Goals (HAP); effective January 2025.
- 06eThe Joint Commission. NPSG.03.04.01 — label all medications, medication containers, and solutions on and off the sterile field (name, strength, amount, diluent, expiration). EP 4 requires two-individual verification when preparer ≠ administrator. National Patient Safety Goals (HAP); effective January 2025.
- 06fThe Joint Commission. NPSG.06.01.01 — clinical alarm safety; clinically appropriate settings, authority to change parameters, monitoring/response, and periodic accuracy checks for high-risk alarms. National Patient Safety Goals (HAP); effective January 2025.
- 07The Joint Commission. IC.02.02.01 — implement evidence-based practices to prevent HAIs (isolation precautions, PPE, transmission-based controls; hand-hygiene anchor is now NPSG.07.01.01 below). 2024.
- 08CDC HICPAC. Guidelines for the prevention of intravascular catheter-related infections, 2011. Atlanta, GA; 2011.
- 09Infusion Nurses Society. Infusion therapy standards of practice. J Infus Nurs. 2024;47(1S):S1–S285.
- 10Buetti N, Marschall J, Drees M, et al. Strategies to prevent CLABSI in acute-care hospitals: 2022 update. Infect Control Hosp Epidemiol. 2022;43(5):553–569. PMID 35437133.
- 11Lin MR, Chang PJ, Hsu PC, et al. Comparison of efficacy of 2% chlorhexidine gluconate-alcohol and 10% povidone-iodine-alcohol against catheter-related bloodstream infections and bacterial colonization at central venous catheter insertion sites. J Clin Med. 2022;11(8):2242. PMID 35456335.
- 12UCI APP Class 2 Training Plan Process. Department of Neurology, University of California, Irvine. April 2026.
CVL Placement · References
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