CENTRAL

 VENOUS  CATHETER  POSITIONING  

 
Central  venous  catheters  (CVC)  are  common  in  critical  care  and  anaesthesia.  
Correct  positioning  of  the  CVC  tip  must  be  considered.  

There   is   not   universal   agreement   for   the   most   appropriate   CVC   tip   position.   The   following  
principles  are  agreed:  

• The  tip  should  lie  in  as  large  a  vein  as  possible  
• The  tip  should  ideally  be  outside  the  heart  
• The  tip  should  lie  parallel  with  the  long  axis  of  the  vein  

Standard  teaching  states  that  the  tip  should  lie  above  the  pericardial  reflection  to  avoid  the  small  
but   potentially   fatal   risk   of   pericardial   tamponade   if   the   CVC   erodes   through   the   vessel   wall.  
Catheter  placement  in  the  right  atrium  can  also  cause  arrhythmias  and  tricuspid  valve  damage.  
 
It  is  not  possible  to  see  the  pericardial  reflection  on  a  chest  radiograph  but  it  is  accepted  that  it  is  
below  the  carina  on  chest  radiograph  (CXR).  
However,   placement   of   the   tip   above   the   right   atrium   is   also   associated   with   significant  
complications.  

Inadequate  insertion  of  the  catheter  carries  the  risk  that  proximal  ports  may  not  be  fully  within  the  
vein.  Extravasation  of  infusate  can  occur  with  potentially  injurious  effect.  

Mechanical   irritation   of   the   vein   wall   can   occur.   It   causes   pain,   thrombosis   and   infection.   It   can  
cause   lead   to   perforation.   It   is   more   likely   if   the   tip   abuts   the   wall  of   a   vein   at   an   angle   greater   than  
40°  (more  commonly  seen  with  left  sided  lines).    

                  This  CXR  is  demonstrates  a  CVC  tip    

                  abutting  the  SVC  wall    
 

                 

 
 
It   is   generally   considered   to   be   undesirable   to   advance   a   CVC   further   into   the   vein   after   initial  
insertion   (i.e.   once   sterile   insertion   has   finished).   It   is   also   known   that   rewiring   a   CVC   can   be  
difficult  or  unsuccessful.  

When  inserting  a  CVC  into  the  right  side,  use  a  15cm  catheter  for  most  patients.  
When  inserting  a  CVC  into  the  left  side,  strongly  consider  using  a  20cm  catheter.  
 50

40

30

  20
10
 
0
−40 −20 The   0 following  
20 40 recommendations  
60 80 100 should  be  considered  when  assessing  positioning  of  CVC  for  
Above carina
Distancecritical   care  patients.  
from carina (mm)

to the vertical. Each point represents an individual catheter tip.

 
 

 
          Zone  C     Zone  A:   below  carina  (probably        
    Zone   B               within  pericardial  reflection)  
  Zone A
                Zone  B:   ideal  position  (unless  tip  likely  to      
   reflection  
Pericardial
  Right             be  abutting  wall  of  SVC)  
atrium
 
                Zone  C:   inadequate  insertion  –  be  aware      
                    of  extravasation  risk  
wo CVCs in situ, both
standard multilumen                  
 
the former is poorly
VC. The stiffer larger

 
utting and tenting the
of pain, thrombosis,
further explanation.
  Fig 5 Stylized anatomical figure dividing the great veins and upper RA into
three zones (A–C), representing different areas of significance for place-
and relationship to This  
the is  a  guide  as  to  what  should  be  done  when  CVC  position  is  assessed  on  CXR:  
ment of CVCs. See text for further description. Zone A, upper RA and lower
se were so high in the SVC; Zone B, upper SVC and junction of left and right innominate veins;
ine   Zone C, left innominate vein.
carina On  the  CXR  decide  where  the  tip  lies  and  if  it  looks  to  be  abutting  the  SVC  wall.  Then:  
CVC below
more ready to withdraw them to a safer position after post-
7
  insertion chest radiographs.
0 Tip  is  Schematic
beyond  lzones imit  oforf  zcatheter
one  A   tip positioning can be
0 categorized as shown in Figure 5.1
Where   Zone the  Atrepresents
ip  is   the lower SVCDefinitely   and upper RA. in  In
heart  
this and  inserted  too  far  
What  
erted to their full zone to  CVCs
do   placed from the left sideWithdraw   are likely to lieCparallel
VC  
  to the vessel walls. However, a part of this zone lies within
lly inserted from
elow the carina.13 the RA and therefore within the pericardial reflection.
nicians should Tip  
be iThis
s  in  may
Zone   A     a necessary
represent   compromise for left-sided
Where  the  tip  is   Within  pericardial  reflection.  May  be  in  right  atrium  
What  to  do     Withdraw  aiming  to  get  tip  into  ideal  position  (Zone  B)  
Page 4 of 6
(Right  sided  lines)  
What  to  do     Left  sided  CVC  are  more  likely  to  abut  the  SVC  if  withdrawn  into  Zone  B  
(Left  sided  lines)   Leave  tip  within  Zone  A  
 
Tip  is  in  Zone  B    
Where  the  tip  is   Within  SVC  and  probably  outside  pericardial  reflection  
What  to  do   This  is  the  ideal  position  
(No  wall  abutment)    
What  to  do   Withdraw  CVC  1-­‐2cm  
(Risk  of  wall  abutment)   CHECK:    
  If  aspiration  through  all  ports  is  easy,  use  CVC  as  normal  
  If  aspiration  in  doubt  through  any  port,  insert  new  CVC  (rewiring  is  acceptable)  
 
Tip  is  in  Zone  C    
Where  the  tip  is   Large  vein  draining  into  SVC  (probably  subclavian).  Risk  of  extravasation  
What  to  do   CHECK:    
If  aspiration  through  all  ports  is  easy,  use  CVC  as  normal.    
If  aspiration  in  doubt  through  any  port,  insert  new  CVC  (rewiring  is  acceptable).  
 
After  repositioning  a  CVC,  repeat  CXR  to  assess  new  position.  
Always  ensure  that  after  repositioning,  the  CVC  (not  just  the  clasp)  is  sutured  securely.  
 
Insertion   techniques   must   always   follow   best   practice   steps   that   are   described   in   another  
document.