Bleeding is a relative contraindication and benefits should be weighed against risks. Active infection and deep venous thrombosis (DVT) at the site of cannulation are contraindications and if present, a different site should be used. For internal jugular (IJ) and subclavian (SC) venous access, contralateral pneumothorax or high pressure ventilator settings should prompt consideration of an alternative site (Table 13.1).

Central venous cannulation requires a sterile field. Methodological full-body draping reduces the incidence of central venous line infections. Local anesthetic, an ultrasound machine with a sterile cover, central line access kit (which includes an 18-gauge needle, syringes, guide wire, scalpel, dilator, and central line -single or multi-lumen), sterile saline flushes, suture, and a dressing are needed to complete the procedure. The usual length of central venous catheters is 12–20 cm.

The site of access should be chosen carefully. The IJ, SC, and femoral veins are among the most widely accessed sites. Peripherally inserted central catheters (PICC) are also an option, particularly when the catheter is needed for a longer period of time (>1 week). Inspection of the site and using ultrasound to identify the target vessel prior to setting up a sterile field increases the odds of a successful procedure and obviates the need to change the site because of anatomical anomalies or DVT. Once the site is identified, meticulous antiseptic technique must be followed while preparing a sterile field and the access site. The use of ultrasound has become the standard of care in accessing the IJ vein as it has been shown to reduce the incidence of carotid puncture, neck hematoma, hemothorax, pneumothorax, number of attempts, access time, and catheter related blood stream infection [1]. The vein is identified using ultrasound; it is compressible and has continuous flow compared to the pulsatile and not-easily compressible artery (Fig. 13.1).

Solely using anatomic landmarks to achieve IJ access, is discouraged as it is associated with a higher rate of complications [2]. The patient is placed in a supine or Trendelenburg position, the apex of the triangle formed by the two heads of the sternocleidomastoid and the clavicle is infiltrated with local anesthetic with the needle directed towards the ipsilateral nipple (Fig. 13.2). The use of a 22-gauge “finder” needle to cannulate the vein is sometimes performed to “map the way” for the 18-gauge needle.

For SC vein access, the needle is inserted at the point where the medial third of the clavicle meets the middle third (just medial to the midclavicular line) and the needle is inserted using a shallow angle underneath the clavicle with the needle pointing towards the suprasternal notch. The vein is cannulated underneath the clavicle. It is important to position the patient in a Trendelenburg position to distend the SC vein and increase the odds of venous cannulation. Some operators prefer placing a pillow or rolled-up towel under the patient, between their shoulder blades. In patients with coagulopathy the SC vein should, in general, not be used as it is non-compressible. Aspiration of bright red pulsatile blood indicates arterial puncture and the needle should be withdrawn and pressure is applied. Aspiration of air bubbles may indicate a pneumothorax. The SC vein is associated with less risk of catheter related systemic infection compared to femoral and IJ routes, but a higher risk of pneumothorax [3].