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Diagnostics & Procedures · Topic 11 of 16

Central Venous & Intraosseous Access

Procedures · vascular access

Central Venous & Intraosseous Access

Place central lines under ultrasound with full sterile barriers, confirm the tip before use, and go intraosseous when IV access fails in arrest.

Key numbers
Confirm tip at cavoatrial junction, no pneumothoraxtip: lower SVC
Platelets below 10,000: transfuse before CVCplt < 10,000/mcL
No PICC for 5 days or lessPICC: not ≤ 5 days
No PICC if eGFR below 45 without nephrologyeGFR < 45
No IO in a fractured or punctured boneremove IO ≤ 24 h
01 · DoInsert every CVC under real-time ultrasound

Place central venous catheters with real-time ultrasound guidance: it raises success and reduces arterial puncture, hematoma and other mechanical complications, and it is the standard of care when trained operators are available.

02 · DoConfirm tip at cavoatrial junction, no pneumothorax

Before using a jugular or subclavian line, get a chest radiograph confirming the tip in the lower superior vena cava near the right atrium — never inside the atrium — and no pneumothorax.

03 · FirstArrest: IV first, then IO, then central

In cardiac arrest, attempt peripheral IV access first; intraosseous access is reasonable if IV attempts fail or are not feasible, and trained clinicians may consider central venous access only after both fail (2025 AHA).

01

Diagnosis & monitoring

Work-up
Platelets below 10,000: transfuse before CVCTransfuse platelets before placing a central venous catheter at a compressible site only when the count is below 10,000/mcL (2025 AABB/ICTMG).
02

Management

Orders
Head down for insertion and removalPrevent air embolism: insert jugular and subclavian lines supine or head-down, never leave a hub open, and remove CVCs flat or head-down during exhalation or Valsalva, then apply an occlusive dressing.
IO sites: proximal humerus or tibiaAdult IO sites: distal tibia (preferred for manual insertion), proximal humerus at the greater tuberosity (closer to the central circulation) or proximal tibia with a powered device; any IV drug, fluid or blood can run.
03

Red flags & don'ts

Avoid harm
No subclavian with coagulopathy or dialysis need avoidAvoid the subclavian site with uncorrected coagulopathy, because the puncture cannot be seen or compressed, and in patients who need or may need hemodialysis, because of venous stenosis; correct coagulopathy whenever feasible before any CVC.
Artery dilated? Leave it in, call surgery complicationBright red pulsatile blood means arterial puncture: withdraw the needle and hold pressure 10 minutes. If the dilator or catheter has entered the carotid, leave it in place and obtain surgical consultation.
Air embolism: left side, head down, oxygen complicationSuspected venous air embolism (sudden dyspnea, hypoxemia, hypotension, falling end-tidal CO₂): close the open line, place the patient left lateral decubitus and head down (Durant maneuver) and give 100% oxygen.
No PICC if eGFR below 45 without nephrology avoidAvoid PICCs in chronic kidney disease (eGFR < 45 mL/min) without nephrology approval, to preserve arm veins for future dialysis access.
No IO in a fractured or punctured bone avoidDo not place an IO needle in a fractured bone, one with a recent IO attempt (fluid extravasates) or through infected or burned skin; remove it once IV access is secured and within 24 hours.
04

The rules

Know these
Maximal sterile barriers and chlorhexidine prep must knowInsertion bundle: hand hygiene, maximal sterile barriers (cap, mask, sterile gown and gloves, full-body drape) and alcoholic chlorhexidine (≥ 2%) skin prep allowed to dry; no systemic antibiotic prophylaxis (see Catheter-Related Bloodstream Infection).
Review need daily; no routine replacementRemove a CVC as soon as it is no longer needed to cut thrombosis and infection, inspect the site daily, and do not replace catheters on a routine schedule.
No PICC for 5 days or lessMAGIC: a PICC is inappropriate for peripherally compatible infusions of 5 days or less; for 6–14 days prefer a midline or ultrasound-guided peripheral IV; critically ill patients needing ≤ 14 days get a nontunneled CVC.
05

PICC or midline?

Commonly confused
Catheter typeCentral venous catheter
Vasopressors or vesicantsAcceptable (appropriate for vesicants in cancer)
Avoid whenTherapy ≤ 5 days; eGFR < 45 without nephrology approval
Best fitLong-term or vesicant therapy
06

Commonly confused

Tell apart
Subclavian least infection; femoral mostSite trade-offs: subclavian has the lowest infection risk (SHEA 2022 prefers it in the ICU) but more pneumothorax and bleeding; femoral has the highest infection risk; in emergencies the fastest site wins.
07

More detail

Reference
Show 6 reference facts
For an awake patient, slowly infuse 40 mg (2 mL) of preservative-free 2% lidocaine through the IO needle over 2–3 minutes before the flush; IO complications include extravasation, compartment syndrome and, rarely, osteomyelitis.
During CPR, drugs given through a femoral CVC may not circulate above the diaphragm, so an internal jugular or subclavian line is preferred when central access is needed in arrest.
Pneumothorax occurs in about 1% of CVC insertions and CLABSI in roughly 4 per 1000 catheter-days; guidewire-induced arrhythmias are usually self-limited once the wire is withdrawn — never let go of the wire.
A right internal jugular or left subclavian approach is preferred for transvenous pacing or a pulmonary artery catheter; left bundle branch block is a relative contraindication to deep guidewire passage (risk of complete heart block).
Internal jugular contraindications: a thrombosed or inaccessible vein on ultrasound, infection at the site and an untrained operator; raised intracranial pressure and severe cardiorespiratory failure are relative because of head-down positioning.
In patients with cancer, PICCs are rated appropriate for irritant or vesicant infusions regardless of duration (MAGIC).
Pearl

Ultrasound for the needle, an x-ray for the tip — and in cardiac arrest, the bone is the backup vein.

Sources · Buetti N et al. Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 Update (SHEA/IDSA/APIC). Infect Control Hosp Epidemiol 2022;43:553–569 · Merck Manual Professional — Vascular Access · Merck Manual Professional — How To Do Internal Jugular Vein Cannulation (Ultrasound-Guided) · Merck Manual Professional — How To Place an Intraosseous Catheter, Manually and With a Power Drill · 2025 AHA Guidelines for CPR and ECC — Part 9: Adult Advanced Life Support (vascular access in cardiac arrest) · Chopra V et al. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC). Ann Intern Med 2015;163(6 Suppl):S1–S40 (abstract via Europe PMC) · Barriers and facilitators for implementing PICC appropriateness guidance (eGFR < 45 without nephrology approval) across 34 Michigan hospitals. PLoS One 2022 · McCarthy CJ et al. Air Embolism: Practical Tips for Prevention and Treatment. J Clin Med 2016;5:93 · Metcalf RA et al. Platelet Transfusion: 2025 AABB and ICTMG International Clinical Practice Guidelines. JAMA 2025;334(7):606–617 (abstract via Europe PMC) · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).