Placement of central venous catheters is a routine procedure in modern anesthesia care. The somewhat routine nature of this procedure should not lull the anesthesia provider into complacency regarding the importance of meticulous attention to technique. Of the many thousands of central venous catheters placed each year, the U.S. Food and Drug Administration (FDA) estimates that approximately 10% will be associated with a complication, 52% of which are related to practitioner technique. The cost of these complications to the U.S. health care system exceeds $1 billion annually.

In anesthesia practice, right internal jugular vein cannulation is most commonly selected. This is because of the relatively straight path to the superior vena cava, increased distance from the cupola of the lung (vs. left side), and absence of the thoracic duct on the right side. The potential for nerve, vessel, or lung injury exists for any approach to central venous catheterization, including the right internal jugular approach. The subclavian approach increases the risk of pneumothorax because of the proximity of the pleura to the subclavian vein. In addition, if the subclavian artery is punctured, it is not possible to control hemorrhage with direct pressure. Femoral vein cannulation is associated with increased risk of infection, but can be a good alternative if the line is intended for rapid volume infusion. Peripherally inserted central catheters can also be used. Catheter length hinders this option for the purpose of rapid volume infusion.

Although infections are responsible for approximately 75% of catheter complications, American Society of Anesthesiologists (ASA) closed claims data indicate that technical complications during placement are the most deadly. Pneumothorax, wire or catheter embolization, air embolism, extravasation of fluid or blood into the neck, and a variety of cardiac and vascular injuries may occur. Of these, direct arterial injury and vascular injury resulting in cardiac tamponade or hemo/hydrothorax have the worst mortality (Table 24.1). In addition to site of catheter placement, the risk of pneumothorax can be diminished by using ultrasonic guidance and properly angling the needle away from the pleura on initial approach to the vessel. Wire embolization is avoided by using a technique of catheter insertion that permits one hand to continuously control the wire until it is removed. Catheter embolization is
prevented by taking care to avoid withdrawing the catheter at any time over a needle with a cutting bevel, which can shear the tip. Air embolization is of particular concern when the patient is breathing spontaneously or when the insertion site is above the level of the heart. Avoid this complication by using the Trendelenburg position (which improves identification of neck vessels as well), occluding the catheter/introducer with a gloved finger, and taking care to eliminate air from the catheter itself with aspiration and flushing either before or after insertion. The risk of fluid or blood extravasation is avoided by ensuring that the skin nick for the introducer does not lacerate the vein being cannulated, and by suturing the catheter securely to avoid the tip slipping. Cardiac tamponade usually results from a catheter with the tip inside the right atrium or angled against the wall of the superior vena cava, which can erode through the thin-walled atrium or vessel. This usually occurs after hours or days. The most serious direct vascular injury is caused by the inadvertent insertion of the catheter or introducer sheath directly into an artery that was mistaken for a vein.