Non-Tunneled Central Venous Catheters: Clinical Guide to Insertion, Use, and Complications

The non-tunneled central venous catheter (CVC) — placed via the internal jugular (IJ), subclavian, or femoral vein — is the most commonly used central access device in acute care and critical care settings. It provides immediate, multi-lumen central access for hemodynamic monitoring, vasopressor infusion, resuscitation, and high-acuity medication delivery. It also carries the highest procedural risk of any vascular access device type and significant CLABSI risk with prolonged dwell.

Understanding CVC site selection, insertion technique, complication prevention, and appropriate dwell management is essential for every acute care clinician.

Parent guide: Central Venous Catheters: Complete Clinical Reference

Indications for Non-Tunneled CVC

Acute indications:

Immediate central access required for hemodynamically unstable patient
Vasopressor infusion (norepinephrine, vasopressin, phenylephrine) — peripheral vasopressor delivery is associated with extravasation risk; most institutions require central access for prolonged vasopressor therapy
CVP monitoring in the ICU
Rapid volume resuscitation with large-bore device
Emergency medication delivery (cardiac arrest, rapid sequence intubation medications)

Urgent but non-emergent indications:

Multi-lumen access needed for complex ICU patient (multiple incompatible infusions)
TPN when PICC is not feasible or immediately available
Short-term central access (days) when PICC is not warranted

Non-tunneled CVC is generally NOT appropriate for:

Stable patients who could safely await PICC placement
Expected dwell >2 weeks (PICC, tunneled CVC, or port preferred)
Patients where less invasive central access is feasible and clinically appropriate

Site Selection: IJ vs Subclavian vs Femoral

Site selection is the most important decision in non-tunneled CVC placement. It affects both procedural complication risk and CLABSI risk.

Comparison Table

Feature	Internal Jugular (IJ)	Subclavian	Femoral
CLABSI risk	Intermediate	Lowest	Highest
Pneumothorax risk	Low (<0.1% with US guidance)	1–3% (landmark); lower with US	None
Hemothorax risk	Rare	0.5–1%	None
Arterial puncture risk	Moderate (carotid)	Low (subclavian artery)	Moderate (femoral artery)
DVT risk	Low-moderate	Low	Highest
Access difficulty	Low-moderate	Moderate	Easy
Ultrasound guidance	Highly effective (superficial vessel)	Effective but more challenging	Effective (vein visible beside artery)
Patient tolerance	Generally well tolerated	Generally well tolerated	Restriction of hip movement
Contraindications	Ipsilateral carotid disease; neck surgery	Rib/clavicle deformity; chest surgery	Obesity; groin infection; thrombosis

CDC/INS Site Preference

Per CDC 2011 guidelines:

Subclavian preferred over IJ or femoral for CVCs in adults when technically feasible (lowest CLABSI rate)
Femoral vein should be avoided when alternative sites are available (highest CLABSI rate, DVT risk, patient mobility limitation)
IJ is an acceptable alternative to subclavian, particularly when subclavian is contraindicated or technically difficult

Per Parienti et al. (2015, NEJM): In a randomized controlled trial of IJ vs. subclavian vs. femoral CVC placement, subclavian had the lowest overall complication composite; femoral had the highest DVT rate; IJ was intermediate. The benefit of site selection must be balanced against individual patient anatomy and clinician experience.

Ultrasound guidance changes the risk calculus: With US guidance, IJ insertion has a very low pneumothorax rate (<0.1%), making it increasingly preferred at institutions with US-trained clinicians. US-guided IJ may be preferred over non-guided subclavian in many clinical scenarios.

Insertion Technique (Seldinger Technique)

CVC insertion uses the standard Seldinger technique: needle → guidewire → dilator → catheter.

Pre-Insertion

Maximal sterile barrier (MSB) is required for all non-tunneled CVC insertions:

Full-length body drape
Sterile gown and gloves for inserter
Surgical mask and cap for inserter and all present in room
Sterile probe cover for ultrasound if used

CHG antisepsis: Apply 2% CHG/70% IPA to a large insertion field; allow complete dry time.

Informed consent: Obtain and document for elective CVC insertions. In true emergencies, document emergency circumstances.

Positioning:

IJ approach: Patient supine, head turned 30–45° to contralateral side; Trendelenburg position (10–15°) to distend IJ and reduce air embolism risk during insertion.

Subclavian approach: Patient supine; roll towel or sheet placed vertically between scapulae to slightly extend chest and retract clavicle; Trendelenburg position.

Femoral approach: Patient supine; leg slightly externally rotated; no Trendelenburg required.

Ultrasound-Guided Approach (IJ)

Identify IJ in short axis (transverse plane): vein is medial to carotid, compressible, non-pulsatile
Mark insertion point; maintain sterile probe
Advance needle under real-time US guidance, visualizing needle tip entering vein
Confirm venous blood return; advance guidewire through needle
Confirm guidewire in vein with long-axis scan (guidewire visible in vein lumen)
Remove needle; nick skin; advance dilator over guidewire
Advance catheter to appropriate length (right IJ: 15–16 cm; left IJ/subclavian: 17–19 cm)
Aspirate all lumens; flush all lumens with saline

Post-Insertion

Apply sterile dressing
Order post-procedure CXR
Document tip location once CXR is read
Do not begin infusion of critical medications until tip position is confirmed (exception: life-threatening emergency requiring immediate use)

Tip Position

Same standard as PICC: lower SVC at the cavoatrial junction.

For femoral CVC (access via femoral vein): tip should be in the inferior vena cava (IVC), above the iliac vein bifurcation, ideally at the level of the diaphragm.

Post-procedure CXR remains the standard confirmation method for most non-tunneled CVCs. ECG guidance is primarily validated for PICC placement; use in CVCs is less standardized.

Complications

Pneumothorax

Risk: 1–3% with landmark subclavian approach; <1% with ultrasound-guided IJ; essentially zero with femoral.

Recognition: Dyspnea, decreased breath sounds, hypoxia after CVC insertion. Confirmed on post-procedure CXR.

Management: Small pneumothorax may be observed with serial CXR. Tension pneumothorax or significant pneumothorax requires needle decompression and tube thoracostomy.

Prevention: Use US guidance; recognize failure to advance guidewire smoothly as a stop point (do not dilate if uncertain of wire position).

Arterial Cannulation

Risk: Highest with landmark technique. With US guidance, rates <1%.

Recognition: Bright red, pulsatile blood return; high oxygen saturation of aspirated blood; waveform on hemodynamic monitoring if transducer connected.

Management: Remove needle; apply firm pressure for 5 minutes. If dilator or catheter has been advanced into the artery, do not remove without vascular surgery consultation — catheter removal without arterial repair risks major hemorrhage.

Prevention: Always confirm venous placement (dark, non-pulsatile blood return; guidewire passes without resistance; US visualization of wire in vein) before dilating.

Air Embolism

Risk: Any time the catheter hub is open to air (during insertion, cap removal, line disconnection). Trendelenburg positioning during insertion and occlusion of hub during open intervals reduces risk.

Recognition: Sudden hypoxia, “mill-wheel” murmur, cardiovascular collapse (large air embolism). See Air Embolism policy for emergency management.

CLABSI

See CLABSI Prevention for complete bundle information. Key points for CVCs:

Daily necessity review is mandatory — remove CVC as soon as it is no longer required
Subclavian is the preferred site for CLABSI risk reduction
CHG-impregnated dressings are standard for CVAD maintenance
Dressing change every 5–7 days (TSM) or every 2 days (gauze)

Dwell Time and Transition Planning

Non-tunneled CVCs should not be used as indefinite long-term access devices.

Recommended maximum dwell:

Non-tunneled CVC: Remove or exchange as soon as clinically possible; no absolute maximum by INS standards, but evidence supports increased CLABSI risk with prolonged dwell. Most institutional policies recommend transition planning at 7–10 days.
Femoral CVC: Maximum 72–96 hours strongly preferred (high DVT and CLABSI risk); transition to IJ or subclavian access as soon as clinically feasible.

Transition to PICC: Once a patient is hemodynamically stable and central access is expected to continue >7–10 days, consider converting from CVC to PICC to reduce CLABSI risk from the IJ or femoral access site.

Routine guidewire exchange is NOT recommended per CDC guidelines — it does not reduce CLABSI rates and may introduce new complications.

Related guides:

Related policies:

References

Gorski LA, et al. (2021). INS Infusion Therapy Standards of Practice. J Infus Nurs, 44(Suppl 1).
Parienti JJ, et al. (2015). Intravascular complications of CVC by insertion site. N Engl J Med, 373(13):1220–1229.
O’Grady NP, et al. (2011). CDC Guidelines for Prevention of Intravascular Catheter-Related Infections. MMWR, 60(RR-1).
Brass P, et al. (2015). Ultrasound guidance versus anatomical landmarks for subclavian or femoral vein catheterization. Cochrane Database Syst Rev, (1):CD011447.
McGee DC & Gould MK. (2003). Preventing complications of CVC insertion. N Engl J Med, 348(12):1123–1133.