Read this Review of Vascular Complications of CVC Placement

(J Cardiothoracic and Vascular Anesthesia 2014;28(2):358)

When to Confirm

I prefer to confirm all non-crash introducers and especially HD caths prior to dilation. There are times I will place a triple lumen and then confirm the line after insertion (do the latter at your own risk)

Confirming Venous Placement (Choose at least 1)

* Observation of the intravascular pressure waveform using an electronic transducer and pressure tubing

* Determination of the of the intravascular pressure using sterile tubing as a venous manometer

* Analysis of the PO2 of a blood specimen drawn from the needle/catheter compared to simultaneously drawn arterial blood (this is stupid!)

* Bubble Test-when saline is rapidly injected through the catheter, there is opacification of the echocardiographic view of the right heart structures.

* Using real-time fluoroscopic or echocardiographic confirmation of venous catheterization (e.g., visualizing the guide wire or catheter within the superior vena cava)

* Using a contrast study to opacify the venous structures.

Less Desirable

* Guidewire Visualization in the Vein

The Methods in Depth

Pressure Transduction

Easiest way to do this is use the casing of the wire was packaged in--this tip thanks to my friend Taku Taira, MD.

How to Use Wire Casing to Transduce Pressure

[cite source='pubmed']19377052[/cite]

[cite source='pubmed']9412883[/cite]

Numerous other studies cited here: (J Cardiothoracic and Vascular Anesthesia 2014;28(2):358)

Study specifically on using tube transduction (Anesth Analg 2009;109:130)

Or if doing IJ, Just use the Catheter-Over-Needle from the Get-go (but I will lose all respect for you)

thankfully Reub provided the study showing the needle technique is superior [cite source='doi']10.1097/CCM.0000000000001167[/cite]

Or Using a Commercial Device

Compass Single Use Manometers with or without guidewire slot

Bubble Test, Flush Test, Rapid Atrial Swirl Sign (RASS)

Inject 10 ml of saline and observe Right Atrium/Right Ventricle

* [cite source='doi']doi:10.1016/j.ajem.2014.10.010[/cite]

* [cite source='pubmed']24552526[/cite]

* [cite source='pubmed']25624649[/cite]

* [cite source='pubmed']17006130[/cite]

* [cite source='pubmed']19829102[/cite]

* [cite source='pubmed']23242559[/cite]

* Should appear in <2 seconds for properly placed neck line [cite source='pubmed']25550065[/cite]

* Saline Flush and Pneumo Exclusion obviates immediate chest radiography [cite source='pubmed']26112633[/cite]

* For Hemodialysis Caths (Kidney International Reports 2017;2:952

* Crit Care Med 2017;45(7):1192

* SR DOI 10.1097/CCM.0000000000002188

* Ultrasound to Detect Central Venous Catheter Placement Associated Complications: A Multicenter Diagnostic Accuracy Study. Anesthesiology. 2020 Jan 21. doi: 10.1097/ALN.0000000000003126.