Central venous catheterization

Background

  • Central venous catheters (CVCs) are often required to establish venous access in critically ill patients in order to administer rapid fluid resuscitation, blood products, and vasopressors.
  • The sites of insertion fall into three locations:
    • Internal jugular (IJ)
    • Subclavian
      • Although subclavian lines appear to have a lower infection rate, there is greater incidence of mechanical complications.[1]
    • Femoral
  • The major complications of concern include:
    • Catheter-related bloodstream infections (CRBI)
    • DVT
    • Mechanical complications (e.g. pneumothorax and arterial puncture)

Types

Depths

  • All +/- 2 cm
  • Right IJ - 13 cm or height (cm)/10
  • Right subclavian - 15 cm or height (cm)/10 - 2cm
  • Left IJ - 15 cm or height (cm)/10 + 4cm
  • Left subclavian - 17 cm or height (cm) + 2cm

Indications

  • Central venous pressure monitoring
  • Administration of multiple medications and drips
  • High volume/flow resuscitation
  • Emergency venous access
  • Inability to obtain peripheral venous access
  • Repetitive blood sampling
  • Administering hyperalimentation, vasopressors, caustic agents, or other concentrated fluids
  • Insertion of transvenous cardiac pacemakers
  • Hemodialysis or plasmapheresis
  • Insertion of pulmonary artery catheters

Contraindications

Absolute[2]

  • Infection over the placement site
  • Anatomic obstruction (thrombosis of target vein, other anatomic variance)
  • Site-specific
    • Subclavian - trauma/fracture to ipsilateral clavicle or proximal ribs

Relative

  • Coagulopathy (see below)
  • Distortion of landmarks by trauma or congenital anomalies
  • Prior vessel injury or procedures
  • Morbid obesity
  • Uncooperative/combative patient

Central line if coagulopathic

  • Preferentially use a compressible site such as the femoral location (avoid the IJ and subclavian if possible, though IJ preferred over subclavian)
  • No benefit to giving FFP unless artery is punctured[3]

Flow Rates

Flow rate depends on diameter and length of IV; the Hagen–Poiseuille equation.[5]

PIV

  • 16G IV: 13.2 L/hr
  • 18G IV: 6.0 L/hr
  • 20G IV: 3.6 L/hr

Central Line

Complications

Complications vary by site

Removal

Central Line: Removal

See Also

Vascular access types

References

  1. ↑ 3SITES Trial
  2. ↑ Graham, A.S., et al. Central Venous Catheterization. N Engl J Med 2007;356:e21
  3. ↑ Fisher NC, Mutimer DJ. Central venous cannulation in patients with liver disease and coagulopathy—a prospective audit. Intens Care Med 1999; 25:5
  4. ↑ Morado M.et al. Complications of central venous catheters in patients with haemophilia and inhibitors. Haemophilia 2001; 7:551–556
  5. ↑ Vascular Access. In: Marino, P. The ICU Book. 4th, North American Edition. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2013:3-41
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