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.
  • Femoral
• The major complications of concern include:
  • Catheter-related bloodstream infections (CRBI)
  • DVT
  • Mechanical complications (e.g. pneumothorax and arterial puncture)

Types

• Central line: internal jugular
• Central line: subclavian
• Central line: supraclavicular
• Central line: femoral
• Pediatric central line
• Sheath introducer
• Peripherally Inserted Central Catheter (PICC)

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^{[citation needed]}
• 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

• 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
  • However, consider giving FFP if patient has hemophilia

Flow Rates

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

PIV

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

Central Line

• 5 Fr PICC/Port: 1.75 L/hr
• 7 Fr TLC 16G distal port: 1.9 L/hr
• 7 Fr TLC 18G proximal port: 3.4 L/hr
• 12 Fr HD: 23.7 L/hr
• 8.5 Fr Cordis/introducer sheath: 7.6 L/hr
• 8.5 Fr Cordis/introducer sheath with pressure bag: 20.0 L/hr

Complications

Complications vary by site

• Pneumothorax (more common with subclavian)
• Arterial puncture (more common with femoral)
• Catheter malposition
• Subcutaneous hematoma
• Hemothorax
• Catheter related infection (historically more with femoral)
• Catheter induced thrombosis
• Arrhythmia (usually from guidewire insertion)
• Venous air embolism (avoid with Trendelenburg position)
• Bleeding

Removal

Central Line: Removal

See Also

• CVC catheter problems
• Central Line Placement Videos from EMCRIT
• Central Line Micro Skills from EMCRIT
• Critical care quick reference
• Access options
• 3SITES Trial

Vascular access types

• Central venous catheterization
  • Central line: internal jugular
  • Central line: subclavian
  • Central line: supraclavicular
  • Central line: femoral
  • Pediatric central line
  • Sheath introducer
• Rapid infusion catheter
• Intraosseous access
• Venous cutdown
• Umbilical vein catheterization
• Ultrasound assisted peripheral line placement
• External jugular vein cannulation
• The "Easy IJ"
• Midlines