central venous catheter

Indications

• hypotension requiring large fluid volume & rapid infusion
• dehydration with no peripheral intravenous access
• administration of pharmaceutical agents & nutrition not possible through peripheral access
  • vasopressors, parenteral nutrition
• for administration of intravenous antiarrhythmic agents & vasopressors
• measurement of central venous pressure for assessing circulating volume status
• management of heart failure

Contraindications

• thrombocytopenia
• increased prothrombin time or partial thromboplastin time
  • INR > 1.5 not a problem
• avoid central venous catheters if possible in patient with chronic renal failure who may eventually need hemodialysis

Benefit/risk

• no difference in risk of catheter-related infection or deep vein thrombosis for femoral catheter vs subclavian catheter
• number needed to harm = 73 for pneumothorax (subclavian catheter)

Caution:

• Never lose sight of the guidewire
• observe for arrhythmias is close to right atrium
• if an attempt on one side in unsuccessful, verify the absence of pneumothorax before attempting other side

Procedure

approaches*

• subclavian vein
  • from above & below the clavicle
  • complications
    • pneumothorax 1-2%
    • subclavian artery puncture 1%
    • long term access
    • measurement of central venous pressure
  • elective, real-time, ultrasound-guided cannulation may reduce mechanical complications & insertion time, & improve the overall success rate
• external jugular vein*
  • external jugular vein runs at lateral edge of sternocleidomastoid
  • eliminates risk of pneumothorax
  • bleeding is easily controlled
  • major problem is difficulty advancing catheter
  • not well tolerated by conscious patients
  • may lead to impairment of neck mobility in patients with coagulopathy
  • measurement of central venous pressure
• internal jugular vein
  • access between bifurcation of sternocleidomastoid
  • risk of carotid puncture 2-10%
  • need to rule out pneumothorax
  • contraindicated if platelets < 50,000/mm3 or if PT is > 3 sec more than control
  • measurement of central venous pressure
  • a small bore single lumen catheter in the internal jugular less likely to impair venous drainage from the arm than a subclavian catheter
• femoral vein
  • access 1-2 cm medial to femoral artery below inguinal ligament
  • no risk of pneumothorax
  • bleeding easily controlled
  • increased risk of infection if left in place more than 3 days
  • thrombosis (10%)
  • femoral artery puncture 10%
  • limits flexion at hip
  • location of a femoral venous line can be confirmed with injection of agitated saline during echocardiogram

* the most effective means of preventing complications is ultrasound-guided internal jugular catheterization, with daily assessment for continued need

* 2-dimensional ultrasound helps with vein localization; reduces procedure failure, vessel injury, pneumothorax

Complications

• 3-10% of central venous catheters are associated with major complications
• pneumothorax*
• intravascular catheter-related infection*
  • more common with femoral vein & internal jugular vein catheters than subclavian catheters
  • central venous catheters inserted under emergency condition at high risk & should be replaced within 48 hours
• deep vein thrombosis* (including pulmonary embolism)
  • more common with femoral vein & internal jugular vein catheters than subclavian catheters
  • superior vena cava syndrome
• central venous stenosis most commonly occurs from endothelial damage from central venous catheters
  • use peripheral venous access if possible
• occlusion of the catheter
  • when a catheter permits infusion, but blood cannot be aspirated, the most likely cause is early thrombosis of the line
  • remove the catheter & replace it with a new one at a different site
  • catheters that allow neither infusion or aspiration should also be replaced
  • changing a line over a guide wire is not recommended
• dislodgement of catheter
• bleeding
  • platelet counts < 50,000/uL prior to placement result in more bleeding
• arrhythmias
• for short-term indications, midline catheters associated with a lower risk of bloodstream infection & occlusion compared with PICC

* pneumothorax can be diagnosed promptly & treated immediately intravascular catheter-related infection or deep-vein thrombosis may be more problematic

* also see Procedure: (above)

Management

• central venous catheters inserted under emergency condition should be replaced within 48 hours
• hospitalized patients with central venous catheter should be assessed daily to determine if the catheter is still needed
• central venous catheters should be removed if fever & positive blood cultures
• see intravascular catheter-related infection
• patients with mild coagulopathy (INR > 1.5) do not need fresh frozen plasma or other transfusion prior to procedure
• chlorhexidine dressings at the catheter insertion site reduce catheter-associated infections
  • chlorhexidine impregnated sponges
  • chlorhexidine-gel dressings allow visualization of the insertion site

Notes

• 20% of clinicians unaware their patient has a central line
  • teaching physicians & hospitalist more likely to be unaware of central line than interns, residents, nurse practitioners, & physician assistants (27% vs 16%)

More general terms

• intravenous catheter (intravenous access)

More specific terms

• central venous catheter with subcutaneous port
• dialysis vascular catheter
• midline catheter
• peripherally-inserted central catheter (PICC)

Additional terms

• cardiac catheterization
• central venous pressure (CVP)