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, and femoral. The major complications of concern include: catheter-related bloodstream infections (CRBI), DVT, and mechanical complications (e.g. pneumothorax and arterial puncture).
The 3SITES Trial study, a multicenter randomized trial, investigated the complications of the three anatomic sites for CVC insertion in relation to blood stream infections or DVTs. Although subclavian lines appear to have a lower infection rate, there is greater incidence of mechanical complications.
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[1]
- 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[2]
- However, consider giving FFP if patient has hemophilia[3]
Flow Rates
Flow rate depends on diameter and length of IV; the Hagen–Poiseuille equation.[4]
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
See Also
- 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
- Rapid infusion catheter
- Intraosseous access
- Venous cutdown
- Umbilical vein catheterization
- Ultrasound assisted peripheral line placement
- External jugular vein cannulation
- The "Easy IJ"
- Midlines
References
- ↑ Graham, A.S., et al. Central Venous Catheterization. N Engl J Med 2007;356:e21
- ↑ Fisher NC, Mutimer DJ. Central venous cannulation in patients with liver disease and coagulopathy—a prospective audit. Intens Care Med 1999; 25:5
- ↑ Morado M.et al. Complications of central venous catheters in patients with haemophilia and inhibitors. Haemophilia 2001; 7:551–556
- ↑ Vascular Access. In: Marino, P. The ICU Book. 4th, North American Edition. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2013:3-41