Central venous catheterization: Difference between revisions
No edit summary |
|||
| (14 intermediate revisions by 7 users not shown) | |||
| Line 1: | Line 1: | ||
==Background== | ==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.<ref>[[EBQ:3SITES Trial|3SITES Trial]]</ref> | |||
**Femoral | |||
*The major [[CVC catheter problems|complications]] of concern include: | |||
**[[Catheter-related bloodstream infections]] (CRBI) | |||
**[[DVT]] | |||
**Mechanical complications (e.g. [[pneumothorax]] and [[arterial puncture]]) | |||
==Types== | ==Types== | ||
| Line 8: | Line 17: | ||
*[[Central line: femoral]] | *[[Central line: femoral]] | ||
*[[Pediatric central line]] | *[[Pediatric central line]] | ||
*[[Sheath introducer]] | |||
*Peripherally Inserted Central Catheter (PICC) | *Peripherally Inserted Central Catheter (PICC) | ||
==Depths== | ==Depths== | ||
*All | *All +/- 2 cm | ||
*Right IJ - 13 cm | *Right IJ - 13 cm or height (cm)/10 | ||
*Right subclavian - 15 cm | *Right subclavian - 15 cm or height (cm)/10 - 2cm | ||
*Left IJ - 15 cm | *Left IJ - 15 cm or height (cm)/10 + 4cm | ||
*Left subclavian - 17 cm | *Left subclavian - 17 cm or height (cm) + 2cm | ||
{{Central line indications}} | {{Central line indications}} | ||
| Line 34: | Line 44: | ||
*7 Fr TLC 18G proximal port: 3.4 L/hr | *7 Fr TLC 18G proximal port: 3.4 L/hr | ||
*12 Fr HD: 23.7 L/hr | *12 Fr HD: 23.7 L/hr | ||
*8.5 Fr Cordis/introducer sheath: 7.6 L/hr | *8.5 Fr [[Sheath introducer|Cordis/introducer sheath]]: 7.6 L/hr | ||
*8.5 Fr Cordis/introducer sheath | *8.5 Fr [[Sheath introducer|Cordis/introducer sheath]] with pressure bag: 20.0 L/hr | ||
==Complications== | ==[[CVC catheter problems|Complications]]== | ||
''Complications vary by site'' | ''Complications vary by site'' | ||
*Pneumothorax (more common with subclavian) | *[[Pneumothorax]] (more common with subclavian) | ||
*Arterial puncture (more common with femoral) | *Arterial puncture (more common with femoral) | ||
*Catheter malposition | *Catheter malposition | ||
*Subcutaneous hematoma | *Subcutaneous hematoma | ||
*Hemothorax | *[[Hemothorax]] | ||
*Catheter related infection (historically more with femoral) | *Catheter related infection [[EBQ:3SITES Trial|(historically more with femoral)]] | ||
*Catheter induced thrombosis | *Catheter induced thrombosis | ||
*Arrhythmia (usually from guidewire insertion) | *[[Arrhythmia]] (usually from guidewire insertion) | ||
*Venous air embolism (avoid with Trendelenburg position) | *Venous air embolism (avoid with Trendelenburg position) | ||
*Bleeding | *[[Hemorrhagic shock|Bleeding]] | ||
==Removal== | ==Removal== | ||
| Line 54: | Line 64: | ||
==See Also== | ==See Also== | ||
*[[CVC catheter problems]] | |||
*[https://emcrit.org/central-lines/ Central Line Placement Videos from EMCRIT] | |||
*[https://emcrit.org/emcrit/microskills-dilation/ Central Line Micro Skills from EMCRIT] | |||
*[[Critical care quick reference]] | *[[Critical care quick reference]] | ||
*[[Access options]] | *[[Access options]] | ||
*[[EBQ:3SITES Trial|3SITES Trial]] | *[[EBQ:3SITES Trial|3SITES Trial]] | ||
{{Vascular access types}} | |||
==References== | ==References== | ||
Latest revision as of 19:55, 30 July 2025
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
- 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[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]
- However, consider giving FFP if patient has hemophilia[4]
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
- 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
- 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
- Rapid infusion catheter
- Intraosseous access
- Venous cutdown
- Umbilical vein catheterization
- Ultrasound assisted peripheral line placement
- External jugular vein cannulation
- The "Easy IJ"
- Midlines
References
- ↑ 3SITES Trial
- ↑ 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