Central venous access

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Placement of a catheter in a large, central vein provides reliable venous access in patients who are critically ill, have poor venous access, and/or require administration of vesicants, irritant solutions, or large volumes of fluid. It also allows for specialist interventions such as advanced hemodynamic monitoring, transvenous pacing, and hemodialysis. The type of catheter used and anatomical location of placement are based on the patient's condition or injury and comorbidities. Large-gauge, single-lumen catheters are used for the rapid administration of fluid or blood products. Smaller gauge, multiple-lumen catheters are used for prolonged fluid and medication administration. The internal jugular vein is frequently chosen for central line placement because it is easy to access and is associated with fewer procedural adverse events than other sites. Insertion is most commonly performed using the Seldinger technique and usually occurs under ultrasound guidance. Complications include arterial puncture, pneumothorax, bloodstream infections, and venous thrombosis.

• Central venous line (CVL): a vascular catheter that is inserted into a large central vein, e.g., subclavian, femoral, or internal jugular vein (IJV), usually under ultrasound guidance.

Properties of CVLs

• Slower flow rates than peripheral venous catheters of the same diameter because they are longer
• High flow rate can be achieved with large-gauge central venous catheters (e.g., sheath introducer, dialysis catheters).

The flow rate is subject to Poiseuille law: The flow rate is 16 times slower if a lumen's diameter is halved, but flow rate doubles if the catheter's length is halved!

CVL insertion sites

Types of CVLs ^[4][5]

• Short-term CVLs: nontunneled CVLs typically intended to remain in place ≤ 14 days ^[6][7]
  • Triple-lumen CVL: 3 channels; allows simultaneous administration of multiple solutions at different rates
  • Double-lumen CVL: 2 channels; typically large gauge that allows high rates of fluid exchange, e.g., for hemodialysis or plasmapheresis
  • Single-lumen CVL: 1 channel; allows administration of a single solution at a given rate
    • Small gauge: decreases the risk of vessel thrombosis
    • Sheath introducer (large gauge): used for rapid or high-volume fluid administration, or to aid insertion of other lines (e.g., Swan-Ganz catheter)
• Long-term CVLs: e.g., PICC lines , tunneled CVLs , surgically implantable catheters
• Hemodialysis catheters: can be a long-term CVL or a short-term CVL
  • Tunneled CVLs for long-term use; nontunneled CVLs for short-term use
  • Usually a large gauge double-lumen CVL

• Large-volume fluid resuscitation
• Anticipated long-term IV therapy
• Poor peripheral IV access
• Administration of vesicants or irritant medications
• Hemodynamic monitoring
• Therapies requiring high-volume extracorporeal circulation

• Absolute: allergy to an antibiotic impregnated within the catheter ^[2]
• Relative ^[2]
  • Infection or thrombosis at the site of insertion
  • Superior vena cava syndrome (for subclavian and IJV venipuncture)
  • Coagulopathy (especially for subclavian venipuncture) ^[8]

We list the most important contraindications. The selection is not exhaustive.

• Ultrasound machine
• Sterile gown and gloves
• Sterile full-body drape
• Sterile ultrasound probe cover
• Chlorhexidine skin preparation
• 1% lidocaine without epinephrine
• 25-gauge needle and syringe
• Thin-wall introducer needle (TWN) and syringe
• 5 mL syringe
• Guidewire
• Scalpel
• Vascular dilator
• Central venous catheter
• Nonabsorbable suture
• Sterile dressing

• Ready the ultrasound machine.
• Apply cardiac monitors to the patient.
• Place the patient in the Trendelenburg position.
• Perform a preprocedure ultrasound examination.
• Perform skin preparation to create a sterile field.
• Apply a sterile full-body drape.
• Prepare the sterile ultrasound transducer cover.
• Administer single-point local anesthesia for conscious patients.

IJ line insertion in adults ^[2][8]

This approach uses a thin wall needle (referred to as “needle” from here on) and the Seldinger technique.

1. Center the probe above the IJV.
2. Place the needle beneath the center of the probe at a 45° angle to the skin.
3. Apply negative pressure to the syringe plunger and advance the needle until blood flashback occurs.
4. Hold the needle firmly and remove the syringe.
5. Feed 15–20 cm of guidewire through the needle. ^[8]
6. Remove the needle while holding the guidewire in place.
7. Make a small skin incision over the guidewire.
8. Thread the vascular dilator over the guidewire and advance 5–7 cm in a spiral motion into the vein.
9. Remove the dilator and advance the catheter ∼ 16 cm (right IJV) or ∼ 20 cm (left IJV) over the guidewire. ^[2][8][10]
10. Remove the guidewire, aspirate blood from all ports, and flush each port with saline.
11. Secure the catheter to the skin and apply a sterile dressing.

Hold the guidewire at all times when performing steps according to the Seldinger technique. ^[2]

The distal end of the catheter should be cranial to the tracheal bifurcation on CXR. ^[8][12]

• Guidewire removed and inspected
• All ports aspirated and flushed
• Sterile dressing applied
• CXR obtained
• Correct catheter location confirmed
• Pneumothorax ruled out
• Procedure documented
• Postprocedural CLABSI prevention measures ordered

• Complications of indwelling catheters
  • Infection, e.g., CLABSI
  • Thrombosis
• Complications of CVC insertion
  • Arrhythmia
  • Arterial injury
  • Venous air embolism
  • Pneumothorax
  • Hemothorax
  • Guidewire embolism
  • Incorrect catheter placement

Whenever possible, insert CVLs under ultrasound guidance to reduce procedure time and risk. ^[9][16][17]

Obtain a CXR following placement of a CVL to confirm proper positioning of the catheter and identify mechanical complications (e.g., pneumothorax)

We list the most important complications. The selection is not exhaustive.