Central Line (Central Venous Catheter/CVC)

Central Line (Central Venous Catheter/CVC)

David Ray Velez, MD

Table of Contents

Definitions and Function
Choice of Line and Site
Placement/Technique
Complications

Definitions and Function

Anatomy

  • Internal Jugular (IJ) Vein
    • Lies Under the Sternocleidomastoid Muscle (SCM)
    • Vein Runs Anterior and Lateral to the Carotid Artery
  • Subclavian (SC) Vein
    • Runs Under Clavicle
    • Subclavian Artery and Brachial Plexus Are Deep to the Vein
  • Femoral Vein
    • Runs Medial to the Femoral Artery
    • From Lateral-to-Medial: Nerve, Artery, Vein, Empty Space, Lymphatics

Types of Central Lines

  • Non-Tunneled CVC
    • A Catheter Placed Directly from the Skin into the Vein
    • Placed at Bedside
    • Higher Risk of Infection and Generally Considered a Temporary Measure for 2-3 Weeks
    • *Generally What is Meant When Referring to a “Central Line”
  • Tunneled CVC
    • A Catheter is Tunneled Under the Skin for a Distance Before Entering the Vein at a Separate Site
    • Placed by IR or in the OR
    • Lower Risk of Infection and May Be Used for a Longer-Term
  • Peripherally Inserted Central Catheter (PICC)
    • Longer Line Placed Peripherally into an Arm Vein
    • Less Invasive and Lower Infection Risk
    • Smaller Caliber Lumens
    • Often Used if Anticipating Long-Term Need (TPN or Antibiotics)
  • Subcutaneous Port (Port-a-Cath)
    • Completely Tunneled Catheter with Port Beneath the Skin and No Exposed Ports
    • Placed Under Anesthesia
    • Lower Infection Risk than Tunneled or Non-Tunneled CVC
    • Longer Patency – Ideal for Chemotherapy

Flow Rate

  • Hagen-Poiseuille Equation
    • Flow (Q) = ΔP x πr4 / 8 µL
      • P = Pressure, r = Radius, µ = Viscosity, L = Length
    • Directly Related to Radius4
    • Inversely Related to Length1
  • Increased Flow with Higher Radius (Strongest Factor) and Lower Length

Internal Jugular Vein and Subclavian Vein

Femoral Vein

Choice of Line and Site

Choice of Line

  • General Use in the ICU: 7 Fr Triple-Lumen is Standard
    • Multiple Lumens Allow for Infusion of Multiple Agents at the Same Time
  • Hemorrhagic Shock: Large-Bore (8-11 Fr) Single-Lumen Catheter
    • Often Referred to as a “Cordis” (The Manufacturing Company)
    • Used in Trauma, GI Bleed, Ruptured AAA, etc.
    • Largest Bore Allows the Most Rapid Blood Transfusion
  • Hemodialysis Access: Medium-Large Bore (14.5 Fr) Double-Lumen Catheter
    • Two Lumens are Large Enough to Support Dialysis Flow Rates
      • May Have an Additional Smaller Lumen Port for Additional Access
    • “VasCath”: Placed in a Typical Non-Tunneled-Fashion for Short-Term Access
      • Generally What is Initially Placed While in the Hospital
    • “PermaCath”: Placed in a Tunneled-Fashion for Longer Access
      • Generally Placed When Anticipating Discharge and Long-Term Need
  • Long-Term Need for TPN or Antibiotics: PICC Generally Preferred Over a Traditional CVC

Choice of Site

  • Internal Jugular (IJ) Vein
    • Most Often the Preferred Site Under Ultrasound Guidance if Able
    • Straight Path into the SVC Allows a Low Rate of Catheter Malposition
    • Able to Provide Compression for Bleeding Easier than the Subclavian
  • Subclavian (SC) Vein
    • Lowest Infection Risk
    • Lowest DVT Risk
    • Highest Risk of Mechanical Complication (Pneumothorax, etc.)
    • *If Patient Already Has a Pneumothorax and Chest Tube – Strongly Consider Placing Central Line on the Ipsilateral Side (If Placement is Complicated by Pneumothorax it is Already Treated – “Free Shot”)
  • Femoral Vein
    • Lowest Mechanical Complication Risk
    • IJ and Femoral Have a Similar Risk of Infection (Debated)

Placement/Technique

Techniques

  • Blind Placement: Based Solely on Anatomy and Palpation without US Guidance
  • Ultrasound Guidance: Placed Using an Ultrasound in Real-Time
    • Benefits to Ultrasound Use:
      • Decreased Complication Rate
      • Decreased Failure Rate
      • Increased First-Pass Success
    • Should Always be Utilized if Available
  • *Either Method Utilizes a Seldinger Technique

Position/Prep

  • Supine or Head-Down 10-20 Degrees
  • For Subclavian Vein CVC, Arm Should be Completely Adducted
    • Having an Assistant Pull the Ipsilateral Arm Inferiorly During Placement Can Provide Help
  • Procedure Should be Performed in a Sterile Manner Unless Absolutely Unable (“Dirty Lines” Used in Trauma for a Crashing Patient in Hemorrhagic Shock)

Blind Placement

  • Internal Jugular (IJ) Vein
    • Insertion:
      • Anterior Approach: Along the Medial Border of the SCM, 2-3 Fingerbreadths Above the Clavicle
      • Central Approach: The Apex of the Bifurcation of the SCM Heads
    • Angle: 30-45 Degrees
    • Aim: Ipsilateral Nipple
    • *Palpate the Carotid Artery During Placement (Vein Should be Lateral to the Pulse)
  • Subclavian Vein
    • Insertion: 2-3 cm Below Midpoint of Clavicle (1-2 cm Lateral of Bend About the Deltopectoral Fascia)
    • Aim: Just Deep to Sternal Notch
      • If Clavicle is Hit, Withdraw and March Down
  • Femoral Vein
    • Insertion: 1-2 cm Below the Inguinal Ligament and 1 cm Medial to the Femoral Artery Pulse (About 2 Finger-Breadths Lateral to the Pubic Tubercle
    • Angle: 30-45 Degrees
    • *Palpate the Femoral Artery During Placement (Vein Should be Medial to the Pulse)

Seldinger Technique

  • Needle
    • Puncture Vein with a Hollow Introducer Needle
    • Attach Syringe with Gentle Negative Pressure During Advancement
    • Dark Non-Pulsatile Blood Indicates Venipuncture (Caution: Arterial Blood in Hypoxic Patients May Also be Dark)
  • Guidewire
    • Pass a Guidewire Through the Needle
    • Withdraw the Needle Over the Guidewire, Leaving the Guidewire in Place
    • Always Maintain Control of the Guidewire During Placement – Should Never Completely Enter the Vein
  • Dilate the Tract
    • Make a Small Skin Incision at the Entry Site
    • Pass a Dilator Over the Guidewire and Remove it to Dilate the Tract
  • Place the Catheter
    • Pass Catheter Over the Guidewire
    • Withdraw Guidewire
    • Cap the Ports
    • Confirm the Each Port is Able to Withdraw Blood and Flush
  • Suture Catheter to Skin and Place a Sterile Dressing
  • *Always Obtain Post-Procedure Chest XR to Confirm Appropriate Positioning and Look for Pneumothorax (Not Necessary for Femoral Access)

Goal CVC Tip Location

  • Internal Jugular/Subclavian: 1-2 cm Above the Right Atrium-SVC Junction
    • Seen as Just Above the Carina on Chest XR
  • Femoral: Generally Not Evaluated

Approximate Insertion Length

  • Equation Based on Height (cm):
    • Right SC: Height/10 – 2 cm
    • Right IJ: Height/10
    • Left SC: Height/10 + 2 cm
    • Left IJ: Height/10 + 4 cm
  • General Lengths:
    • Right SC: 11-14 cm
    • Right IJ: 13-15 cm
    • Left SC: 15-17 cm
    • Left IJ: 17-18 cm

US Guidance Showing Compressible IJ (V) and Noncompressible Carotid (A) 1

Complications

Carotid Cannulation (Arterial Injury)

  • Can Cause Life-Threatening Hemorrhage
  • Reduce Risk by Using Ultrasound-Guidance for Placement
  • Diagnosis:
    • ABG from the Catheter Showing Arterial Rather than Venous Values
    • Pressure Transducer Attached to the Catheter Showing an Arterial Waveform
    • Chest XR Showing Catheter to the Left of the Spine
  • Treatment:
    • Cannulation with Needle or Guidewire Only: Remove and Hold Pressure for 5-10 Minutes
    • Cannulation with Dilator or Catheter: Remove Under Fluoroscopy or in OR

CVC in the Aorta

Malposition

  • Tip Abutting into the Wall of the Superior Vena Cava
    • Risk for SVC Puncture
    • Treatment: Retract to the Innominate Vein (Do Not Advance – Risk for Introducing Bacteria and Infection)
  • Tip in the Right Atrium
    • Risk for Atrial Wall Puncture
    • Treatment: Retract to the Right-Atrium-SVC Junction

Pneumothorax (PTX)

  • Risk: 1-6.6% (Higher Risk in Emergency Setting or if Multiple Needle Passes are Required to Find the Vein)
  • Treatment:
    • Asymptomatic and Small (< 3 cm): Repeat Chest XR in 6 Hours to Monitor Progression
      • Supplemental Oxygen May Enhance Reabsorption – Reduces Partial Pressure of Nitrogen for a Diffusion Gradient
    • Symptomatic or Large (> 3 cm): Chest Tube
      • Smaller Tubes (8-14 Fr) are Generally Preferred for PTX
  • *See Pneumothorax (PTX)

Cardiac Tamponade

Catheter-Related Thrombosis (CRT)

  • Risk Factors:
    • Hypercoagulable State (Malignancy, Sepsis, etc.)
    • Increased Lumen Diameter
    • Left Sided Placement
    • Malposition with Tip Above the Junction of the SVC and Atrium
    • Multiple Insertion Attempts
  • Presentation:
    • Asymptomatic – Most Common
    • Swelling of the Head, Neck, or Limb
    • Headache
    • Localized Pain or Numbness
    • Superficial Venous Distention
    • Limb Erythema
    • Catheter Malfunction – Difficulty with Infusion or Aspiration
  • Complications:
    • Pulmonary Embolism (PE) (10-15%)
    • Infection
    • Post-Thrombotic Syndrome
    • Loss of Access
  • Diagnosis: Duplex Ultrasound
    • Contrast Venogram is the Gold Standard Test – Used if Duplex is Negative Despite High Suspicion
  • Treatment: Systemic Anticoagulation and Remove Catheter (If Able)
    • May Consider Keeping Catheter Only if it is Functional, Well Positioned, and Not Infected
    • Line Must Be Removed if Anticoagulation is Contraindicated, the Thrombosis is Limb/Life Threatening, or Symptoms Do Not Resolve

Air Embolism

  • Presentation: Hypoxemia and Respiratory Distress
    • “Millwheel” Murmur: Loud Churning – Late Finding
    • Neurologic Abnormalities if Embolized to Arterial System
  • Diagnosis: Demonstration of Intravascular Air with a Known Risk Factor
    • Often Rapidly Absorbed Prior to Imaging
    • TEE is the Most Sensitive Test
    • End Tidal Nitrogen Rises (If Available) Before End Tidal CO2 Decreases
  • Treatment: Reposition and Supportive Care (Supplemental Oxygen)
  • Repositioning:
    • “Durant’s Maneuver” – Left Lateral Decubitus
    • Steep Trendelenburg – Head Down
    • Goal: Trap Air in the Right Ventricle
  • If Hemodynamically Unstable Can Attempt Aspiration Through a Central Venous Catheter
  • *See Air Embolism

Central Line-Associated Bloodstream Infection (CLABSI)

  • Also Known as Catheter-Related Bloodstream Infection (CRBSI)
  • Risk Increases with Duration of Placement (However there is No Indication for Routine Catheter Changing Based on the Number of Days)
  • Skin Colonization is the Most Common Source
  • Most Common Organisms:
    • Coagulase-Negative Staphylococci (CoNS/S. epidermidis) (Most Common)
    • Staphylococcus aureus
    • Enterococci
    • Candida
    • Klebsiella
    • Escherichia coli
    • Enterobacter
    • Pseudomonas
  • Risk Factors:
    • Duration of Catheterization
    • Non-Sterile Insertion
    • Poor Catheter Cares
    • Immune Compromised/Neutropenic
    • Malnutrition
    • Femoral or IJ Location (Lowest for Subclavian)
  • Presentation:
    • Inflammation and Purulence at the Catheter Insertion Site
    • Fever
    • Sepsis (Often Sudden Onset)
  • Complications:
    • Septic Thrombophlebitis
    • Infective Endocarditis
  • Diagnosis: Obtain Two Peripheral Blood Cultures from Separate Sites Before Antibiotic Initiation
    • Increased Risk of Contamination if Drawing from the Central Line
    • Catheter Tip Cultures are Not Recommended – Low Positive Predictive Value
    • A Single Coagulase-Negative Staphylococci (CoNS) Culture is Often a Contaminant and Should Consider Repeating the Cultures
    • Consider Infective Endocarditis if Bacteremia is Persistent > 48-72 Hours
  • Prevention:
    • Remove as Soon as Possible
    • Use Sterile Technique in Placement
    • Use Ultrasound Guidance
    • Chlorhexidine-Impregnated Dressings
    • Use of Antimicrobial-Impregnated Central Lines
    • Disinfect Hubs and Ports Before Accessing
    • Use an Antiseptic-Containing Hub or Port to Cover Connectors
  • Interventions Without Proven Benefit:
    • Prophylactic Antibiotics
    • Routine Replacement of Central Lines
    • Daily Bathing with Chlorhexidine
    • Securing the Catheter with a Suture – Creates Another Wound
  • Treatment: Catheter Removal and Antibiotics
    • *For CoNS – May Consider Withholding Antibiotics and Just Removing the Central Line – No Increased Risk of Complications or Recurrence
    • If Clinically Unable to Remove the Catheter – Consider Exchange Over a Guidewire
  • *See Central Line-Associated Bloodstream Infection (CLABSI)

References

  1. Gillman LM, Blaivas M, Lord J, Al-Kadi A, Kirkpatrick AW. Ultrasound confirmation of guidewire position may eliminate accidental arterial dilatation during central venous cannulation. Scand J Trauma Resusc Emerg Med. 2010 Jul 13;18:39. (License: CC BY-2.0)