Central Venous Catheter

Overview

Definition

Central venous catheters are IV catheters inserted into the large central veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins: Histology that are directly joining the superior or inferior venae cavae Venae Cavae The inferior and superior venae cavae. Veins: Histology.

Indications

• Central venous pressure (CVP) monitoring
• Prolonged administration of certain medications (i.e., pressors, chemotherapeutic agents)
• Total parenteral nutrition Total parenteral nutrition The delivery of nutrients for assimilation and utilization by a patient whose sole source of nutrients is via solutions administered intravenously, subcutaneously, or by some other non-alimentary route. The basic components of tpn solutions are protein hydrolysates or free amino acid mixtures, monosaccharides, and electrolytes. Components are selected for their ability to reverse catabolism, promote anabolism, and build structural proteins. IPEX Syndrome
• Inability to obtain peripheral access

Considerations before insertion

• Peripheral IV catheters are more effective at providing volume resuscitation Resuscitation The restoration to life or consciousness of one apparently dead. . Neonatal Respiratory Distress Syndrome and are preferred in initial trauma management.
• Unnecessary central venous catheter insertion should be avoided, as the procedure carries risks and complications.
• Site selection Selection Lymphocyte activation by a specific antigen thus triggering clonal expansion of lymphocytes already capable of mounting an immune response to the antigen. B cells: Types and Functions: can be placed in internal jugular, subclavian, or femoral vein
• Adherence to a strict sterile Sterile Basic Procedures technique: full-barrier precautions during insertion
• Central venous catheters should be daily assessed for necessity and removed as soon as feasible.

Adequate maintenance

• Daily inspection Inspection Dermatologic Examination
• Appropriate hand hygiene Hand hygiene Practices involved in preventing the transmission of diseases by hand. Surgical Infections and aseptic technique for manipulating and accessing the catheter

Central Venous Catheter Insertion

The central veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins: Histology are accessed percutaneously under local anesthesia Anesthesia A state characterized by loss of feeling or sensation. This depression of nerve function is usually the result of pharmacologic action and is induced to allow performance of surgery or other painful procedures. Anesthesiology: History and Basic Concepts. Bedside ultrasound guidance can be used and is recommended particularly for internal jugular insertion, where the vein can be easily visualized, which can help avoid inadvertent carotid artery cannulations.

Seldinger technique

The Seldinger technique is most commonly used for central venous catheter placement:

1. The vein is cannulated with an 18-gauge needle.
2. A guidewire is introduced into the vein through the needle itself or through the angiocatheter sheath.
3. A catheter is placed over the guidewire and the wire is removed.

Insertion sites

• Internal jugular vein Internal jugular vein Parapharyngeal Abscess:
  • Right side is preferred, as it makes a straight line to the superior vena cava Superior vena cava The venous trunk which returns blood from the head, neck, upper extremities and chest. Mediastinum and Great Vessels: Anatomy.
  • Left-side approach also carries additional risk of injury to the thoracic duct Thoracic Duct The largest lymphatic vessel that passes through the chest and drains into the subclavian vein. Lymphatic Drainage System: Anatomy.
  • If available, bedside ultrasonography Bedside Ultrasonography ACES and RUSH: Resuscitation Ultrasound Protocols is used for visualization of the internal jugular vein Internal jugular vein Parapharyngeal Abscess.
  • The vein can be accessed at:
    • The lower lateral neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess at the tip of the triangle formed by the 2 insertions of the sternocleidomastoid Sternocleidomastoid Muscles of the Neck: Anatomy muscle and the clavicle Clavicle A bone on the ventral side of the shoulder girdle, which in humans is commonly called the collar bone. Clavicle Fracture
    • Lateral to the carotid artery at the level of the thyroid Thyroid The thyroid gland is one of the largest endocrine glands in the human body. The thyroid gland is a highly vascular, brownish-red gland located in the visceral compartment of the anterior region of the neck. Thyroid Gland: Anatomy cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage: Histology
• Subclavian vein:
  • Carries greater risk of pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax than internal jugular and should be attempted only by an experienced clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship.
  • Ultrasound guidance usually is not helpful as the subclavian vein is difficult to visualize at the bedside.
  • The vein is accessed under the clavicle Clavicle A bone on the ventral side of the shoulder girdle, which in humans is commonly called the collar bone. Clavicle Fracture at the juncture of middle and medial thirds.
• Femoral vein:
  • Least preferred site: carries greatest risk of infection
  • Can be used as an emergency access, though, and is not associated with the risk of lung puncture and pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax
  • Vein is accessed in the groin Groin The external junctural region between the lower part of the abdomen and the thigh. Male Genitourinary Examination medial to the femoral artery Femoral Artery The main artery of the thigh, a continuation of the external iliac artery. Femoral Region and Hernias: Anatomy identified by pulse palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination or with ultrasound guidance.

Peripherally Inserted Central Venous Catheters and Tunneled Catheters

Peripherally inserted central venous catheter

• A long catheter that is inserted in the basilic or cephalic vein at the antecubital fossa Antecubital Fossa Molluscum Contagiosum and extends all the way into the superior vena cava Superior vena cava The venous trunk which returns blood from the head, neck, upper extremities and chest. Mediastinum and Great Vessels: Anatomy.
• Performed under ultrasonographic or fluorographic guidance
• Potentially the safest approach, since the likelihood of adverse events (i.e., pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax) is much lower.
• Hemorrhage and thrombophlebitis can still occur.
• Allows for administration of medications, parenteral nutrition, and CVP monitoring

Tunneled central venous catheters

• A catheter is inserted into the central vein and tunneled under the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions.
• Allows for long-term central venous access in the outpatient setting
• Examples:
  • Hickmann’s catheter: dialysis Dialysis Renal replacement therapy refers to dialysis and/or kidney transplantation. Dialysis is a procedure by which toxins and excess water are removed from the circulation. Hemodialysis and peritoneal dialysis (PD) are the two types of dialysis, and their primary difference is the location of the filtration process (external to the body in hemodialysis versus inside the body for PD). Peritoneal Dialysis and Hemodialysis access
  • Port-a-cath: chemotherapy Chemotherapy Osteosarcoma administration

Complications

Placement of a central venous catheter is an invasive procedure associated with numerous complications. Therefore, these catheters should be inserted carefully and removed as early as feasible.

Complications associated with insertion

• Air embolism Air embolism Blocking of a blood vessel by air bubbles that enter the circulatory system, usually after trauma; surgical procedures, or changes in atmospheric pressure. Nonthrombotic Embolism: catheter should be flushed and free of air bubbles prior to insertion.
• Pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax: lung puncture during subclavian or internal jugular central venous catheter placement
• Guidewire or line embolism: due to fragments breaking off during insertion
• Arterial puncture (carotid, subclavian, or femoral)
• Nonplacement or misplacement of the line
• Cardiac tamponade Tamponade Pericardial effusion, usually of rapid onset, exceeding ventricular filling pressures and causing collapse of the heart with a markedly reduced cardiac output. Pericarditis: perforation Perforation A pathological hole in an organ, blood vessel or other soft part of the body, occurring in the absence of external force. Esophagitis of heart with a guidewire
• Hemorrhage/site hematoma Hematoma A collection of blood outside the blood vessels. Hematoma can be localized in an organ, space, or tissue. Intussusception: usually associated with multiple attempts and difficult placement or coagulopathy

Complications of prolonged central venous catheter use

• Nonfunction of the line: due to occlusion, kinking, thrombus
• Infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease:
  • Entry-site infection
  • Suppurative thrombophlebitis
  • Catheter-related sepsis Sepsis Systemic inflammatory response syndrome with a proven or suspected infectious etiology. When sepsis is associated with organ dysfunction distant from the site of infection, it is called severe sepsis. When sepsis is accompanied by hypotension despite adequate fluid infusion, it is called septic shock. Sepsis and Septic Shock
• Vessel thrombosis Thrombosis Formation and development of a thrombus or blood clot in the blood vessel. Epidemic Typhus