II. Indications

  1. Medications causing tissue necrosis on extravasation or otherwise harmful via peripheral IV
  2. Large volume infusion required
  3. Hemodialysis
  4. Unobtainable or unreliable Intravenous Access
  5. Pulmonary artery pacing
  6. Invasive Monitoring
    1. Right Ventricular Filling Pressures (Central Venous Pressure) and oxygenation (ScvO2)
    2. Left ventricular filling pressure (pulmonary artery catheter or wedge pressure)

III. Preparation

  1. Perform under dynamic Ultrasound guidance
    1. Confirms vessel location and patency
    2. Real-time confirmation of vessel cannulation
    3. Decreases the number of access attempts
    4. Decreases the time to central vein catheterization
    5. Decreases central access complication rate
  2. Perform under sterile conditions to reduce infectious complications
    1. Mask, cap, sterile gown and sterile gloves
    2. Large sterile drape
    3. Antimicrobial Dressing at catheter insertion site
    4. Sterile transducer sleeve around Ultrasound probe and cord

IV. Approach: Site Selection in stabilized patients

  1. Precaution
    1. Site selection should avoid sites with overlying infection, altered anatomy, Trauma or distortion
  2. General patient without other risk factors
    1. Internal Jugular Central Line is preferred (lowest risk site)
    2. Avoid femoral Central Line overall (aside from codes) due to the highest rate of complications (DVT, infection)
    3. Consider alternatives to central access
      1. Ultrasound-Guided Antecubital Line
      2. PICC Line
  3. Morbidly obese
    1. Subclavian Central Line is preferred
    2. Internal Jugular Vein landmarks are typically difficult to localize in the morbidly obese
    3. Avoid femoral vein Central Line due to infection risk
  4. Pneumothorax or Hypoxemia
    1. Internal Jugular Central Line is preferred
    2. Avoid subclavian Central Line (unless on same side as the Pneumothorax)
  5. Coagulopathy (increased bleeding risk such as Hemophilia, Thrombocytopenia)
    1. Internal Jugular Central Line is preferred
    2. Avoid subclavian Central Line as it is a noncompressible site
  6. Hypercoagulable state (increased thrombosis risk)
    1. Subclavian Central Line is preferred
    2. Avoid Internal Jugular Central Line (highest risk site for DVT)

V. Approach: Site Selection by circumstance

  1. Crashing patient (Code, CPR) or Trauma patient (C-Spine Immobilization)
    1. Intraosseous Access
    2. Femoral Line
      1. Replace with supraclavicular line (IJ, EJ, Subclavian) when stabilized
  2. Children
    1. Femoral line (if intraosseous fails)
  3. Central Venous Pressure monitoring or Sepsis catheter
    1. Supraclavicular line (IJ, EJ, Subclavian)

VI. Approach: Pediatric Patients

  1. Central catheter sizes in children
    1. Infant: 3 French (24 gauge)
    2. Toddler/Preschool: 4 French (20 gauge)
    3. School age: 5 French (18 gauge)
  2. Catheter placement pearls
    1. Sedation allows for procedure (e.g. Ketamine 4 mg/kg IM)
    2. May use introducer (catheter over needle only) for initial Resuscitation
      1. May later, use guidewire through introducer catheter to place standard Central Line
    3. Catheter wire kinking, looping or fracturing (or dilator displacement)
      1. Gently move the wire in and out of dilator while dilator is being advanced
    4. Dilator misdirected down divergent path
      1. Rotate the dilator while inserting through subcutaneous tissue
  3. References
    1. Claudius, Behar, Chang and Santillanes in Herbert (2016) EM:Rap 16(4): 3-4
    2. Claudius, Behar and Hofmann, Santillanes, Bowman in Herbert (1018) EM:Rap 18(6):13-4

VII. Approach: Line Maintenance

  1. Check Central Lines daily for signs of infection
  2. Change Central Lines at 10 days or at signs of infection
  3. Consider Central Line removal when not used for >1 day

VIII. Preparations: Devices

  1. Triple lumen catheter (typical Central Line)
    1. cvTripleLumenCatheter.png
  2. Double lumen catheter
  3. Hemodialysis catheter
  4. Cordis catheter
    1. Indicated for Hemodialysis or critically ill patients requiring advanced hemodynamic monitoring

IX. Complications: General

  1. Catheter Related Bloodstream Infections (CRBI)
    1. See Catheter Related Bloodstream Infections (CRBI)
  2. Collateral injury to surrounding structures
    1. Pneumothorax (IJ, EJ, Subclavian Line)
    2. Bladder or retroperitoneal injury (Femoral line)
  3. Immobilization-related effects
    1. Deep Vein Thrombosis (especially femoral line)
  4. Retained Central Catheter Guidewire
    1. Unrecognized at time of procedure in up to one third of cases
      1. Missed on post-procedure imaging while focused on other features (e.g. IV position, excluding Pneumothorax)
      2. Unrecognized in some cases for up to years after procedure
    2. Delayed diagnosis risks serious complications
      1. Dysrhythmias
      2. Cardiovascular injury
      3. Venous Thrombosis
      4. Cardiac Tamponade
      5. Death
    3. Removal
      1. Typically requires Intervention Radiology for wire retrieval under fluoroscopy
      2. If guide wire is still partially encased in IV catheter, negative pressure technique may be attempted
        1. Repeatedly aspirate from catheter to attempt drawing wire back into channel toward skin surface
        2. When wire reaches skin level, a clamp may be applied to catheter (and wire within), and both withdrawn
    4. References
      1. Broder (2023) Crit Dec Emerg Med 37(10): 18-20
  5. Central Line Occlusion
    1. Attempt to flush the line with saline first
    2. Next, inject a few milligrams of Alteplase into the line and wait a few minutes
      1. Repeat saline flush
    3. References
      1. da Costa (2019) Pediatrics 144(6) +PMID:31757859 [PubMed]

X. Complications: Site specific risks (may direct site selection)

  1. Internal Jugular Central Line
    1. Venous thrombus (>2 fold increased risk over subclavian Central Line)
      1. Timsit (1998) Chest 114: 207-13 [PubMed]
      2. Parienti (2015) N Engl J Med 373(13):1220-9 [PubMed]
  2. External Jugular Central Line
    1. Failed placement
    2. Pneumothorax
  3. Subclavian Central Line
    1. Pneumothorax (highest risk site)
    2. Noncompressible (uncontrolled bleeding risk)
    3. Lowest risk site for Central Line-Associated Bloodstream Infection (compared with femoral, internal jugular)
  4. Femoral Central Line
    1. Deep Vein Thrombosis
    2. Infection risk
    3. Preferred site in children (lower risk than IJ)
    4. In 2015 study, femoral lines had similar risks to internal jugular: infection rate (1.2%), thrombus rate (1.4%)
      1. Femoral also had the lowest failed placement rate (5%) compared with 9% IJ and 15% subclavian
      2. Parienti (2015) N Engl J Med 373(13):1220-9 [PubMed]

XI. Complications: Misplaced or Malpositioned Central Venous Catheter

  1. Background
    1. Central venous catheter (CVC) is considered malpositioned if its tip is not in the superior vena cava or right atrium
    2. Mild catheter tip migration is common, often with torso or neck movement
    3. More significant misplaced CVCs include catheter tip floated distally (e.g. from IJ into subclavian towards hand)
  2. Procedure: Arterial Misplacement
    1. Leave in Place Pending Consultation
    2. Risk of Hemorrhage on large bore Arterial Line removal
    3. Consult vascular surgery or Intervention Radiology regarding guidance
  3. Procedure: Venous Misplacement - Catheter Repositioning or Replacement
    1. Catheter Repositioning
      1. Increases risk of infection and may be more difficult to redirect
      2. Perform under same sterile conditions as if placing a new catheter
      3. Requires determining length the catheter needs to be withdrawn before advancing again
      4. Consider Balloon tipped 2F Fogarty Catheter (longer than CVC) to help float tip into correct position
      5. Compress the unintended vessel (e.g. subclavian vein) when attempting to reposition into SVC and right atrium
    2. Catheter Replacement
      1. Risks loss of access, but is preferred for decreased infection risk
      2. Practice same sterile technique and procedure as per new CVC placememt
      3. New sterile catheter set reduces risk of infection
      4. Guidewire from new set may be used to change over the old catheter
    3. Precautions
      1. Use portable XRay or Bedside Ultrasound to monitor catheter positioning during procedure
  4. References
    1. Warrington (2021) Crit Dec Emerg Med 35(4): 9
    2. Roldan (2015) West J Emerg Med 16(5): 658-64 +PMID: 26587087 [PubMed]
      1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4644031/

XII. Complications: Catheter Site Bleeding

  1. Apply manual pressure to bleeding site for 20 minutes (e.g. sandbag, compression device)
  2. Purse Stitch
  3. Woggle Technique
    1. https://cairweb.ca/en/news/a-pearl-i-learned-and-remembered-the-woggle-technique/
    2. https://www.stepwards.com/?page_id=24971
    3. Technique
      1. Suture (3-0 Monofilament) placed through skin, under the Central Line (careful not to puncture the line)
      2. Cut off the needle and pull the ends up, twist ends together and thread through an open stopcock
      3. Push the stopcock against skin (or against intervening gauze) and tighten the stopcock to cinch
      4. Leave in place for 30 minutes, release the stopcock and remove the Suture
      5. Sacchetti in Swadron (2022) EM:Rap 22(8): 8
  4. Other measures
    1. See Hemorrhagic Shock
    2. Reverse Coagulopathy
    3. Topical Hemostatic Agents

XIII. Resources

  1. Internal Jugular Vein cannulation video (ACEP Critical Decisions Video)
    1. http://www.acep.org/cdem_2014_lesson_10-1/
  2. Subclavian vein cannulation from a supraclavicular approach video (ACEP Critical Decisions Video)
    1. http://www.acep.org/cdem_2014_lesson_10-2/
  3. Subclavian vein cannulation from an infraclavicular approach video (ACEP Critical Decisions Video)
    1. http://www.acep.org/cdem_2014_lesson_10-3/
  4. Femoral vein cannulation video (ACEP Critical Decisions Video)
    1. http://www.acep.org/cdem_2014_lesson_10-4/

XIV. References

  1. Killu and Sarani (2016) Fundamental Critical Care Support, p. 93-114
  2. Jacquet and Hong (2014) Crit Dec Emerg Med 28(5): 15-22
  3. Swaminathan and Herbert in Majoewsky (2013) EM:Rap 13(9): 6

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