Central Venous Catheter: Technique

Central venous catheters are IV lines placed into the large central veins for monitoring of central venous pressure (CVP), prolonged drug administration, or administration of parenteral nutrition. The most common sites of insertion are the internal jugular and subclavian veins. Peripherally inserted central catheters and tunneled central venous catheters are variations that are often used when a prolonged need for central access is anticipated and are common in outpatient settings. Although often lifesaving, these catheters are associated with numerous complications and should be used judiciously.

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Overview

Definition

Central venous catheters are IV catheters inserted into the large central veins that are directly joining superior or inferior venae cavae.

Indications

  • Central venous pressure (CVP) monitoring
  • Prolonged administration of certain medications (i.e., pressors, chemotherapeutic agents)
  • Total parenteral nutrition
  • Inability to obtain peripheral access

Considerations before insertion

  • Peripheral IV catheters are more effective at providing resuscitation and are preferred in initial trauma management.
  • Unnecessary central venous catheter insertion should be avoided, as the procedure carries risks and complications.
  • Site selection: can be placed in internal jugular, subclavian, or femoral vein
  • Adherence to a strict sterile 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
  • Appropriate hand hygiene and aseptic technique for manipulating and accessing the catheter

Central Venous Catheter Insertion

The central veins are accessed percutaneously under local anesthesia. 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:
    • Right side is preferred, as it makes a straight line to the superior vena cava.
    • Left-side approach also carries additional risk of injury to the thoracic duct.
    • If available, bedside ultrasonography is used for visualization of the internal jugular vein.
    • The vein can be accessed at:
      • The lower lateral neck at the tip of the triangle formed by the 2 insertions of the sternocleidomastoid muscle and the clavicle
      • Lateral to the carotid artery at the level of the thyroid cartilage
  • Subclavian vein:
    • Carries greater risk of pneumothorax than internal jugular and should be attempted only by an experienced clinician.
    • Ultrasound guidance usually is not helpful as the subclavian vein is difficult to visualize at the bedside.
    • The vein is accessed under the clavicle 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
    • Vein is accessed in the groin medial to the femoral artery identified by pulse palpation 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 and extends all the way into the superior vena cava.
  • Performed under ultrasonographic or fluorographic guidance
  • Potentially the safest approach, since the likelihood of adverse events (i.e., 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.
  • Allows for long-term central venous access in the outpatient setting
  • Examples:
    • Hickmann’s catheter: dialysis access
    • Port-a-cath: chemotherapy administration
Port-a-cath

Port-a-cath:
Example of a tunneled central venous catheter. The port is placed in a subcutaneous pocket and can be easily accessed with a needle.

Image: “Porta cath” by Tristanb. License: Public Domain

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: catheter should be flushed and free of air bubbles prior to insertion.
  • 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: perforation of heart with a guidewire
  • Hemorrhage/site hematoma: 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:
    • Entry-site infection
    • Suppurative thrombophlebitis
    • Catheter-related sepsis
  • Vessel thrombosis

References

  1. Mole, D. J. (2018). Practical procedures and patient investigation. In: Garden, O. James, et al. (Eds.), Principles and Practice of Surgery. Elsevier, pp. 112–127. https://www.elsevier.com/books/principles-and-practice-of-surgery/garden/978-0-7020-6859-1
  2. Adams, G.A., et al. (2020). Intravascular access. In Adams, G.A., et al. (Eds.), On Call Surgery, 4th ed. Elsevier, pp. 265–308. https://www.clinicalkey.es/#!/content/3-s2.0-B9780323528894000193

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