Central Line


Article Author:
Ari Leib
Bryan England


Article Editor:
John Kiel


Editors In Chief:
David Wood
Andrew Wilt
Hajira Basit


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
6/16/2019 7:47:21 PM

Introduction

Central venous catheterization (CVC) is a procedure frequently required in acute or critical care resuscitation. Indications include patients with multiple, incompatible intravenous (IV) medications with limited peripheral access, or who are being treated with vasoactive or phlebosclerotic agents which may not be suitably cared for with a peripheral IV alone. Some central lines are also placed for temporary or permanent hemodialysis access; these dialysis catheters are significantly larger than traditional double, triple, or quadruple lumen catheters placed in the emergency department (ED) or intensive care unit (ICU) setting. Central lines may also be placed to introduce Swan Ganz catheters to measure internal hemodynamics of the heart, or to introduce temporary transvenous pacemaker leads in the critically ill patient who has severe bradycardia or high-degree heart block: these are called introducer catheters. Most central lines are placed today via the Seldinger technique (a safety enhancement over the previous "cut-down" technique), in which the chosen vein is cannulated with a needle, a guide wire is inserted to maintain a tract through the skin into the vein, and the catheter is then inserted over the wire into the vein before the wire is removed. This procedure is generally performed with ultrasound guidance unless an ultrasound machine is unavailable or there are other exigent circumstances, in which case a palpation guided approach can be used. Despite the general overall safety of this procedure, complications do occur. This activity focuses on the complications of line placement. [1],[2],[3]

Anatomy

Central venous catheters are placed typically in one of 3 large central veins: the internal jugular vein (IJ), subclavian vein (SCL), or femoral vein. These large diameter central veins are located universally near a large artery. In the lateral neck, the IJ is located next to the carotid artery, with the vein lying lateral to the artery in most patients, deep to the sternocleidomastoid muscle. The subclavian vein lies next to the subclavian artery, and courses out of the axilla across the lateral upper chest where it quickly dives deep to the clavicle before forming a confluence with the internal jugular vein which then becomes the brachiocephalic vein. The right and left brachiocephalic veins then join together to form a common superior vena cava. The femoral vein lies in the femoral triangle of each thigh and maintains a medial relationship to the common femoral artery.[4] A common mnemonic to remember the anatomic relationship of the femoral triangle is 'NAVeL' from lateral to medial indicating femoral nerve, femoral artery, femoral vein and lymphatics. Proximity to adjacent vital structures (arteries and lungs principally) is perhaps of greatest concern when striving to perform this procedure without causing harm to the patient.[5],[6]

Indications

Central lines are placed for the following indications:

  • Hemodynamic instability that requires vasopressor support
  • Need to instill hyperosmolar agents or agents known to cause vein scarring (phlebosclerosis)
  • Inadequate peripheral IV access (either failure to obtain peripheral access anywhere, or needing multiple IVs to sustain and resuscitate a patient)
  • Mass transfusion protocol in patients with inadequate peripheral access

Contraindications

Contraindications to central line placement may vary based on the site chosen to cannulate. Common contraindications to central line placement are:

  • Coagulopathy (anticoagulated status, DIC, or other inherited or acquired coagulopathy): Placement at noncompressible sites are relatively contraindicated, due to the risk of hemorrhage.  However, in a large retrospective study, there was no increased predictability of bleeding in patients with underlying coagulopathy, and there was no decrease in bleeding complications in those patients receiving platelettes or FFP prior to line placement.
  • Infection at the insertion site (cellulitis, abscess)
  • History of surgical manipulation or trauma
  • Trauma to other structures (e.g. cervical spine collar is a soft contraindication to an IJ CVC, pelvic binder is a contraindication to a femoral CVC)

Equipment

  • Central line insertion kit, which is usually manufacturer specific should contain the all the equipment for the central line and seldinger technique, including central venous catheter, guide wire, syringe, an introducer needle, a scalpel, a silk suture (on a Keith or curved needle) and a skin dilator
  • Sterile gloves and gown
  • Hat and mask
  • Drape or sterile towels to create a sterile barrier (to protect equipment and materials from becoming contaminated)
  • Antiseptic agent for skin preparation
  • Proper caps for each lumen port
  • Dressing to cover the insertion site
  • Local anesthetic (1% to 2% lidocaine is supplied in most commercial kits) with a syringe and needle to instill the medication

It is also helpful to ask if any specific additional items are needed per your institutional protocols (such as antibiotic sponges). If an ultrasound-guided technique is used, a sterile probe cover should also be available.[7],[8]

Personnel

When possible, having an assistant present during the procedure is helpful. However, the well-prepared and well-practiced clinician can place a central venous catheter with little to no assistance.  It is also recommended that the performer of the procedure, have a second team member (i.e nurse) confirm the removal of the wire from the patient and document this in the nursing charts to match the physician charting.

Preparation

If the patient is conscious and available to provide consent, risks and benefits of the procedure should be reviewed and written consent should be obtained. Before any medical procedure, it is appropriate to take a moment to confirm that you are with the right patient, performing the right procedure at the right site (commonly called a "time out").[9] Once the site is chosen, a topical antiseptic such as chlorhexidine or betadine is applied circularly to the skin in ever-enlarging circles. Once applied, the antiseptic should be allowed to dry to maximize the decrease in skin surface bacterial cell count. After securing the line in vivo, it is also common practice to flush the central line with sterile saline to prevent clotting within the catheter, as well as to confirm functionality of all ports.  This step should be performed both prior to insertion and after insertion of the catheter.

Technique

After donning sterile gown and gloves, and a hat and mask, and after the selected vein is prepped and draped, anesthetize the insertion site by injecting local anesthetic sufficient to create a wheal under the skin.  Continue to aim this needle towards the venous target, aspirating then injecting anesthetic into the subcutaneous tissue. Once the area is anesthetized, place the introducer needle into the skin, and advance toward the vein being cannulated, all the while aspirating with steady pressure. Once blood return is seen in the syringe attached to the introducer needle, the syringe can be removed. A guidewire is inserted through the needle into the vein, to a depth of at least 15 centimeters (although this will vary based on the insertion site). Some commercial kits include a syringe with a wire-port located on the base of the plunger; another option is to insert the wire through this port into the vein. Make sure to insert enough wire to pass through the needle and syringe, as well as at least 10 centimeters into the cannulated vein. Next, remove the needle (and syringe if still attached), careful to leave the wire inserted in the skin and vein. Use the scalpel to make a small stab incision (approximately 2 mm) into the path of the guidewire, then slide the skin dilator over the wire into the subcutaneous tissue, to dilate the soft tissue all the way to and into the vein. Remove the dilator, you will likely have increased bleeding from the site due to the dilation. Using gauze and direct moderate pressure over the cannulation site, will decrease bleeding and also allow continued security of the wire.  Next, carefully insert the central line over the wire without ever taking one hand off the wire. Before allowing the distal tip to enter the skin, manually back the guidewire through the central line until the wire emerges from the central line port. In triple lumen catheters, the wire will emerge from the brown port.  Secure the proximal end of the wire and continue to guide the central line into the skin, subcutaneous tissue, and vein, over the wire. Remove the wire, apply appropriate caps to the central line ports (or clamp the line so that no blood can escape, and no air can enter the patient). Secure the central line to the skin with suture or staple per institutional guidelines, and apply a sterile dressing to cover the insertion site.  Confirm that all lines draw back and flush easily.  Completely flush each line with saline to prevent blood from clotting within each lumen.[10]

Confirmation of line placement and evaluation for post-procedural complications must then occur.

Complications

  • Pneumothorax
  • Pericardial effusion/tamponade
  • Bleeding
  • Arterial puncture with an expanding hematoma (can cause airway compromise in IJ)
  • Infection
  • Thrombosis
  • Injury to the nerves
  • Losing guidewire inside the vein
  • Air embolism
  • Arrhythmias [11]

After a completed procedure of line placement, evaluation for all of the above must begin.  During any line placement that is occurring within the thorax (i.e. subclavian, IJ, supraclavicular approaches), it is recommended that the patient is on continuous cardiac monitoring to watch for any arrhythmia or significant ectopy which could indicate to deep a placement of the line itself or simply irritation of the myocardium by the wire.  Rare, but well-documented cases of fatal cardiac arrhythmias, including asystole, have been documented.  Other acute complications include the development of bleeding at the site, expanding hematoma nerve injury, pericardial effusion, and pneumothorax.  If the patient is awake a neurologic exam is recommended to assess for possible peripheral nerve injury.  Evaluation for hematoma is performed clinically, however, ultrasound is also a useful tool for this as well as these other rapid complications.  While chest x-ray has been considered the gold standard for evaluation of line placement and its complications, ultrasound has significant usefulness in these patients.  Ultrasound can be used to assess for pneumothorax, and as in trauma patients, patients undergoing central line placement are often supine and air may not be as readily seen on a chest x-ray as air tracks anterior.  Evaluation for lung slide with ultrasound is a quick and accurate way to assess for this in experienced hands.[12]  Ultrasound also allows for quick assessment for pericardial effusion and for expanding hematoma concerns at the site of placement.  Studies have also shown that line placement confirmation using RASS (rapid atrial swirl sign) at the bedside is faster, just as accurate, and exposes patients to less radiation than x-ray in confirmation of successful placement of a central venous catheter.  This method involves simply flushing 10cc of normal saline under ultrasound visualization of the heart and watching for the swirling of flow within the right atrium.[1][13]

Clinical Significance

With a central line, the patient cannot only be resuscitated, but the hydration status can be monitored by measuring the right atrial pressure.[14] One can also administer medications and total parenteral nutrition (TPN) via a central line. It is important to remember however, that a standard triple lumen or quad lumen catheter that is often used for cooling is not the best way to provide rapid infusion of crystalloid or blood products.  While there are many indications, it is imperative to remember, that rapid infusion is more easily obtainable through a single 16 or 18 guage peripheral line.  In fact, in order to infuse the same amount of fluids in the same time frame, all three ports (one 16 guage and two 18 guage lumens) of a triple lumen must be infusing under pressure at the same time in order to match the speed of a single 16 guage peripheral line under equivalent pressure.  This is due to the length of the tubing and the resistance to flow associated with the longer catheter.  Multi-lumen central venous lines,  however are certainly indicated for those patients requiring multiple medications infusing at the same time, especially those medications known to be damaging to smaller vessels (i.e. pressors); those patients requiring multiple repeated blood draws; those patients who may benefit from CVP monitoring; and those patients needing dialysis or CVVP. 

Enhancing Healthcare Team Outcomes

Central lines are inserted by many healthcare professionals, but the monitoring of these lines is done by the nurses. Today, in order to avoid line infections, most hospitals have a central line team that regularly monitors the duration and need of these lines. Anyone who inserts a central line must be familiar with the anatomy and how to deal with complications.  While in the past it was believed that lines within the thorax were cleaner and less likely to develop infection complications, more recent data would suggest that with appropriate line management by these teams and with appropriate prep and sterile technique utilization at the time of line placement, there is no statistically significant difference in the development of infectious complications based solely upon location of line insertion within the body.


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Central Line - Questions

Take a quiz of the questions on this article.

Take Quiz
Which of these is of least concern when present at a central line insertion site?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient is receiving total parenteral nutrition through a central line. A small amount of milky fluid is noted to be leaking at the site of the central line dressing. Which of the following should be the initial action?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Using standard and sterile technique, you rapidly place a right sided subclavian central venous line in a multiply injured blunt trauma patient in whom you have not been able to clear the C-spine, and whom required mechanical ventilation for respiratory support is needed. Shortly after placing the line, the patient becomes increasingly tachycardic with some occasional ectopy and the SBP drops from 107 to 88. The line seems to still be working but you note that it seems to flush with more difficulty than it did when you first inserted it. The oxygen saturations do not seem to have changed. The next most appropriate action would be which one of the following?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 66-year-old male patient presents in septic shock and does not respond to appropriate fluid resuscitation. The patient requires a central venous line (CVL) placement. However, the patient is taking warfarin for atrial fibrillation and his INR is highly deranged i.e. 7.6. Which of the following measures need to be taken immediately?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A gunshot wound victim is brought to the emergency department. He is intubated and provided supportive measures. A large bore central line is planned for massive transfusion protocol. The placement is complicated by a pneumothorax which is appropriately managed with needle decompression. The patient is stabilized and then transferred to the trauma center. While cleaning up sharps and line kit, the provider notices the wire for the central line is missing. A nurse states that she is pretty sure she cleaned it up at threw it out. The provider is fairly certain he recovered it but realizes he was too distracted and cannot be sure. What is the next most appropriate course of action?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Central Line - References

References

Korsten P,Mavropoulou E,Wienbeck S,Ellenberger D,Patschan D,Zeisberg M,Vasko R,Tampe B,Müller GA, The     [PubMed]
Najari F,Amirian M,Sadjadi S,Baradaran Kayal I, Loss of Guide Wire as an Important Complication of Central Venous Catheterization; a Case Report. Emergency (Tehran, Iran). 2018     [PubMed]
Björkander M,Bentzer P,Schött U,Broman ME,Kander T, Mechanical complications of central venous catheter insertions: A retrospective multicenter study of incidence and risks. Acta anaesthesiologica Scandinavica. 2018 Jul 11     [PubMed]
Arafa R,Khammas H,Agrawal A, Guidewire-induced asystole complicating a right internal jugular catheter placement in a patient with pre-existing left bundle branch block: A case report. The journal of vascular access. 2018 Jul 1     [PubMed]
Silvetti S,Aloisio T,Cazzaniga A,Ranucci M, Jugular vs femoral vein for central venous catheterization in pediatric cardiac surgery (PRECiSE): study protocol for a randomized controlled trial. Trials. 2018 Jun 25     [PubMed]
Hojsak I,Lacaille F,Gupte GL,Köglmeier J, Central line in long term parenteral nutrition in children - a European survey. Journal of pediatric gastroenterology and nutrition. 2018 Jun 18     [PubMed]
Soffler MI,Hayes MM,Smith CC, Central venous catheterization training: current perspectives on the role of simulation. Advances in medical education and practice. 2018     [PubMed]
Cleff C,Boensch M,Eifinger F,Hinkelbein J, [Correct positioning of central venous catheters in pediatrics : Are current formulae really useful?] Der Anaesthesist. 2018 May 7     [PubMed]
Paik P,Arukala SK,Sule AA, Right Site, Wrong Route - Cannulating the Left Internal Jugular Vein. Cureus. 2018 Jan 9     [PubMed]
Goizueta AA,Bhimji SS, Anatomy, Thorax, Lung, Pleura And Mediastinum null. 2018 Jan     [PubMed]
Rivard AB,Burns B, Anatomy, Neck, Veins, Internal Jugular null. 2018 Jan     [PubMed]
Lambert I,Tarima S,Uhing M,Cohen SS, Risk Factors Linked to Central Catheter-Associated Thrombosis in Critically Ill Infants in the Neonatal Intensive Care Unit. American journal of perinatology. 2018 Aug 6     [PubMed]
Weekes AJ,Keller SM,Efune B,Ghali S,Runyon M, Prospective comparison of ultrasound and CXR for confirmation of central vascular catheter placement. Emergency medicine journal : EMJ. 2016 Mar;     [PubMed]
Amir R,Knio ZO,Mahmood F,Oren-Grinberg A,Leibowitz A,Bose R,Shaefi S,Mitchell JD,Ahmed M,Bardia A,Talmor D,Matyal R, Ultrasound as a Screening Tool for Central Venous Catheter Positioning and Exclusion of Pneumothorax. Critical care medicine. 2017 Jul;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Pediatrics-Medical Student. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Pediatrics-Medical Student, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Pediatrics-Medical Student, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Pediatrics-Medical Student. When it is time for the Pediatrics-Medical Student board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Pediatrics-Medical Student.