How many different types of central lines exist?
What is the role for using ultrasound in the placement of central lines?
Is there a preferred vein for the placement of a central line?
Are there any absolute contraindications to central line placement?
What is considered to be the best “skin prep” for site sterilization in preparation for central line insertion?
What are the three critical elements of proper sharps safety?
The practice of hospital-based internal medicine has traditionally required proficiency in the insertion of central venous catheters (CVCs) for intravenous access. Athough the requirement that physicians-in-training become proficient in the placement of CVCs has been questioned by some, the fact remains that CVCs are a mainstay of inpatient medical care and many hospitals in the United States frequently rely on residents and hospitalists to place CVCs. This chapter reviews a number of key elements related to CVC placement, maintenance, and removal; indications and contraindications for CVC placement, procedure set-up and insertion techniques, and potential complications of CVCs. Lastly, we will comment on the essential nature of using real-time ultrasound guidance for optimal CVC placement.
A central line, or central venous catheter, is any vascular access device whose tip terminates in a large blood vessel of the body (most commonly the superior vena cava or inferior vena cava). On rare occasions (due to proximal thrombosis or stenosis) central lines will terminate in the subclavian vein; these “midline” catheters are also considered to be CVCs.
Almost any peripheral or central vessel can be the entry point for a CVC; the most commonly used veins for the insertion of CVCs include the internal jugular (IJ), subclavian (SC), and femoral veins. PICCs (peripherally inserted central catheters) are also considered to be CVCs and are inserted into a peripheral mid-arm vein such as the basilic vein or cephalic vein.
CVCs are made of either polyurethane or silicone. Some CVCs are designed to withstand the pressures required for the power injection of IV contrast for CT scans, and others have been impregnated with antibiotics (either chlorhexidine/silver sulfadiazine or rifampin/minocycline) in order to prevent catheter-related bloodstream infection (CR-BSI). CVCs range widely in diameter, from 3-Fr single lumen PICCs to 7-Fr 5-lumen CVCs to 15-Fr double-lumen dialysis catheters. The required diameter depends in part on the desired flow rate, which varies based on the indication, eg, 3 cc/min for CT contrast infusion, 70 cc/min for pheresis, or >300 cc/min for hemodialysis. Some CVCs have a natural safety lifespan of 10 to 14 days, while others can safely remain in place for years.
Ports are a unique type of CVC. Ports are canisters (made of plastic or metal) that are implanted into a subcutaneous pocket in either the chest (Port-a-cath) or arm (PAS-port). The canister is attached to a polyurethane catheter which is inserted into the vascular space; the internal jugular, subclavian, or basilic veins are most commonly ...