Central venous catheter

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Central venous catheter
Intervention
Diagram showing a central line CRUK 059.svg
Diagram showing a tunneled central line inserted into the right subclavian vein.
MeSH D002405
Central line equipment
CVC with three lumens
This is a photo of a dialysis two-lumen catheter inserted on the patient's left side. Scars at the base of the neck indicate the insertion point into the left jugular vein.

In medicine, a central venous catheter ("central line", "CVC", "central venous line" or "central venous access catheter") is a catheter placed into a large vein in the neck (internal jugular vein), chest (subclavian vein or axillary vein) or groin (femoral vein). It is used to administer medication or fluids, obtain blood tests (specifically the "central venous oxygen saturation"), and measure central venous pressure.

Medical uses[edit]

Indications for the use of central lines include:[1]

Central venous catheters usually remain in place for a longer period of time than other venous access devices, especially when the reason for their use is longstanding (such as total parenteral nutrition in a chronically ill patient). For such indications, a Hickman line, a PICC line or a Port-a-Cath may be considered because of their smaller infection risk. Sterile technique is highly important here, as a line may serve as a porte d'entrée (place of entry) for pathogenic organisms, and the line itself may become infected with organisms such as Staphylococcus aureus and coagulase-negative Staphylococci.[citation needed]

Types[edit]

There are several types of central venous catheters:[2]

Non-tunneled vs. tunneled catheters[edit]

Non-tunneled central venous catheter.

Non-tunneled catheters are fixed in place at the site of insertion, with the catheter and attachments protruding directly. Commonly used non-tunneled catheters include Quinton catheters.

Tunneled catheters are passed under the skin from the insertion site to a separate exit site, where the catheter and its attachments emerge from underneath the skin. The exit site is typically located in the chest, making the access ports less visible than if they were to directly protrude from the neck. Passing the catheter under the skin helps to prevent infection and provides stability. Commonly used tunneled catheters include Hickman catheters and Groshong catheters.

Implanted port[edit]

A port is similar to a tunneled catheter but is left entirely under the skin. Medicines are injected through the skin into the catheter. Some implanted ports contain a small reservoir that can be refilled in the same way. After being filled, the reservoir slowly releases the medicine into the bloodstream. An implanted port is less obvious than a tunneled catheter and requires very little daily care. It has less impact on a person's activities than a PICC line or a tunneled catheter. Surgically implanted infusion ports are placed below the clavicle (infraclavicular fossa), with the catheter threaded into the right atrium through large vein. Once implanted, the port is accessed via non-coring "Huber" needles inserted through the skin. The health care provider may need to use topical anesthetic prior to accessing port. Ports can be used for medications, chemotherapy, TPN, and blood. As compared to CVC or PICC catheters, ports are easy to maintain for home-based therapy.

Ports are typically used on patients requiring only occasional venous access over a long duration course of therapy. Since the port must be accessed using a needle, if venous access is required on a frequent basis a catheter having external access is more commonly used.

PICC line[edit]

A peripherally inserted central catheter, or PICC line (pronounced "pick"), is a central venous catheter inserted into a vein in the arm rather than a vein in the neck or chest with the tip positioned in the superior vena cava.

Technical description[edit]

Triluminal catheter

Depending on its use, the catheter is monoluminal, biluminal or triluminal, dependent on the actual number of lumens (1, 2 and 3 respectively). Some catheters have 4 or 5 lumens, depending on the reason for their use.

The catheter is usually held in place by an adhesive dressing, suture, or staple which is covered by an occlusive dressing. Regular flushing with saline or a heparin-containing solution keeps the line open and prevents blood clots. There is no evidence that heparin is better than saline at doing this.[3] Certain lines are impregnated with antibiotics, silver-containing substances (specifically silver sulfadiazine) and/or chlorhexidine to reduce infection risk.[citation needed]

Specific types of long-term central lines are the Hickman catheters, which require clamps to make sure the valve is closed, and Groshong catheters, which have a valve that opens as fluid is withdrawn or infused and remains closed when not in use. Hickman lines also have a "cuff" under the skin, to prevent bacterial migration[citation needed] and to cause tissue ingrowth into the device for long term securement.

Insertion[edit]

Video of an ultrasound-assisted central line insertion through the internal jugular vein
Triple lumen in jugular vein
Chest x-ray with catheter in the right subclavian vein

The skin is cleaned, and local anesthetic applied if required. The location of the vein is then identified by landmarks or with the use of a small ultrasound device. A hollow needle is advanced through the skin until blood is aspirated; the color of the blood and the rate of its flow help distinguish it from arterial blood (suggesting that an artery has been accidentally punctured), although this method is inaccurate.[citation needed] Ultrasound probably now represents the gold standard for central venous access and skills, within North American and Europe, while landmark techniques are diminishing.[4][5]

The line is then inserted using the Seldinger technique: a blunt guidewire is passed through the needle, then the needle is removed. A dilating device may be passed over the guidewire to slightly enlarge the tract. Finally, the central line itself is then passed over the guidewire, which is then removed. All the lumens of the line are aspirated (to ensure that they are all positioned inside the vein) and flushed.[citation needed] A chest X-ray is typically performed afterwards to confirm that the line is positioned inside the superior vena cava and, in the case of insertion through the subclavian vein, that no pneumothorax was caused as a side effect. Vascular positioning systems can also be used to verify tip placement during insertion without the need to a chest X-ray, but this technique is not yet a standard of practice.

Videos are available demonstrating placement of a central venous catheter without[6] and with ultrasound guidance.[7]

Complications[edit]

Central line insertion may cause a number of complications. The benefit expected from their use therefore needs to outweigh the risk of those complications.

Pneumothorax[edit]

Pneumothorax (for central lines placed in the chest); the incidence is thought to be higher with subclavian vein catheterization. In catheterization of the internal jugular vein, the risk of pneumothorax can be minimized by the use of ultrasound guidance. For experienced clinicians, the incidence of pneumothorax is about 1.5-3.1%. Some official bodies, e.g. the National Institute for Health and Clinical Excellence (UK), recommend the routine use of ultrasonography to minimize complications.[8]

Central-Line Associated Bloodstream Infections (CLABSIs)[edit]

All catheters can introduce bacteria into the bloodstream, but CVCs are known for occasionally causing Staphylococcus aureus and Staphylococcus epidermidis sepsis. The problem of central line-associated bloodstream infections (CLABSI) has gained increasing attention in recent years. They cause a great deal of morbidity and deaths, and increase health care costs. Historically, a small number of CVC infections were considered an acceptable risk of placing central lines. However, the seminal work by Dr. Peter Pronovost at Johns Hopkins Hospital turned that perspective on its head. From 2003 to 2006, the Agency for Healthcare Research and Quality provided $300,000 a year to fund the Comprehensive Unit-Based Safety Program (CUSP) that helped participating hospitals in Michigan lower CLABSIs. By 2012, the project had become a $20 million nationwide initiative.[9] Additionally, the Institute for Healthcare Improvement (IHI) has done a tremendous amount of work in improving hospitals' focus on central line-associated bloodstream infections (CLABSI), and is working to decrease the incidence of this particular complication among US hospitals.

The National Patient Safety Goals NPSGs and specifically NSPG 7.04 address how to decrease infections.[10] The NSPG 7.04 has 13 elements of performance to decrease CLABSIs.

The 13 Elements of Performance (EPs):

  • EP 1 & 2 deal with educating staff and patients about Central Vascular Catheters and their potential complications
  • EP 3 specifically directs facilities to implement policies and practices to reduce CLABSI
  • EP 4 & 5 are about how to perform surveillance for Central-Line Associated Bloodstream Infections (CLABSIs)
  • EP 6-13:

- Institute for Healthcare Improvement (IHI) bundle

  • 3. Chlorhexidine gluconate skin anti-septic
  • 4. Selection of Optimal site for Central venus Catheter (CVC)
  • 5. Daily review of ongoing need for CVC

- Disinfection of intravenous access ports before use

National Patient Safety Goals require documentation of a checklist for CVC insertion and Disinfection of intravenous (IV) access ports before use (scrub the hub). Some literature has suggested the use of a safer vascular access route - such as intraosseous (IO) vascular access - when central lines are not absolutely necessary (such as when central lines are being placed solely for vascular access). Infection risks were initially thought to be less in jugular lines, but this only seems to be the case if the patient is obese.[11]

If a patient with a central line develops signs of infection, blood cultures are taken from both the catheter and from a vein elsewhere in the body. If the culture from the central line grows bacteria much earlier (>2 hours) than the other site, the line is the likely source of the infection. Quantitative blood culture is even more accurate, but this is not widely available.[12]

Generally, antibiotics are used, and occasionally the catheter will have to be removed. In the case of bacteremia from Staphylococcus aureus, removing the catheter without administering antibiotics is not adequate as 38% of such patients may still develop endocarditis.[13]

In a clinical practice guideline, the American Centers for Disease Control and Prevention recommends against routine culturing of central venous lines upon their removal.[14] The guideline makes a number of further recommendations to prevent line infections.[14]

To prevent infection, stringent cleaning of the catheter insertion site is advised. Povidone-iodine solution is often used for such cleaning, but chlorhexidine appears to be twice as effective as iodine.[15] Routine replacement of lines makes no difference in preventing infection.[16]

Thrombosis[edit]

CVCs are a risk factor for forming venous thrombosis[17] including upper extremity deep vein thrombosis.[18]

Other complications[edit]

Rarely, small amounts of air are sucked into the vein as a result of the negative Intra-thoracic pressure and insertion technique. Valved insertion devices can reduce this risk.[citation needed] If these air bubbles obstruct blood vessels, this is known as an air embolism.

Hemorrhage (bleeding) and formation of a hematoma (bruise) is slightly more common in jugular venous lines than in others.[11]

Arrhythmias may occur during the insertion process when the wire comes in contact with the endocardium. It typically resolved when the wire is pulled back.[citation needed]

References[edit]

  1. ^ Central Venous Catheter Placement - Department of Surgery, Baylor College of Medicine, Texas, Houston
  2. ^ Central Venous Catheters - Topic Overview from WebMD
  3. ^ López-Briz, E; Ruiz Garcia, V; Cabello, JB; Bort-Marti, S; Carbonell Sanchis, R; Burls, A (Oct 8, 2014). "Heparin versus 0.9% sodium chloride intermittent flushing for prevention of occlusion in central venous catheters in adults.". The Cochrane database of systematic reviews 10: CD008462. PMID 25300172. 
  4. ^ O'Leary, R; Bodenham, A (2011). "Future directions for ultrasound-guided central venous access.". European Journal of Anaesthesiology 28 (5): 327–8. doi:10.1097/EJA.0b013e328343b148. PMID 21487264. 
  5. ^ Bodenham, A (2011). "Reducing major procedural complications from central venous catheterisation". Anaesthesia 66 (1): 6–9. doi:10.1111/j.1365-2044.2010.06583.x. PMID 21198502. 
  6. ^ Central Venous Catheter Placement & Pulmonary Artery Cathete - Vìdeo Dailymotion
  7. ^ http://www.youtube.com/watch?v=Ahz1SPKTiBU
  8. ^ National Institute for Health and Clinical Excellence (September 2002). "Technology appraisal: the clinical effectiveness and cost effectiveness of ultrasonic locating devices for the placement of central venous lines". Retrieved 2008-06-01. 
  9. ^ "A National Campaign to Scale Up and Spread CUSP-CLABSI: Interviews with James B. Battles and Stephen Hines". Agency for Healthcare Research and Quality. 2012-05-30. Retrieved 2013-08-27. 
  10. ^ The Joint Commission. NPSG 7 Healthcare-Associated Infections Webinar http://www.jointcommission.org/npsg_7_healthcare-associated_infections_webinar/
  11. ^ a b Parienti JJ, Thirion M, Mégarbane B et al. (May 2008). "Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: a randomized controlled trial". JAMA 299 (20): 2413–22. doi:10.1001/jama.299.20.2413. PMID 18505951. 
  12. ^ Safdar N, Fine JP, Maki DG (2005). "Meta-analysis: methods for diagnosing intravascular device-related bloodstream infection". Ann. Intern. Med. 142 (6): 451–66. doi:10.7326/0003-4819-142-6-200503150-00011. PMID 15767623. 
  13. ^ Watanakunakorn C, Baird IM (August 1977). "Staphylococcus aureus bacteremia and endocarditis associated with a removable infected intravenous device". Am. J. Med. 63 (2): 253–6. doi:10.1016/0002-9343(77)90239-X. PMID 888847. 
  14. ^ a b O'Grady NP, Alexander M, Dellinger EP et al. (2002). "Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control 51 (RR–10): 1–29. PMID 12233868. 
  15. ^ Mimoz O, Villeminey S, Ragot S et al. (October 2007). "Chlorhexidine-based antiseptic solution vs alcohol-based povidone-iodine for central venous catheter care". Arch. Intern. Med. 167 (19): 2066–72. doi:10.1001/archinte.167.19.2066. PMID 17954800. 
  16. ^ Cobb DK, High KP, Sawyer RG et al. (1992). "A controlled trial of scheduled replacement of central venous and pulmonary-artery catheters". N. Engl. J. Med. 327 (15): 1062–8. doi:10.1056/NEJM199210083271505. PMID 1522842. 
  17. ^ Rosendaal FR, Reitsma PH (July 2009). "Genetics of venous thrombosis". J. Thromb. Haemost. 7 (suppl 1): 301–4. doi:10.1111/j.1538-7836.2009.03394.x. PMID 19630821. 
  18. ^ Lee JA, Zierler BK, Zierler RE (2012). "The risk factors and clinical outcomes of upper extremity deep vein thrombosis". Vasc Endovascular Surg 46 (2): 139–44. doi:10.1177/1538574411432145. PMID 22328450. 

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