Overview of central venous access
- Alan C Heffner, MD
Alan C Heffner, MD
- Director of Critical Care
- Director of ECMO Services
- Pulmonary and Critical Care Consultants
- Department of Internal Medicine
- Department of Emergency Medicine
- Carolinas Medical Center
- Associate Clinical Professor
- University of North Carolina School of Medicine
- Mark P Androes, MD
Mark P Androes, MD
- Assistant Professor of Surgery
- University of South Carolina School of Medicine
- Section Editors
- Allan B Wolfson, MD
Allan B Wolfson, MD
- Section Editor — Adult Procedures
- Professor of Emergency Medicine
- University of Pittsburgh
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery, Texas A&M Health Sciences Center - Dallas Campus
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
Central venous access is a commonly performed procedure with approximately 8 percent of hospitalized patients requiring central venous access during the course of their hospital stay. More than five million central venous catheters are inserted in the United States each year [1,2].
Central venous access is also needed to place pulmonary artery catheters, plasmapheresis and hemodialysis catheters, as well as to place inferior vena cava filters, introduce wires for transvenous pacing and defibrillator devices, and for venous interventions. The central venous access site and manner in which access is achieved depend upon the indication for placement, patient anatomy, and other patient-related factors.
The indications for central venous access, types of central catheters, catheter selection, site selection, and general issues of preparation and placement will be reviewed here. The role of catheters and devices for monitoring cardiac parameters, or administering chemotherapy or parenteral nutrition is discussed in separate topic reviews.
The placement of jugular, subclavian, and femoral catheters; issues specific to these anatomic sites; routine maintenance and care of catheters and port devices; and complications of central venous catheters and related devices are discussed elsewhere. (See "Placement of jugular venous catheters" and "Placement of subclavian venous catheters" and "Placement of femoral venous catheters".)
●Common indications for the placement of central catheters include [3-5]:
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- Timsit JF. Central venous access in intensive care unit patients: is the subclavian vein the royal route? Intensive Care Med 2002; 28:1006.
- Marik PE, Flemmer M, Harrison W. The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis. Crit Care Med 2012; 40:2479.
- Biffi R, Pozzi S, Bonomo G, et al. Cost effectiveness of different central venous approaches for port placement and use in adult oncology patients: evidence from a randomized three-arm trial. Ann Surg Oncol 2014; 21:3725.
- O'Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control 2011; 39:S1.
- Sterner S, Plummer DW, Clinton J, Ruiz E. A comparison of the supraclavicular approach and the infraclavicular approach for subclavian vein catheterization. Ann Emerg Med 1986; 15:421.
- Sznajder JI, Zveibil FR, Bitterman H, et al. Central vein catheterization. Failure and complication rates by three percutaneous approaches. Arch Intern Med 1986; 146:259.
- Arrighi DA, Farnell MB, Mucha P Jr, et al. Prospective, randomized trial of rapid venous access for patients in hypovolemic shock. Ann Emerg Med 1989; 18:927.
- Merrer J, De Jonghe B, Golliot F, et al. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA 2001; 286:700.
- Eisen LA, Narasimhan M, Berger JS, et al. Mechanical complications of central venous catheters. J Intensive Care Med 2006; 21:40.
- Mansfield PF, Hohn DC, Fornage BD, et al. Complications and failures of subclavian-vein catheterization. N Engl J Med 1994; 331:1735.
- Reeves ST, Roy RC, Dorman BH, et al. The incidence of complications after the double-catheter technique for cannulation of the right internal jugular vein in a university teaching hospital. Anesth Analg 1995; 81:1073.
- The clinical anatomy of several invasive procedures. American Association of Clinical Anatomists, Educational Affairs Committee. Clin Anat 1999; 12:43.
- Lorente L, Henry C, Martín MM, et al. Central venous catheter-related infection in a prospective and observational study of 2,595 catheters. Crit Care 2005; 9:R631.
- Biffi R, Orsi F, Pozzi S, et al. Best choice of central venous insertion site for the prevention of catheter-related complications in adult patients who need cancer therapy: a randomized trial. Ann Oncol 2009; 20:935.
- Ge X, Cavallazzi R, Li C, et al. Central venous access sites for the prevention of venous thrombosis, stenosis and infection. Cochrane Database Syst Rev 2012; :CD004084.
- Parienti JJ, Thirion M, Mégarbane B, et al. Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: a randomized controlled trial. JAMA 2008; 299:2413.
- Parienti JJ, du Cheyron D, Timsit JF, et al. Meta-analysis of subclavian insertion and nontunneled central venous catheter-associated infection risk reduction in critically ill adults. Crit Care Med 2012; 40:1627.
- Parienti JJ, Mongardon N, Mégarbane B, et al. Intravascular Complications of Central Venous Catheterization by Insertion Site. N Engl J Med 2015; 373:1220.
- O'Grady NP, Alexander M, Burns LA, et al. Summary of recommendations: Guidelines for the Prevention of Intravascular Catheter-related Infections. Clin Infect Dis 2011; 52:1087.
- Joynt GM, Kew J, Gomersall CD, et al. Deep venous thrombosis caused by femoral venous catheters in critically ill adult patients. Chest 2000; 117:178.
- Timsit JF, Bouadma L, Mimoz O, et al. Jugular versus femoral short-term catheterization and risk of infection in intensive care unit patients. Causal analysis of two randomized trials. Am J Respir Crit Care Med 2013; 188:1232.
- Drew DA, Weiner DE. Peripherally Inserted Central Catheters (PICCs) in CKD: PICC'ing the Best Access for Kidney Disease Patients. Am J Kidney Dis 2016; 67:724.
- Greene MT, Flanders SA, Woller SC, et al. The Association Between PICC Use and Venous Thromboembolism in Upper and Lower Extremities. Am J Med 2015; 128:986.
- Shingarev R, Allon M. Peripherally inserted central catheters and other intravascular devices: how safe are they for hemodialysis patients? Am J Kidney Dis 2012; 60:510.
- Al Raiy B, Fakih MG, Bryan-Nomides N, et al. Peripherally inserted central venous catheters in the acute care setting: A safe alternative to high-risk short-term central venous catheters. Am J Infect Control 2010; 38:149.
- Chopra V, O'Horo JC, Rogers MA, et al. The risk of bloodstream infection associated with peripherally inserted central catheters compared with central venous catheters in adults: a systematic review and meta-analysis. Infect Control Hosp Epidemiol 2013; 34:908.
- Hilty WM, Hudson PA, Levitt MA, Hall JB. Real-time ultrasound-guided femoral vein catheterization during cardiopulmonary resuscitation. Ann Emerg Med 1997; 29:331.
- Dronen S, Thompson B, Nowak R, Tomlanovich M. Subclavian vein catheterization during cardiopulmonary resuscitation. A prospective comparison of the supraclavicular and infraclavicular percutaneous approaches. JAMA 1982; 247:3227.
- Kaye W, Bircher NG. Access for drug administration during cardiopulmonary resuscitation. Crit Care Med 1988; 16:179.
- Emerman CL, Bellon EM, Lukens TW, et al. A prospective study of femoral versus subclavian vein catheterization during cardiac arrest. Ann Emerg Med 1990; 19:26.
- Ely EW, Hite RD, Baker AM, et al. Venous air embolism from central venous catheterization: a need for increased physician awareness. Crit Care Med 1999; 27:2113.
- Mirski MA, Lele AV, Fitzsimmons L, Toung TJ. Diagnosis and treatment of vascular air embolism. Anesthesiology 2007; 106:164.
- Bellazzini MA, Rankin PM, Gangnon RE, Bjoernsen LP. Ultrasound validation of maneuvers to increase internal jugular vein cross-sectional area and decrease compressibility. Am J Emerg Med 2009; 27:454.
- Samy Modeliar S, Sevestre MA, de Cagny B, Slama M. Ultrasound evaluation of central veinsin the intensive care unit:effects of dynamic manoeuvres. Intensive Care Med 2008; 34:333.
- Parry G. Trendelenburg position, head elevation and a midline position optimize right internal jugular vein diameter. Can J Anaesth 2004; 51:379.
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- Gillman LM, Blaivas M, Lord J, et al. Ultrasound confirmation of guidewire position may eliminate accidental arterial dilatation during central venous cannulation. Scand J Trauma Resusc Emerg Med 2010; 18:39.
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- Coagulopathy and/or thrombocytopenia
- CENTRAL CATHETERS AND DEVICES
- Introducer sheath
- - Tunneled
- - Subcutaneous port
- Specialized venous devices
- DEVICE SELECTION
- SITE SELECTION
- Subclavian versus internal jugular access
- Femoral access versus other sites
- Peripheral versus central vein insertion
- Emergency central access
- Informed consent
- Site preparation
- Sterile technique
- Antimicrobial prophylaxis
- Analgesia and sedation
- USE OF ULTRASOUND
- GENERAL TECHNIQUE
- Nontunneled central catheters
- Other devices
- - Venous sheath placement
- - Tunneled catheters
- - Subcutaneous ports
- CONFIRMATION OF CATHETER TIP POSITIONING
- CATHETER MANAGEMENT
- SUMMARY AND RECOMMENDATIONS