CENTRAL VENOUS CATHETER 

Central venous catheterization refers to insertion of a catheter into a large central vein (IJV, subclavian, femoral) with tip ideally in:Lower SVC / cavoatrial junction

 COMMON INSERTION SITES

1. Internal Jugular Vein (IJV)

  • Most preferred in ICU (USG guided)
  • Landmark: Triangle between SCM heads + clavicle
  • Advantages:
    • Compressible → safer in coagulopathy
    • Direct path to SVC
  • Disadvantages:
    • Patient discomfort
    • Infection risk > subclavian

2. Subclavian Vein

  • Landmark: 1–2 cm below clavicle at junction of medial & middle third
  • Advantages:
    • Lowest infection rate
    • Comfortable for patient
  • Disadvantages:
    • Non-compressible → bleeding risk
    • Pneumothorax risk


3. Femoral Vein

  • Landmark: Medial to femoral artery (NAVEL: Nerve-Artery-Vein-Empty-Lymphatics)
  • Advantages:
    • Easy, rapid access (emergency)
    • No pneumothorax risk
  • Disadvantages:
    • Highest infection + thrombosis risk

FEMORAL vs IJV vs SUBCLAVIAN 

Feature

IJV

Subclavian

Femoral

Infection

Moderate

Lowest

Highest

Pneumothorax

Low

High

None

Compressibility

Yes

No

Yes

Ease

Moderate

Difficult

Easy
  • Sepsis → avoid femoral
  • Coagulopathy → prefer IJV

INDICATIONS

Hemodynamic

  • CVP monitoring (limited value but still used)
  • ScvO₂ monitoring
  • Advanced hemodynamics (e.g., transpulmonary thermodilution)

 Therapeutic

  • Vasopressors (e.g., Norepinephrine)
  • Hyperosmolar fluids (TPN)
  • Irritant drugs (e.g., Potassium chloride)

Procedural

  • Dialysis catheter
  • Transvenous pacing
  • Difficult peripheral access

CONTRAINDICATIONS

Absolute

  • Infection at insertion site

Relative

  • Coagulopathy / thrombocytopenia
  • Distorted anatomy
  • Previous surgery / radiation
    USG guidance ↓ complications significantly → now standard of care (WHO, NICE, SCCM)

TYPES OF CVC

Based on lumen

  • Single lumen
  • Double lumen
  • Triple lumen (most common in ICU)

Special types

  • Dialysis catheter (large bore)
  • Introducer sheath
  • PICC (peripherally inserted central catheter)
  • Tunneled

Feature

Tunneled CVC

Non-Tunneled CVC

Definition

Catheter passes through subcutaneous tunnel before entering vein

Direct insertion into vein (no tunnel)

Examples

Hickman, Broviac

Triple lumen CVC

Duration of use

Long-term (weeks–months–years)

Short-term (days–weeks)

Insertion technique

Surgical / interventional (often fluoroscopy)

Bedside (ICU) using Seldinger technique

Infection risk

Lower (due to tunnel + cuff)

Higher

Fixation

Dacron cuff → tissue ingrowth stabilizes

Sutures / adhesive only

Exit site

Separate from venous entry site

Same as insertion site

ANATOMY & TIP POSITION 

Ideal tip position:

  • Lower 1/3 SVC / cavoatrial junction
  • At level of carina (CXR landmark)

Why not too deep?

  • Arrhythmias
  • Cardiac perforation

TECHNIQUE — SELDINGER METHOD 

Steps:

  1. Sterile prep + draping
  2. Local anesthesia
  3. Needle insertion → venous blood aspiration
  4. Guidewire insertion
  5. Dilator over guidewire
  6. Catheter insertion
  7. Remove guidewire
  8. Flush + secure

 Golden rule: NEVER lose guidewire (exam + medico-legal point)

CONFIRMATION OF CORRECT CVC PLACEMENT

Method

What it Confirms

Ultrasound (real-time + post-insertion)

Guidewire in vein, absence of pneumothorax

Chest X-ray (CXR)

Tip position (SVC/cavoatrial junction), pneumothorax

ECG-guided tip positioning (Intracavitary ECG)

Tip at cavoatrial junction (P-wave ↑),Most accurate bedside method

Blood aspiration from all ports

Intravascular placement

Pressure waveform (CVP tracing)

Venous waveform confirms venous placement

Manometry (fluid column test)

Venous vs arterial pressure

Transducing pressure

Venous vs arterial waveform

Blood gas analysis

Venous vs arterial (PaO₂ low in venous)

Fluoroscopy

Exact tip location

Echocardiography (TTE/TEE + saline flush)

Tip in RA/SVC (bubble test)-Bubble seen in RA within 2 sec

You can safely omit CXR ONLY if ALL are present:

  • USG-guided insertion
  • Single, uncomplicated attempt
  • Good venous blood aspiration
  • ECG-guided tip confirmation OR ultrasound confirmation
  • No clinical suspicion of complication


COAGULATION REQUIREMENTS FOR IJV CVC INSERTION

 Platelet Count Thresholds

Platelet Count (/µL)

Recommendation

Key Points

> 50,000

Safe

No prophylactic platelet transfusion needed

20,000 – 50,000

 Usually safe

Use USG guidance + experienced operator; consider transfusion if multiple attempts or high bleeding risk

< 20,000

Transfuse

Platelet transfusion recommended before procedure


 INR Thresholds

INR

Recommendation

Key Points

≤ 1.5

Safe

No correction required

1.5 – 2.0

Acceptable

Safe for USG-guided IJV; no routine FFP needed

> 2.0

 Consider correction

Give FFP / PCC depending on urgency and bleeding risk


IJV (USG-guided) = permissive thresholds → Platelets >20k & INR <2 usually acceptable


COMPLICATIONS 

Immediate

  • Arterial puncture
  • Hematoma
  • Pneumothorax (subclavian > IJV)
  • Air embolism
  • Arrhythmias

Early

  • Malposition
  • Thrombosis

Late

  • Infection → Central line-associated bloodstream infection
  • Catheter occlusion

CLABSI PREVENTION BUNDLE (CLABSI reduced by >50–70% with bundle

Based on CDC / WHO / IHI guidelines

Components:

Hand hygieneMethods:

  • Alcohol-based hand rub (preferred)
  • Soap + water (if visibly soiled)

 Single most effective intervention

  • Full barrier precautions
  • Chlorhexidine skin prep(2% chlorhexidine in alcohol (70%)
  • Avoid femoral (if possible)
  • Daily review → remove early

Use of chlorhexidine-impregnated dressings recommended


 CARE & MAINTENANCE

  • Daily site inspection
  • Aseptic handling
  • Flush protocols
  • Dressing change:
    • Transparent: every 5–7 days
    • Gauze: every 2 days

 REMOVAL INDICATIONS

  • No longer needed
  • Suspected infection
  • Malfunction
  • Emergency insertion(replace within 24–48 hrs)
  • Routine change not recommended(Each insertion → new risk:,“Duration alone is NOT an indication for removal”)


CENTRAL VENOUS CATHETER (CVC) FLUSH PROTOCOLS

PURPOSE OF FLUSHING

  • Maintain catheter patency
  • Prevent thrombotic occlusion
  • Reduce infection risk
  • Ensure accurate drug delivery

TYPES OF FLUSH SOLUTIONS

Solution

Use

Key Points

0.9% Normal Saline (NS)

 Routine flushing

Preferred (guideline-recommended)

Heparinized saline

 Selected cases

Not routinely recommended

Antimicrobial lock solutions

 High-risk cases only

e.g., recurrent CLABSI, dialysis lines

 FLUSH VOLUME & FREQUENCY

Situation

Flush Volume

Frequency

After drug administration

10–20 mL NS

Every time

Unused lumen

10 mL NS

Every 8–12 hrs

Before drug administration

5–10 mL NS

Each use

Blood sampling (before & after)

10–20 mL NS

Each time

Flush volume = ≥ 2 × internal volume of catheter (usually ~10 mL safe standard)

FLUSH TECHNIQUE

 Push–Pause (Pulsatile) Technique

  • Intermittent boluses → creates turbulence
  • Prevents fibrin deposition

 Positive Pressure Technique

  • Maintain pressure while disconnecting syringe
  • Prevents blood reflux