Central Venous Catheter Placement: Techniques and Complications

Central venous catheter (CVC) placement is a critical procedure in modern medicine, particularly in surgical and intensive care settings. This article provides an in-depth look at the indications, preoperative evaluation, contraindications, surgical techniques, postoperative care, potential complications, and recent advances in CVC placement. The aim is to offer a comprehensive resource that is both informative and practical for surgeons.

Indications for Central Venous Catheter Placement

CVCs are used for various medical purposes, including:

1. Hemodynamic Monitoring: Central venous pressure (CVP) monitoring is crucial in managing critically ill patients. It helps in assessing fluid status and guiding fluid resuscitation.
2. Administration of Medications: CVCs are essential for administering medications that are irritant to peripheral veins, such as vasopressors, chemotherapy, and hyperosmolar solutions.
3. Nutritional Support: Total parenteral nutrition (TPN) often requires a central venous access due to its high osmolarity.
4. Hemodialysis or Apheresis: CVCs are used for acute or chronic hemodialysis in patients with renal failure.
5. Repeated Blood Sampling: For patients requiring frequent blood sampling, a CVC can reduce the need for multiple venipunctures.
6. Rapid Infusion of Fluids: In cases of severe shock or trauma, a CVC allows rapid administration of large volumes of fluids or blood products.

Preoperative Evaluation

Before proceeding with CVC placement, a thorough preoperative evaluation is necessary to minimize risks and optimize outcomes.

1. Patient History and Physical Examination: Assess the patient’s medical history, including previous central line placements, coagulopathies, and allergies. A physical examination should focus on potential access sites and signs of infection or anatomical abnormalities.
2. Laboratory Tests: Coagulation profile (INR, PT, aPTT) should be evaluated, especially in patients with liver disease, on anticoagulation therapy, or with known coagulopathies.
3. Imaging Studies: Ultrasound (US) can be used preoperatively to evaluate the patency of veins and to identify the optimal insertion site, particularly in patients with difficult anatomy or previous surgeries.
4. Consent: Obtain informed consent, explaining the risks, benefits, and alternatives to the procedure.

Contraindications

While CVC placement is generally safe, certain contraindications must be considered:

1. Absolute Contraindications:
   • Uncorrected coagulopathy or thrombocytopenia
   • Infection at the insertion site
   • Superior vena cava syndrome
   • Thrombosis of the target vein
2. Relative Contraindications:
   • Severe obesity
   • Anatomical abnormalities
   • Previous radiation therapy or surgery to the neck or chest

Surgical Techniques and Steps

The technique for CVC placement varies depending on the site of insertion. The most common sites are the internal jugular vein (IJV), subclavian vein (SCV), and femoral vein. Below is a step-by-step guide for CVC placement in the IJV, which is widely preferred due to its relatively straightforward anatomy and low complication rate.

1. Preparation:

• Position the patient in the Trendelenburg position to distend the IJV and reduce the risk of air embolism.
• Cleanse the insertion site with antiseptic solution, and drape the area using a sterile technique.
• Ensure all necessary equipment is available, including the CVC kit, sterile gloves, gown, and ultrasound machine.

2. Ultrasound Guidance:

• Identify the IJV using ultrasound. The vein should be compressible and located lateral to the carotid artery.
• Use the ultrasound to guide needle insertion in real-time, reducing the risk of arterial puncture.

3. Needle Insertion:

• Insert the needle at a 30-45 degree angle to the skin, aiming toward the ipsilateral nipple. Aspirate while advancing the needle until venous blood is obtained.
• Confirm the position of the needle tip within the IJV using ultrasound.

4. Guidewire Insertion:

• Thread the guidewire through the needle into the vein. Remove the needle while leaving the guidewire in place.
• Ensure the guidewire passes smoothly and without resistance. If resistance is encountered, re-evaluate the wire’s position under ultrasound.

5. Catheter Insertion:

• Make a small skin incision at the entry point to facilitate catheter insertion.
• Thread the CVC over the guidewire and advance it into the vein. Once the catheter is in place, remove the guidewire.
• Confirm the catheter’s position with ultrasound or fluoroscopy.

6. Securing the Catheter:

• Secure the catheter to the skin with sutures and apply a sterile dressing. Attach the catheter to the appropriate intravenous line or monitoring equipment.

7. Post-Insertion Verification:

• Obtain a chest X-ray to confirm the catheter tip’s position, ideally at the junction of the superior vena cava and the right atrium. This step is crucial to rule out complications like pneumothorax or malposition.

Postoperative Care

Postoperative care focuses on monitoring for immediate complications and maintaining catheter function.

1. Monitoring: Regularly monitor the insertion site for signs of infection, bleeding, or thrombosis. Inspect the dressing daily and change it according to protocol or if it becomes soiled.
2. Catheter Patency: Ensure the catheter remains patent by flushing it with saline or heparinized solution, as per institutional guidelines.
3. Patient Education: Instruct the patient and caregivers on how to care for the catheter, recognize signs of complications, and understand the importance of keeping the site clean and dry.
4. Removal: Remove the CVC as soon as it is no longer needed to reduce the risk of infection. Ensure that removal is done under sterile conditions, and apply pressure to the site to prevent bleeding.

Possible Complications

Despite its routine use, CVC placement is associated with potential complications that require careful consideration.

1. Infection: Catheter-related bloodstream infections (CRBSIs) are a significant risk. Preventative measures include strict adherence to aseptic technique and regular site care.
2. Thrombosis: Catheter-induced thrombosis can occur, particularly in the subclavian or femoral veins. Early signs include swelling and pain in the limb on the side of catheter placement.
3. Pneumothorax: This is a risk, particularly with subclavian vein access. Immediate recognition and treatment with a chest tube are necessary.
4. Arterial Puncture: Accidental arterial puncture can lead to hematoma or pseudoaneurysm formation. If arterial puncture occurs, immediate pressure should be applied, and further attempts should be deferred to a different site.
5. Air Embolism: Proper patient positioning and prompt occlusion of the catheter during insertion and removal can prevent this rare but life-threatening complication.
6. Malposition: The catheter tip may end up in an unintended location, such as the internal jugular vein on the opposite side or a tributary vein. Radiographic confirmation is essential to identify and correct malposition.

Different Techniques and Variations

Various techniques can be employed depending on the clinical scenario and the anatomical considerations.

1. Landmark Technique: Traditionally, CVCs were placed using anatomical landmarks without ultrasound guidance. While still used, this technique has a higher complication rate compared to ultrasound-guided placement.
2. Ultrasound-Guided Technique: This has become the standard of care due to its higher success rate and lower incidence of complications. Real-time visualization allows for precise needle placement and avoidance of surrounding structures.
3. Catheter Types: CVCs can be single, double, or triple lumen, depending on the need for simultaneous administration of incompatible medications or simultaneous blood sampling and drug administration.
4. Tunneled vs. Non-Tunneled: Tunneled catheters, such as Hickman or Broviac catheters, are typically used for long-term access, while non-tunneled catheters are used for short-term access in acute care settings.

Prognosis and Outcome

The prognosis after successful CVC placement is generally favorable, especially with proper technique and postoperative care. The outcome depends on the indication for the catheter and the presence of any underlying conditions. Early removal of the catheter, once it is no longer needed, significantly reduces the risk of long-term complications such as infection or thrombosis.

Alternative Options

While CVC placement is a valuable procedure, alternative options may be considered depending on the patient’s condition and the intended use of the catheter.

1. Peripheral IV Access: For short-term access or less irritant medications, peripheral intravenous (IV) access may be sufficient.
2. Peripherally Inserted Central Catheter (PICC): PICC lines offer a less invasive alternative for long-term venous access, particularly in patients who may not tolerate CVC placement.
3. Intraosseous Access: In emergency situations where venous access is challenging, intraosseous (IO) access provides a rapid and effective alternative.
4. Implantable Ports: For long-term access, particularly in oncology patients, implantable ports provide a subcutaneous reservoir connected to a central vein, offering a lower infection risk and greater patient comfort.

Average Cost

The cost of CVC placement varies depending on the setting, the type of catheter used, and the complexity of the procedure. On average, the cost in the United States can range from $1,000 to $3,000, including the procedure, catheter, and postoperative care. Costs may be higher if complications arise or if advanced imaging guidance is required.

Recent Advances

Recent advances in CVC placement have focused on improving safety and reducing complications.

1. Ultrasound Technology: High-resolution ultrasound machines and portable devices have made bedside CVC placement safer and more accessible.
2. Antimicrobial Catheters: The development of catheters impregnated with antimicrobial agents has reduced the incidence of CRBSIs.
3. Simulation Training: Simulation-based training programs for healthcare providers have improved the proficiency and success rates of CVC placement, particularly among trainees.
4. ECG-Guided Placement: The use of intracavitary ECG to confirm the correct catheter tip position during insertion is gaining popularity as an alternative to post-procedure chest X-ray, reducing the need for radiation exposure.
5. Bioengineered Catheters: Research into bioengineered materials aims to reduce thrombosis and infection risks, potentially leading to the development of next-generation CVCs.