8 Central Line

Securing central venous access is a fundamental skill essential to the care of critically ill patients. In the United States, over 5 million central venous access catheters are placed annually1 and on average remain in place for 7 to 10 days. Centrally inserted central venous catheters (CICVCs), or “central lines” as they are commonly known, may be placed in the subclavian, internal jugular, or femoral vein.^{2 3} The concept of central line placement was first introduced by Dr. Werner Forssmann when he self-inserted a ureteric catheter through his cubital vein into his right heart.⁷

8.2 Anatomy/Physiology

Central venous access catheters are placed into a large vein in the body, terminating in the veins within the thorax. The three most common types of central lines placed are subclavian, internal jugular, and femoral. The catheter tip of a central line terminates in the superior vena cava for subclavian and internal jugular vein (IJV) central lines, and inferior vena cava for femoral central lines.

8.2.1 Subclavian Vein Anatomy

The subclavian vein is an extension of the axillary vein that originates at the outer border of the first rib. The vein runs under the clavicle, where it connects to the IJV to form the innominate, or brachiocephalic vein. The subclavian vein measures between 1 to 2 cm in diameter; however, it can be smaller or larger depending on the individual. The subclavian vein follows the subclavian artery and is separated from the subclavian artery by the insertion of the anterior scalene. Thus, the subclavian vein lies anterior to the anterior scalene while the subclavian artery lies posterior to the anterior scalene and anterior to the middle scalene.11 The anatomy of the subclavian vein and surrounding structures is depicted in ▶ Fig. 8.1.

8.2.2 Internal Jugular Vein Anatomy

The IJV is formed by the confluence of the inferior petrosal sinus and the sigmoid sinus. The IJV descends in the carotid sheath with the internal carotid artery. The vagus nerve (CN X) lies between the two. After receiving tributaries from the face and neck, the IJV continues to descend into the thorax, usually between the heads of the sternocleidomastoid muscle, before uniting with the subclavian vein to form the brachiocephalic vein.11 The anatomy of the jugular vein and surrounding structures is depicted in ▶ Fig. 8.2.

8.2.3 Femoral Vein Anatomy

The femoral vein is the main deep vein of the lower limb, and travels next to the superficial femoral artery and common femoral artery. The femoral vein forms the continuation of the popliteal vein at the adductor opening, and becomes the external iliac vein as it ascends posterior to the inguinal ligament. In the distal adductor canal, the vein is posterolateral to the superficial femoral artery. Proximally in the canal, the vein lies posterior to the artery in the distal femoral triangle and medial to the artery at the base of the triangle. In the upper thigh, the vein is between the common femoral artery and femoral canal and therefore occupies the middle compartment of the femoral sheath.¹² The anatomy of the femoral vein and surrounding structures is depicted in ▶ Fig. 8.3.

•Renal replacement therapy8

•Intravascular cooling

Equipment

8.4 Contraindications

Central venous catheters may be tunneled or nontunneled. Tunneled catheters are used when it is anticipated that the catheter will be needed for longer than 3 to 4 weeks. Tunneled catheters have a lower rate of infectious complications9 because of the distance between the skin entry site and the venotomy. Although they provide reliable long-term access, their complications include thrombosis, occlusion, and infection.10 Nontunneled catheters are primarily used for short-term access in the emergency department, operating room, and ICU. These types of catheters are generally easier to place than tunneled catheters.⁹ Nontunneled catheters have a higher rate of infectious complications and should generally be removed or exchanged after 5 to 7 days.¹¹

There are many different models of central venous catheters, including single, dual, and triple lumen catheters, as well as introducer sheaths. Triple lumen catheters are generally preferred for ICU patients requiring multiple ports of access for medication administration. Introducer sheaths are required for rapid fluid resuscitation, transvenous pacing, or insertion of a pulmonary artery catheter. Specialized catheters with at least two large diameter ports are required for renal replacement therapy.

8.6 Technique

The steps below pertain to the insertion of a nontunneled triple lumen central venous catheter.

General steps for ultrasound-guided placement:

1.Connect ultrasound machine to a power source.

2.Select a linear vascular probe and confirm orientation (i.e., tap the left side of the probe and this should correspond with left side of the screen).

3.Examine target vein. Make sure vein is compressible, easily visualized, and centered on the screen.

4.Start with the short-axis view (probe perpendicular to the path of the vessel), as depicted in ▶ Fig. 8.4. Introduce the needle at a 45-degree angle and advance toward the vessel under direct visualization while applying gentle negative pressure to the syringe, as depicted in ▶ Fig. 8.5.

5.Once the vessel is entered blood will fill the syringe. At this point the probe can be rotated 90 degrees so that it is parallel to the path of the vessel to obtain the longitudinal view, as depicted in ▶ Fig. 8.6. This view can help confirm the location of the needle and visualize the guidewire entry into the lumen of the vessel, as depicted in ▶ Fig. 8.7.

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