INTRODUCTION

Central venous catheters terminate in the cranial or caudal vena cava. These catheters may be inserted directly into a large central vein such as the jugular vein or inserted via a peripheral vein: a peripherally inserted central catheter (PICC). Indications for central venous catheter placement include hemodynamic monitoring, drug administration, and serial blood sampling.¹ Central venous catheters often can be left in place for longer periods than peripheral catheters, making them very useful in critically ill patients. The following are situations in which a central catheter may be preferable to a peripheral venous catheter:

• Administration of multiple fluid and drug types that are not compatible with each other, necessitating multiple catheter lumens

• Administration of fluids that have an osmolality greater than 600 mosm/L and constant rate infusions of drugs known to cause phlebitis, such as diazepam, pentobarbital, and mannitol

• Measurement of central venous pressure

• Frequent aspiration of blood samples

• Total parenteral nutrition administration

• Maintenance of venous access for long periods

• When peripheral catheters are at risk of contamination from vomiting, polyuria, diarrhea, or vaginal discharge, because it may be easier to keep a jugular catheter site clean

• To facilitate transvenous pacing

GENERAL CONCEPTS

Because introduction of foreign material or infectious agents into the central circulation can have far more serious consequences than peripheral vessel contamination, maintenance of aseptic technique when placing and using central venous catheters is of utmost importance (see Chapter 116, Catheter-Related Bloodstream Infection). General recommendations for central venous catheter maintenance is to wipe all injection ports with alcohol before needle puncture, keep insertion sites bandaged, prevent catheter hubs dragging on the ground, and immediately respond to witnessed catheter contamination. This may require cleaning and changing injection ports and fluid lines, or it may necessitate catheter removal. Inadvertent disconnection of fluid lines from a central venous catheter or animal-induced trauma to the catheter can lead to significant hemorrhage. Leaving ports of a central venous catheter open to the atmosphere places the patient at risk of air embolism. For this reason the catheter should be occluded by a catheter lock or manual kinking whenever the catheter hub is open to the atmosphere (e.g., when connecting and disconnecting syringes for blood aspiration).

CATHETER TYPES

Through-the-needle, long over-the-needle, long single-lumen, multilumen catheters, and catheter introducers can all be used to access central veins (Figure 63-1).^1-3

Figure 63-1 Examples of catheters used for central venous catheterization. A, Examples of two through-the-needle catheters; the top catheter is a Drum-Cartridge and the other is an Intracath. B, A long over-the-needle-catheter. C, Central venous catheter. D, Triple-lumen catheter. E, Catheter sheath introducer.

Through-the-Needle

Through-the-needle catheters were discussed in Chapter 61, Peripheral Venous Catheterization. They commonly are used to catheterize jugular veins. The Drum-Cartridge is a very long through-the-needle catheter that is an effective PICC for large patients (see Figure 63-1).

Over-the-Needle

Over-the-needle catheters were discussed in Chapter 61, Peripheral Venous Catheterization. When used for jugular catheterization, they must be of a length appropriate for the patient’s size. The subcutaneous tissues in the region of the jugular vein are very loose, resulting in a lot of skin movement. Even though the catheter is well secured to the skin, short catheters can be pulled out of the vein easily.