Central Venous Access

Indications

Therapeutic Use: Administration of blood products, parenteral nutrition, antibiotics, chemotherapy, dialysis/apheresis, and other medications.
Diagnostic Use: Phlebotomy, pressure transduction, and cardiac function evaluation.

Contraindications

Infection: Active local or systemic infection at the access site.
SVC syndrome if upper extremity or neck access.
Coagulopathy: Severe bleeding diatheses (e.g., platelet count <50,000/μL, INR >1.5 for elective cases).
History of Difficult Access: Prior venous anomalies, stenosis, or occlusions that might complicate access, or thrombosis of the access vessel.

Pre-Procedure

Comprehensive imaging review: Analysis of all available non-invasive studies to optimize procedural approach and minimize contrast usage. Detailed knowledge of cardiac anatomy and repairs in cardiac patients.
Allergy history, including contrast and antiseptic solutions.
Medication review, including anticoagulation.
Ensure IR consult is placed, specifying catheter type, size, and access site.
Determine appropriate catheter: PICC vs CVL vs Port-a-cath
Informed consent is obtained after discussing the benefits, risks, and alternatives of the procedure.
Imaging:
- Preprocedural ultrasound is used to assess the target vein’s patency and compressibility.
- Permanent images are archived (e.g., to PACS) to document baseline anatomy.

Labs	Complete blood count with platelet count and differential Comprehensive metabolic panel including BUN, creatinine, electrolytes, and glucose Coagulation studies (PT, INR, aPTT) with specific attention to age-related normal values

Tunneled femoral CVL in an infant.
A. The tunnel is created using the 21G needle, then the femoral vein is punctured. A 0.014" guidewire has been introduced.
B. A 1.9 F single-lumen catheter has been placed with the tip in the IVC.

Technique

Catheter Sizing Guidelines

Infants and toddlers (<15 kg)

Single lumen - 1.9-3.0 Fr
Double lumen - 2.6-4.0 Fr

Older children (>15 kg)

Single lumen - 3-4 Fr
Double lumen - 4-6 Fr

Access Needles, Guide Wires, and Sheaths:

A 21-gauge Echotip needle is used most commonly for ultrasound-guided venipuncture. A 22G angiocath can also be used. Both of these will accommodate a 0.018" guidewire.
For smaller veins, a 24-gauge Angiocath or Galt needle can be used and will accommodate a 0.014" guidewire (Floppy or Galt).
Peel-away sheaths are used in the majority of patients to facilitate catheter introduction.

Local Anesthesia:

Local anesthesia is commonly administered as 1% lidocaine at the access and tunneling sites.

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Vascular Access and Ultrasound Guidance

Site Selection and Preparation:
- Access sites are chosen based on vein patency and overall clinical context (e.g., right or left femoral for smaller patients, left internal jugular for larger children).
- The skin and access area are prepped in a sterile fashion; a small skin nick is made with a #11 blade after administering local anesthesia.
Ultrasound-Guided Venipuncture:
- The target vein is imaged continuously. A 21-gauge Echotip needle is advanced into the vein under real-time ultrasound guidance.
- Permanent images of both the vessel and needle entry are saved for documentation.

Guide Wire Advancement and Sheath Insertion

Guide Wire Exchange:
- After successful venous puncture, an appropriate guide wire (e.g., 0.010-inch, 0.014-inch, or 0.018-inch) is advanced into the central circulation (often confirmed to be in the IVC by fluoroscopy).
- In cases where initial wire passage is challenging, a smaller-diameter wire may be exchanged for a slightly larger one (e.g., from 0.014-inch to 0.018-inch) to facilitate sheath insertion.
Peel-Away Sheath Deployment:
- The needle is exchanged for a peel-away sheath (2.7–3 French), which is advanced over the guide wire into the vein.
- The wire is then measured to ensure proper catheter length, and the catheter is cut accordingly.

Catheter Insertion and Final Positioning

Advancement of the Catheter:
- The prepared catheter (cut-to-length) is advanced through the peel-away sheath.
- Once in place, the sheath is carefully removed while maintaining the catheter position.
- Final positioning is verified with fluoroscopy, ensuring that the tip lies at an optimal location (e.g., within the upper IVC or near the cavoatrial junction).
Securement and Dressing:
- The catheter is secured using appropriate devices (e.g., StatLock dressings or sutures in cases like the left internal jugular approach).
- A Biopatch is applied, followed by a sterile occlusive dressing.

Special Considerations for Tunneled Catheters

Tunneling Technique:
- For tunneled catheters, a separate exit site is established.
- A tunneling device or suture is used to pull the catheter from the venipuncture site to the selected exit site, ensuring that the tunnel is appropriately distanced from the skin entry point.
- Final tip position is confirmed, and the exit site is closed with sutures before dressing.

Tip verification and securement.

Immediate Verification:
- Fluoroscopic or radiographic imaging is used to confirm correct catheter tip placement and rule out complications such as malposition or vessel injury.
Securement and Monitoring:
- Catheters are secured with adhesive devices (e.g., StatLock) and covered with sterile dressings.
- The catheters flushed and aspirated well.
- Heparin lock - 10 units/mL, unless immediate attachment to infusion.

Complications

Immediate/Periprocedural Complications:

Vascular Injury: Risk of arterial puncture, vessel perforation, or cardiac arrhythmias.
Air Embolism: Prevented by using valves in peel-away sheaths and proper patient positioning.
Pneumothorax: Especially with subclavian or jugular access; can be minimized with real-time ultrasound guidance.

Mechanical Complications:

Malposition or Kinking: Inadequate guide wire placement or catheter measurement may result in suboptimal positioning.
Catheter Pinch-Off Syndrome: Often related to subclavian vein access, leading to mechanical compression and eventual fracture.
Catheter-related thrombosis.

Infectious Complications:

Catheter-Related Bloodstream Infections (CRBSI): Emphasizes the importance of strict sterile technique and appropriate dressing protocols.

Post-Procedure

Immediate Post-Procedural Monitoring

Hemostasis management:
- Manual compression for adequate hemostasis
- Can use Stat-Seal or SecurePortIV for persistent oozing at PICC site.

Infection Prevention Measures

Hand hygiene - Before and after all catheter manipulations
Sterile technique - For dressing changes, accessing ports, blood sampling
Catheter hub disinfection - 70% isopropyl alcohol or chlorhexidine before access
Minimal manipulation - Reduce unnecessary catheter access, consolidate blood draws
Daily necessity assessment - Remove catheter as soon as no longer needed

References

Polderman KH, Girbes AR. Central venous catheter use. Part 1: mechanical complications. Intensive Care Med. 2002;28(1):1-17.
Frykholm P, Pikwer A, Hammarskjöld F, et al. Clinical guidelines on central venous catheterisation. Swedish Society of Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiol Scand. 2014;58(5):508-524.
Lamperti M, Bodenham AR, Pittiruti M, et al. International evidence-based recommendations on ultrasound-guided vascular access. Intensive Care Med. 2012;38(7):1105-1117.
Rupp SM, Apfelbaum JL, Blitt C, et al. Practice guidelines for central venous access: a report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology. 2012;116(3):539-573.
Moureau NL, Trick N, Nifong T, et al. Vessel health and preservation (part 1): a new evidence-based approach to vascular access selection and management. J Vasc Access. 2012;13(3):351-356.
O'Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. 2011;52(RR-9):1-32.
Andropoulos DB, Bent ST, Skjonsby B, Stayer SA. The optimal length of insertion of central venous catheters for pediatric patients. Anesth Analg. 2001;93(4):883-886.
Casado-Flores J, Barja J, Martino R, et al. Complications of central venous catheterization in critically ill children. Pediatr Crit Care Med. 2001;2(1):57-62.