The Pre-brief
Placement of central lines has become a controversial topic, especially with the rise of CLABSI and hospital mandates to reduce infections and complications. Furthermore, alternative methods of vascular access have surfaced, along with new research that short-term vasopressor infusions are safe through peripheral IVs. That being said, every physician has a different threshold for placing central lines in ICU patients.
Indications for Central Line Placement
Broadly speaking, here are some of the reasons why we may need central access in our patients (1):
- Infusion of caustic medications that may cause phlebitis or significant tissue damage (ex. prolonged vasopressor infusion, hypertonic saline, total parenteral nutrition)
- Initiation of therapies such as hemodialysis, plasmapheresis, CRRT, MARS
- Hemodynamic monitoring (CVP, PCWP, RV pressures) (undifferentiated shock, Cardiothoracic Surgical cases)
- Venous interventions (transvenous pacing, pulmonary artery catheter)
A slight detour to talk about a more controversial indication:
Inability to obtain venous access in emergent situations
In my opinion, this should no longer be an indication (with one big exception that I mention below). In patients who need emergent vascular access, we have safer, more rapid methods.
The first, and fairly commonly used method, is the intraosseous (IO) needle. Quite possibly the fastest technique of vascular access (can be ready to infuse in about 5 seconds), the IO needle can be used to infuse just about any medication. Labs obtained from an aspirated sample will also be relatively accurate with a few exceptions (WikiEM, LITFL). While the complication rate of IOs is less than 1%, compartment syndrome (caused by dislodgement or faulty placement) due to extravasation of fluid is the most common one. Adverse events are more common with prolonged use of the IO, so get rid of the IO when it is no longer needed.
Another method of vascular access are rapid infusion catheters (RIC). These peripheral cannulas are the epitome of Poiseuille’s law: short, fat catheters that allow for very high infusion rates. The RICs can be exchanged over a wire for a 20ga or larger IV.
There is one big caveat to my conversation detour: exsanguinating patients (trauma, GI bleed, etc.) that require large volumes of fluid or blood, immediately. Large bore peripheral cannulation with a rapid infusion catheter (RIC) requires at least a 20ga IV to be in place already and obtaining one of those first can be challenging in volume-depleted patients. In these cases, placing an ultrasound-guided IJ, subclavian, or femoral vein large cordis or Multi-Lumen Access Catheter can be beneficial for administering large amounts of fluids. The times in the chart below are infusion times by gravity; the infusion times can be further shortened by using a pressure bag or infusion device (Level 1 Rapid Infuser, Belmont Rapid Infuser, etc.).
The contraindications for central line placement are relative and site-specific:
- do not place catheters through infected or burned skin or soft tissue
- avoid tortuous vascular anatomy that could make placement challenging and lead to disastrous trauma to neurovascular structures
- if you see “the swirls”, consider picking a different site because you might be near a thrombus; thanks to my friend Mark Ramzy for sharing!
- coagulopathy
- suspected proximal vascular injury
- unsedated and combative patients
Myth-Busting
- IJ central line catheters do not increase ICP (2,3)
- You don’t need a central line for vasopressors; they can be infused through good peripheral IVs for up to 12-24 hours (check your institution’s guidelines for this)
- More on this by Justin Morgenstern and Salim Rezaie
- There is no BEST location for central line placement; subclavian, IJ, and femoral veins all have associated complications and the position should be individualized to the patient in front of you
Check out our video series on Central Line Tips & Tricks to learn more!
The Debrief
- There are a number of indications for central line placement, some of which are slightly controversial
- Not all central lines were made equal; infusion rates vary
- Consider using IOs and RIC catheters instead
References
- Tse A, Schick MA. Central Line Placement. 2020 Aug 15. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan–. PMID: 29262231.
- Goetting MG, Preston G. Jugular bulb catheterization does not increase intracranial pressure. Intensive Care Med. 1991;17(4):195-8. doi: 10.1007/BF01709876. PMID: 1744302.
- Vailati D, Lamperti M, Subert M, Sommariva A. An ultrasound study of cerebral venous drainage after internal jugular vein catheterization. Crit Care Res Pract. 2012;2012:685481. doi: 10.1155/2012/685481. Epub 2012 May 17. PMID: 22675621
- Petitpas F, Guenezan J, Vendeuvre T, Scepi M, Oriot D, Mimoz O. Use of intra-osseous access in adults: a systematic review. Crit Care. 2016 Apr 14;20:102. doi: 10.1186/s13054-016-1277-6. PMID: 27075364
- Dornhofer P, Kellar JZ. Intraosseous Vascular Access. 2020 Jun 22. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan–. PMID: 32119260.
Listing the flow rates in terms of time-to-completion a of 1 L bolus allows for seamless clinical contextualization. Great article and table. I am curious where a MAC line would fall on this table in relation to a Cordis and sheath introducers. It’s the primary catheter used for hemorrhagic shock at my institution.