Central Venous Catheter Insertion

Excerpt

A central venous catheter (CVC) is an indwelling device inserted into a large, central vein (most commonly the internal jugular, subclavian, or femoral) and advanced until the terminal lumen resides within the inferior vena cava, superior vena cava, or right atrium. These devices and the techniques employed to place them are synonymous with "central line", “central venous line” (CVL), or "central venous access." The placement of a CVC was first described in 1929. Over the following decades, central venous access rapidly developed into an essential experimental instrument for studying cardiac physiology and an indispensable clinical tool in treating many disease processes.

Various access techniques and devices were developed for many indications, including total parenteral nutrition administration, dialysis, plasmapheresis, medication administration, and hemodynamic monitoring, and to facilitate further complex interventions such as transvenous pacemaker placement.

Despite these advancements, the procedure has remained relatively unchanged since the advent of the (now universally employed) Seldinger technique in the 1960s. A notable exception is the adjunct of ultrasound guidance, which has recently become the standard of care for CVCs placed in the internal jugular vein, owing to associated decreases in complications and an increase in first-pass success. Some controversy persists about the merits of specific site selection (e.g., which vein) and the relative associated complication rates of CVCs placed in different central veins. However, there is broad consensus that today, in the modern era, the competency to establish and manage a central venous catheter is an indisputably essential skill set for clinicians involved in the care of critically ill patients. The purpose of this article is to review the indications, contraindications, techniques, complications, and management of centrally placed venous catheters.