Lecture 6.

Central Lines

Definitions and additional information:
Central line: venous catheter with the tip dwelling (or remaining) in the central venous system.
Typically these will only be inpatient

Central locations: IVC, SVC, Subclavian, Right Atrium
Insertion points: IJ, Subclavian. And Femoral
EJ is less often used except for in Emergent situations
Axillary a infrequently used (gets a PICC instead)

PICC lines (Peripherally Inserted Central Catheter)
Is inserted distally and then threaded to place the tip at the SVC/RA junction
Used for long term IV access
Total Parenteral Nutrition (TPN)
IV antibiotics (which can be caustic to veins)
Chronic transfustions
Chemotherapy
Distal locations include:
Brachial, cephalic and axillary arteries
A PICC line is not to allow short term access in a patient with bad veins.
(In that case, insert a line in the neck or groin for a duration of 3-5 days only)

When to use a Central Line:
Going to be in ICU or CCU
Provide access necessary to perform a procedure (stent, angiography)
Hemodialysis
Repeated Transfusion
In peripheral vein cannot be cannulated
veins are collapsed due to low BP or damage from earlier lines and cant be accessed
Administer fluids which are toxic to venous walls (chemotherapy, vancomycin)
To measure CVP (Central Venous Pressure)
Necessary when reperfusing after massive volume loss
to not over perfuse
Necessary when administering fluids after trauma / head injuries
trying to avoid shock
Necessary when pericardial tamponade is suspected
to note when fluid buildup is causing tamponade

Which is better for rapid infusion in hemorrhaging pt: 1 Central line or 2 Peripheral IV
lines?
2 peripheral lines:
Less length = resistance to flow
May have larger diameter openings (greatly decreased resistance)
Twice as many lines delivering fluid




1. Describe the different types of central lines and their specific indications and uses.

Type of
Catheter
Ports Duration Medical
Professional
Use Notes
Triple Lumen 3 3-5 d Any trained prof Transfusion,
deliver meds,
draw blood

Designed
for SVC,
IJ
Typically
not placed
in
Axillary
or
Cephalic
veins
too short
PICC 1-2 Weeks to
months
Trained RN on
the floor or IR
Longer
length >
UE/
Typically
not in
groin
Ports 1 Long term IV
central access
Surgery

CAth is inserted
then the port is
buried in chest
or abdomen
under SQ fat and
skin
Chemo, sickle
pts with long
term med or
infusion needs
Allow
Sub Q
access.
Poke
though
skin using
access
needle

Non-traditional lines
Dialysis line (technically a central line)
2 ports (1 in, 1 out)
Long term
Only for hemodialysis. Never for infusion

Intraosseus Access
Put line into bone. Often used in kids
Use when vascular access iss not possible and life saving measures must be taken
Adult: clavical, Humerus, femur, ileum
Kids (< 5): tibia

Insert into sternum for greater infusion rates and greater risk



2. Identify complications and risks of central line insertion.
a. Pneumothorax from iatrogenic injury
i. Tx: watch pt clinically
1. Tx chest pain, dyspnea,
2. ensure adequate O2 levels
ii. If > 15-20% of lung has Pneumothorax insert chest tube
1. Chest tube stay in for about 24 hrs to allow healing
b. Arterial puncture (Oops)
i. Remove catheter
ii. Apply lots of pressure for a long time (20-30 min)
iii. Release pressure gently and carefully
c. Malpositioning (cath tip isnt where should be dif vein, same vein)
i. Attempt to reposition, then repeat CXR to ensure placement
ii. Call Interventional Radiology
d. Infection
i. PICC low rate
ii. Other options higher rates
iii. Causes:
1. Poor technique or unsterile conditions
2. Pt already has a systemic infection
3. Central line is left in too long
e. Thrombosis
i. Central line is IDd as a foreign body and body may clot around the tip
f. Air Embolism
i. Dont put in a hollow catheter (use saline)
g. Dysrhthmia
i. Tip may cause RA foci
h. Tip perforation
i. May push through wall of vessel / heart
i. Nerve Injury
i. May hit a nerve instead of artery

3. Describe the general procedure of central line insertion and appropriate
radiographic studies for verification of placement.
a. Select site
b. Sterilize location and insert needle
c. Put guide wire in and remove needle
d. Pass dilation device over wire which dilates the subcutaneous tissue
e. Remove the dilation device
f. Put in catheter to desired locale
g. Remove wire
h. Use XR to confirm proper positioning (unless already using realtime XR)