What are the guidelines for choosing medication and lumen, including proximal, distal, and medial lumens, for central venous catheters (CVCs)?

From the Guidelines

When choosing medication and lumen for central venous catheters (CVCs), it is recommended to use a dedicated lumen for parenteral nutrition (PN) infusion to minimize the risk of catheter-related complications, as suggested by the most recent and highest quality study 1.

Key Considerations

• The smallest diameter catheter and minimum number of lumens should be used to minimize the risk of catheter-related complications 1.
• Multilumen catheters may be used when multiple simultaneous therapies are required or when infusion of noncompatible medications and fluids require additional venous access 1.
• In patients who require PN, it is generally recommended that a single lumen be dedicated exclusively to that purpose 1.

Lumen Allocation

• The distal lumen (furthest from insertion site) is ideal for continuous infusions like total parenteral nutrition (TPN), propofol, and vasopressors (norepinephrine, vasopressin) because it exits at the catheter tip where blood flow is highest, reducing irritation and thrombosis risk.
• The medial lumen is suitable for intermittent medications and blood draws, while the proximal lumen (closest to insertion site) works well for maintenance fluids and less irritating medications.

Best Practices

• Incompatible medications should never share the same lumen - for example, keep TPN separate from other infusions to prevent precipitation 1.
• Always flush lumens with normal saline between different medications (5-10 mL) and use dedicated lumens for vasopressors to prevent dangerous interruptions.
• For blood draws, temporarily stop infusions in that lumen, discard the first 5-10 mL of blood, and flush afterward to prevent complications like catheter occlusion, medication incompatibility reactions, and inaccurate lab values 1.

From the FDA Drug Label

Avoid Hypertension: Because of the potency of LEVOPHED and because of varying response to pressor substances, the possibility always exists that dangerously high blood pressure may be produced with overdoses of this pressor agent Site of Infusion: Whenever possible, infusions of LEVOPHED should be given into a large vein, particularly an antecubital vein because, when administered into this vein, the risk of necrosis of the overlying skin from prolonged vasoconstriction is apparently very slight Some authors have indicated that the femoral vein is also an acceptable route of administration. A catheter tie-in technique should be avoided, if possible, since the obstruction to blood flow around the tubing may cause stasis and increased local concentration of the drug Occlusive vascular diseases (for example, atherosclerosis, arteriosclerosis, diabetic endarteritis, Buerger's disease) are more likely to occur in the lower than in the upper extremity. Therefore, one should avoid the veins of the leg in elderly patients or in those suffering from such disorders.

The choice of medication and lumen for central venous catheters (CVCs) depends on various factors, including the patient's condition and the type of infusion.

• Proximal, distal, and medial lumens are terms that refer to the location of the catheter within the vein.
• The proximal lumen is closer to the catheter hub, while the distal lumen is closer to the catheter tip.
• The medial lumen is located between the proximal and distal lumens.
• When administering norepinephrine (IV), it is recommended to use a large vein, such as the antecubital vein, to minimize the risk of necrosis and vasoconstriction 2.
• The choice of lumen for medication administration should be based on the patient's individual needs and the type of infusion, taking into account factors such as blood flow and vascular disease 2.
• Key considerations for medication choice and lumen selection include:
  • Patient condition and medical history
  • Type of infusion and medication
  • Vein selection and catheter placement
  • Risk of complications, such as necrosis and vasoconstriction.

From the Research

Medication Choice and Lumen Choice for Central Venous Catheters (CVCs)

• The choice of medication and lumen for CVCs, including proximal, distal, and medial lumens, is crucial in preventing catheter-related bloodstream infections (CR-BSIs) and other complications.
• According to a systematic literature review 3, guidelines recommend using single-lumen central vascular access devices (CVADs) for the administration of parenteral nutrition (PN) or lipid-based solutions, or a dedicated lumen on a multilumen CVAD.
• A simulation study 4 found that limiting the number of lumens in peripherally inserted central catheters (PICCs) can improve outcomes and reduce costs, with a single-lumen PICC default policy associated with approximately 10% cost savings.

Proximal, Distal, and Medial Lumens

• The use of dedicated lumens for specific medications or solutions can help reduce the risk of CR-BSIs and other complications.
• A study 5 found that 13 antibiotics were stable and compatible with a parenteral nutrition solution, allowing for safe administration through a "piggyback" fashion.
• Another study 6 found that certain antibiotics can increase the pH of a parenteral nutrition solution, leading to the formation of an insoluble calcium phosphate precipitate, and recommended a flush procedure when injecting these antibiotics.

Clinical Considerations

• The choice of medication and lumen for CVCs should be based on individual patient needs and clinical considerations, such as the type of medication or solution being administered, the patient's medical history, and the presence of any underlying conditions.
• A case study 7 highlighted the importance of considering a patient's nutritional needs and medical history when selecting a feeding method, including the use of central venous parenteral nutrition.