What are the indications for central line placement?

Indications for Central Line Placement

Central venous access is indicated when peripheral access is inadequate for the intended therapy, when prolonged intravenous therapy is anticipated, or when specific clinical situations require central venous monitoring. 1, 2

Primary Indications

Administration of Specific Therapies

• Parenteral nutrition: When osmolarity exceeds 850 mOsm/L (requires central delivery) 1
• Vesicant medications: For drugs that can cause tissue necrosis if extravasation occurs 1
• Long-term IV therapy: When therapy is expected to exceed 6 days 1
• Hemodialysis/plasmapheresis: Requires high-flow access 1, 2

Clinical Monitoring Requirements

• Central venous pressure monitoring: For hemodynamic assessment 1
• Central venous oxygen saturation (ScvO2) monitoring: To assess tissue oxygenation 1
• Coronary perfusion pressure estimation: During cardiopulmonary resuscitation 1

Vascular Access Issues

• Poor peripheral access: When peripheral veins are exhausted or unsuitable 1
• Emergency resuscitation: For rapid fluid or medication administration during cardiac arrest 1
• High-volume fluid resuscitation: When large volumes need to be delivered quickly 2

Catheter Selection Considerations

Duration of Therapy

• Short-term therapy: Non-tunneled central venous catheters 1
• Medium-term therapy: PICCs or tunneled catheters 1
• Long-term/home therapy: Tunneled catheters or implantable ports 1

Number of Lumens

• Use the minimum number of ports/lumens essential for patient management 1
• Multiple lumens increase infection risk but may be necessary for incompatible medications 1

Site Selection Algorithm

Adult Patients

1. First choice: Subclavian vein (lowest infection risk for non-tunneled CVCs) 1
2. Second choice: Internal jugular vein (higher infection risk than subclavian) 1
3. Avoid if possible: Femoral vein (highest infection risk in adults) 1

Special Populations

• Hemodialysis patients: Avoid subclavian site (risk of stenosis) 1
• Chronic renal failure: Prefer fistula or graft over CVC for permanent dialysis access 1
• Pediatric patients: Upper/lower extremities or scalp (in neonates) can be used 1

Important Considerations and Contraindications

Contraindications

• Relative contraindications:

  • Coagulopathy (risk of bleeding)
  • Local infection at insertion site
  • Anatomical distortion
  • Previous vascular injury or thrombosis at target site 2

• Site-specific contraindications:

  • Subclavian: Advanced kidney disease (risk of stenosis) 1
  • Femoral: Obesity, groin infection (increased infection risk) 1

Risk Minimization

• Use ultrasound guidance for central venous catheter placement to reduce mechanical complications 1
• Implement maximal sterile barrier precautions during insertion 1, 2
• Remove catheters promptly when no longer essential 1
• Replace catheters inserted during emergencies within 48 hours 1

Peripheral vs. Central Access Decision-Making

Consider peripheral access when:

• Therapy duration is short (<6 days) 1
• Solution osmolarity is <850 mOsm/L 1
• Medications are non-vesicant 1

Consider central access when:

• Therapy duration exceeds 6 days 1
• Solution osmolarity exceeds 850 mOsm/L 1
• Medications are vesicant or irritating 1
• Hemodynamic monitoring is required 1

Pitfalls to Avoid

• Unnecessary catheterization: Only insert central lines when absolutely necessary 2
• Improper site selection: Consider both infection and mechanical complication risks 2
• Inadequate barrier precautions: Maximal sterile barrier precautions reduce infection risk 2
• Prolonged catheter duration: Longer duration increases infection risk 2
• Insertion during emergencies without replacement: Replace within 48 hours 1

Central line placement should be performed by properly trained clinicians using evidence-based techniques to minimize complications and optimize patient outcomes.