What are the contraindications to central line placement?

Contraindications to Central Line Placement

The main contraindications to central line placement include coagulopathy, infection at the insertion site, anatomical distortion, vascular abnormalities, and certain patient-specific factors that increase risk of complications. 1

Absolute Contraindications

• Infection at the insertion site - Local infection increases risk of catheter-related bloodstream infections 1
• Distorted anatomy that prevents clear identification of anatomical landmarks 1
• Known venous thrombosis or stenosis at the proposed insertion site 1
• Vascular injury at the proposed insertion site 1

Relative Contraindications

Patient Factors

• Severe coagulopathy - While not an absolute contraindication, severe coagulation abnormalities may increase bleeding risk, though evidence suggests that even with hemostatic defects, serious hemorrhagic complications are rare 2, 3
• Morbid obesity - Makes landmark identification difficult but can be overcome with ultrasound guidance 1
• Severe respiratory distress - Increases risk of complications during subclavian approach 1
• Previous radiation to the insertion area 1
• Presence of tracheostomy for internal jugular approach 1

Site-Specific Contraindications

• Femoral site should be avoided in adult patients when possible due to:

  • Higher risk of infection compared to other sites 1
  • Increased risk of venous thrombosis 1
  • Difficulty in maintaining sterile dressing 1

• Subclavian site should be avoided in:

  • Patients with advanced kidney disease or on hemodialysis (to prevent subclavian vein stenosis) 1
  • Patients with severe respiratory compromise (increased risk of pneumothorax) 1, 4

Procedural Considerations

• Inability to obtain informed consent (unless emergency situation) 1
• Lack of skilled personnel or appropriate equipment 1
• Lack of ultrasound guidance when anatomical landmarks are difficult to identify 1, 4

Special Situations

Coagulopathy

• Recent evidence suggests that mild to moderate coagulation abnormalities do not significantly increase bleeding risk when ultrasound guidance is used 2, 3
• For severe coagulopathy, consider:
  • Correction of coagulation parameters if time permits
  • Use of ultrasound guidance (reduces arterial puncture risk by 80%) 4, 5
  • Selection of compressible sites (internal jugular preferred over subclavian) 1

Anatomical Variations

• Vascular anomalies - Ultrasound should be used to identify variations 1, 4
• Previous surgery or trauma to the insertion area 1
• Presence of other devices (e.g., pacemakers, existing catheters) 1

Risk Mitigation Strategies

• Use ultrasound guidance - Reduces risk of arterial puncture (RR 0.20) and pneumothorax (RR 0.25) 4
• Select appropriate insertion site based on patient factors and intended duration of use 1
• Use maximal sterile barrier precautions during insertion 1
• Choose appropriate catheter type and size - Smallest caliber compatible with intended therapy 1
• Ensure proper training of personnel performing the procedure 1
• Avoid after-hours procedures when possible (15% vs 6% complication rate) 5

Common Pitfalls to Avoid

• Ignoring site-specific risks - Each approach has unique complications 1
• Failing to use ultrasound guidance when available - Significantly reduces mechanical complications 4, 5
• Overlooking patient-specific factors that may increase risk 1
• Unnecessary correction of mild coagulation abnormalities - May delay necessary treatment without reducing complications 2, 3
• Multiple unsuccessful attempts - Associated with increased complication rates; consider alternative site or more experienced operator after initial failures 4, 5