What are the indications for central line insertion in patients?

Central Line Insertion Indications

Central venous catheters should be inserted when peripheral venous access is inadequate or impossible, when long-term intravenous therapy (>5-14 days) is required, when administering vesicant/irritant medications or high-osmolarity solutions, or when central venous access is needed for hemodynamic monitoring or specific therapies like parenteral nutrition or chemotherapy. 1, 2

Primary Clinical Indications

Duration-Based Indications

• Non-tunneled central catheters are indicated for short-term use (typically <30 days) when peripheral venous access is unachievable 3
• Tunneled central catheters should be used when long-term access (>30 days) is required for chemotherapy, antibiotics, parenteral nutrition, or blood products 3
• Implantable ports are indicated for long-term intermittent therapy (≥6 months) and carry the lowest infection risk among long-term devices 3
• PICCs are appropriate for durations of 15-30 days or longer in general medical patients, but the threshold increases to ≥15 days in critically ill patients 3

Infusate-Based Indications

• High-osmolarity parenteral nutrition requires central venous access with the catheter tip positioned in the lower third of the superior vena cava or upper right atrium to prevent endothelial injury 2
• Vesicant drugs (chemotherapy agents that cause tissue necrosis if extravasated) require central venous access for bolus administration and are essential for continuous infusion 2
• Irritant medications or concentrated solutions that cannot be safely administered peripherally necessitate central access where high-flow blood rapidly dilutes infused solutions 1

Specific Clinical Scenarios

• Frequent phlebotomy or difficult peripheral access warrants central line placement only if the anticipated duration is ≥15 days in hospitalized patients; for shorter durations, midline catheters (6-14 days) or peripheral IV catheters (≤5 days) are more appropriate 3
• Hemodynamically unstable patients or those requiring invasive hemodynamic monitoring should receive CVCs rather than PICCs for urgent central access 3
• Patients with coagulopathies (disseminated intravascular coagulation, severe thrombocytopenia with platelets <9,000) should preferentially receive PICCs over CVCs to minimize insertion-related bleeding complications 3
• Patients with tracheostomy or severe anatomical abnormalities of the neck and thorax are better candidates for PICCs due to difficult positioning and nursing care of centrally placed CVCs 3

Device Selection Algorithm

For Oncology Patients

• Short-term chemotherapy (<3 months): Interval placement of peripheral IV catheters with each treatment is most appropriate; PICCs are acceptable if peripheral access fails 3
• Medium-term therapy (3-6 months): PICCs or tunneled catheters are appropriate; ports are rated as neutral 3
• Long-term therapy (≥6 months): Ports are preferred for intermittent therapy; tunneled catheters are preferred when multiple or frequent infusions are required 3, 2
• Vesicant/irritant chemotherapy: PICCs or tunneled catheters are appropriate at all time intervals; ports become appropriate at ≥6 months 3

For Critically Ill Patients

• Peripherally compatible infusates: PICCs are inappropriate unless duration is ≥15 days; use peripheral IV (≤5 days) or midline catheters (6-14 days) instead 3
• Hemodynamically stable patients: CVCs are appropriate for 6-14 days; beyond 15 days, the rating becomes uncertain due to infection and thrombosis concerns 3
• Hemodynamically unstable or requiring vasopressors: CVCs are preferred over PICCs for durations ≤14 days; PICCs become appropriate for ≥15 days 3

For Chronic Kidney Disease Patients

• CKD Stage 3-5: Restrict venous access and use small-bore catheters via internal jugular vein when central access is necessary 2
• Avoid subclavian access entirely in hemodialysis patients and CKD Stage 3-5 due to risk of subclavian vein stenosis that can compromise future arteriovenous fistula creation 2, 4
• Avoid PICCs in patients with impending dialysis needs to preserve upper-extremity veins for fistula or graft implantation 3, 4

Insertion Site Selection

• Femoral vein should be avoided unless contraindications exist to other sites (e.g., SVC syndrome), as it carries 10 times higher thrombosis risk than subclavian access and increased infection risk 3, 1, 2
• Subclavian access is associated with lower catheter-related bloodstream infection rates compared to femoral and possibly jugular sites 2
• High internal jugular approach (exit site at mid-neck) should be avoided due to high contamination risk from neck movement and difficult dressing maintenance 3
• Low lateral "Jernigan" approach to internal jugular vein (exit site in supraclavicular fossa) may have different infection risk profiles than high approaches 3

Critical Safety Considerations

Mandatory Insertion Practices

• Ultrasound guidance is strongly recommended for all CVC insertions to increase success rates and reduce complications including pneumothorax, arterial puncture, and air embolism 1, 2, 5
• Maximal sterile barrier precautions must be applied: cap, mask, sterile gown, sterile gloves, and sterile full-body drape 2
• Chlorhexidine 0.5% with alcohol for skin preparation; if contraindicated, use tincture of iodine, iodophor, or 70% alcohol 3, 2
• Insertion should occur in the operating room under strict sterile conditions for implantable devices 3
• Antimicrobial prophylaxis is not recommended before insertion or during maintenance 3

Catheter Tip Verification

• Radiologic confirmation with intraoperative fluoroscopy or post-operative chest X-ray is required 3
• Desired tip location is at the junction between the right atrium and SVC 3
• Alternative verification: Intracavitary ECG method where arrhythmia is documented during wire insertion 3

Common Pitfalls to Avoid

• Do not use subclavian access in patients who may need future hemodialysis, as this can have devastating long-term consequences by causing central vein stenosis 2, 4
• Do not place PICCs urgently in hemodynamically unstable critically ill patients; CVCs are preferred in this setting 3
• Do not use multilumen catheters unless multiple ports are essential; single-lumen catheters have lower infection risk 3
• Do not forget post-procedure monitoring: 4-hourly observations including temperature, pulse, blood pressure, and respiratory rate; chest X-ray if dyspnea or chest pain develops 3
• Air embolism risk (0.5-0.8% incidence) can be minimized by proper Trendelenburg positioning during insertion and removal, meticulous technique, and avoiding deep inspiration during catheter manipulation 6