When is a central line (central venous catheter) indicated for a patient?

Central Line Indications

A central venous catheter is indicated when parenteral nutrition solutions exceed 850 mOsm/L osmolarity, when vesicant or irritant infusions are required, when peripheral access is inadequate for the anticipated duration of therapy, or when specific clinical conditions necessitate central venous access. 1

Primary Indications for Central Venous Access

Parenteral Nutrition Requirements

• Central venous access is needed for most patients requiring parenteral nutrition (PN), particularly when solutions have high osmolarity (>850 mOsm/L). 1
• Peripheral PN through short cannulas or midline catheters is acceptable only for limited time periods and only when osmolarity does not exceed 850 mOsm/L. 1
• The catheter tip must be positioned in the lower third of the superior vena cava, at the atrio-caval junction, or in the upper portion of the right atrium for high osmolarity PN delivery. 1

Infusion Characteristics

• Vesicant or irritant infusions require central venous access regardless of duration. 2
• Compatible peripheral infusions warrant central access when expected duration is ≥15 days. 2
• The osmolarity rate (milliOsmols infused per hour) correlates strongly with phlebitis risk (r = 0.95), making central access necessary for high-rate infusions. 1

Venous Access Challenges

• For patients with difficult peripheral venous access, central access (preferably PICC) is appropriate if expected duration is ≥6 days. 2
• Patients requiring frequent phlebotomies (≥3/day) warrant central access if duration is ≥6 days. 2
• Ultrasonography-guided peripheral IV attempts should precede PICC insertion in patients with difficult access, except in those with stage 3b or greater chronic kidney disease. 1

Specific Clinical Scenarios

Patients with tracheostomy: PICCs are preferable to conventional central catheters because the arm exit site is farther from oral and nasal secretions, reducing contamination risk. 1, 2

Coagulation abnormalities: PICCs reduce insertion-related bleeding complications compared to subclavian or internal jugular approaches. 1, 2

Severe thrombocytopenia (<9,000 platelets): PICC placement is safer than traditional central line insertion. 2

Device Selection Based on Duration

Short-Term Access (Days to Weeks)

• Non-tunneled central venous catheters (CVCs) or PICCs are suitable for hospitalized patients requiring short-term PN. 1
• Single-lumen catheters are preferred unless multiple ports are essential, as multi-lumen catheters increase infection risk. 1

Medium-Term Access (Up to 3 Months)

• PICCs, Hohn catheters, and tunneled catheters are appropriate for medium-term access. 1
• Non-tunneled CVCs are discouraged for home PN due to high rates of infection, obstruction, dislocation, and venous thrombosis. 1

Long-Term Access (>3 Months)

• Tunneled catheters (Hickman, Broviac, Groshong) or totally implantable ports are required for long-term home PN. 1
• For patients requiring frequent (daily) access, tunneled devices are generally preferable to ports. 1
• Implantable ports have the lowest infection incidence (0.1 per 1,000 catheter days) compared to tunneled CVCs (1.6 per 1,000 catheter days) and non-tunneled CVCs (2.7 per 1,000 catheter days). 1

Critical Contraindications

Absolute Contraindications

• Chronic kidney disease stages 3-5 requiring imminent dialysis: avoid PICCs and upper extremity central lines to preserve veins for future fistula creation. 2, 3
• Active bacteremia at time of planned insertion should prompt delay until blood cultures clear. 4

Relative Contraindications

• Femoral vein access for PN is relatively contraindicated due to high contamination risk at the groin exit site and elevated venous thrombosis risk. 1
• High approaches to the internal jugular vein (anterior or posterior to the sternoclavicular muscle) are not recommended due to difficult exit site nursing and increased infection risk. 1

Site Selection Priorities

Upper body insertion sites (subclavian or internal jugular) should be selected over femoral sites to minimize infection risk in adult patients. 1

• Subclavian vein catheterization shows lower risk of bloodstream infection and symptomatic thrombosis but higher pneumothorax rates compared to jugular or femoral approaches. 1
• Right-sided insertion is preferred over left to reduce thrombosis risk. 2
• Ultrasound-guided venipuncture is strongly recommended for all CVC insertions, as it reduces complications and increases success rates. 1, 2

Common Pitfalls to Avoid

• Never use non-tunneled CVCs for home PN beyond short periods due to exponentially increasing infection rates after 2-4 weeks. 1
• Avoid PICC placement in areas with hematomas, corded veins, open wounds, or burns. 2
• Do not place PICCs for hemodynamically unstable patients requiring urgent access; use traditional CVCs instead. 2
• Consult appropriate specialists (infectious disease for prolonged antibiotics, hematology-oncology for chemotherapy) before insertion. 2
• Verify tip position radiographically before initiating therapy, especially when infraclavicular subclavian approach is used. 1