When is central venous catheterization recommended and what are the guidelines for its insertion and management in patients with difficult peripheral access or requiring prolonged intravenous access?

Central Venous Catheterization: Indications and Management

Primary Indications for Central Venous Access

Central venous catheterization is indicated when peripheral access is inadequate and the expected duration of therapy, infusate compatibility, and patient-specific factors determine the optimal device type. 1

Core Indications Include:

• Administration of vesicant or irritant medications requiring central access (mandatory at any duration) 1, 2
• Hemodynamic monitoring and vasoactive drug infusion in unstable patients 3, 4
• Prolonged intravenous therapy when peripheral access is unachievable 1
• Frequent phlebotomy (≥3 times daily) for ≥6 days 1
• Extracorporeal blood circuits and renal replacement therapy 3

Device Selection Algorithm Based on Duration and Access Type

For Difficult Peripheral Access with Peripherally Compatible Infusates:

Duration ≤5 days:

• Use ultrasound-guided peripheral IV catheters as first-line 1, 5
• Avoid PICC placement—this is inappropriate and increases unnecessary complications 1, 2

Duration 6-14 days:

• Prefer ultrasound-guided peripheral IVs or midline catheters over PICCs 1, 2, 5
• Midline catheters (10-20 cm length in upper arm veins) have lower complication rates than PICCs for this duration 2, 5
• Non-tunneled CVCs are appropriate for 6-14 days, particularly in hemodynamically unstable patients 1, 2

Duration 15-30 days:

• PICCs become preferred over midlines due to higher midline failure rates beyond 14 days 2

Duration ≥31 days:

• Tunneled catheters or totally implantable ports are appropriate 1
• Ports have the lowest infection rates and are ideal for intermittent long-term access 1, 2

For Non-Peripherally Compatible Infusates (Vesicants/Irritants):

PICCs or CVCs are mandatory at any duration because central access is required 1, 2

• Do not use midlines for vesicants—they lack central tip positioning and risk extravasation 2

Insertion Site Selection and Technique

Preferred Insertion Sites:

Internal jugular vein is the preferred site for most central venous access 1

• Lower thrombosis risk than femoral access 6
• Better infection control than high neck approaches 6

Avoid femoral vein unless contraindications exist to other sites (e.g., SVC syndrome) 1

• Femoral access carries increased infection and thrombosis risk 1, 7
• If femoral access necessary, limit to <5 days 6

Insertion Requirements:

• Perform under strict sterile conditions in operating room for implantable devices 1
• Use chlorhexidine solutions with alcohol for skin preparation 1
• Ultrasound guidance is essential—it accounts for anatomical variations, facilitates visualization, and prevents inadvertent arterial puncture 3, 8
• Local anesthesia with or without sedation 1

Seldinger Technique (Standard Approach):

1. Needle passed toward chosen vessel under ultrasound guidance 3
2. Guidewire introduced through needle into vessel, needle removed 3
3. Small skin incision at guidewire base 3
4. Dilator advanced over guidewire, then removed 3
5. Central venous catheter railroaded over guidewire into vein, guidewire withdrawn 3

Critical Special Population Considerations

Chronic Kidney Disease Patients (Stage 3b or Greater, eGFR <45 mL/min):

PICC lines and midline catheters in arm veins are absolutely contraindicated regardless of indication 1, 6, 2

• Vein preservation for future hemodialysis access is paramount 1, 6
• PICC use strongly associated with arteriovenous fistula failure (OR 2.8,95% CI 1.5-5.5, P=0.002) 6

For CKD patients requiring central access:

• Duration ≤5 days: Place peripheral IVs only in dorsum of hand (avoid forearm veins) for peripherally compatible infusates 1, 6
• Duration >5 days or non-peripherally compatible drugs: Use tunneled small-bore central catheter (4-French single-lumen or 5-French double-lumen) via internal jugular vein, tunneled toward chest 1, 6
• Consult nephrology to discuss medication administration during dialysis procedures 6

Cancer Patients:

• Tunneled catheters indicated for long-term access >30 days (chemotherapy, antibiotics, parenteral nutrition, blood products) 1
• Fully implantable ports preferred for long-term intermittent access (≥31 days) with lowest infection risk 1
• Raise threshold for PICC use to ≥15 days in hospitalized cancer patients 2

Hemodynamically Unstable Patients:

CVCs are preferred over PICCs in acute resuscitation 2, 4

• CVCs provide more secure access for vasoactive drugs 4
• Do not urgently place PICCs in unstable patients 2

Common Pitfalls and How to Avoid Them

Device Selection Errors:

• Never place PICCs for <6 days with peripherally compatible infusates—this increases complications without benefit 1, 2
• Never rationalize PICC placement in dialysis patients based on "no other options"—short-term convenience is vastly outweighed by long-term AVF failure consequences 6
• Never use midlines for vesicants/irritants—central access is mandatory 2

Vein Preservation Errors:

• In CKD patients, avoid all arm vein devices (PICCs, midlines) 1, 6, 2
• If peripheral IV attempted in CKD patients, use only dorsum of hand, never forearm veins 1, 6
• In patients with lymphedema, avoid insertion in affected limbs except acute situations 5

Technical Errors:

• Do not use landmark technique—ultrasound guidance is essential 3, 8
• Do not routinely change peripheral cannulae at 72-96 hours 5
• Use smallest practical cannula size to minimize vein trauma 5

Complications and Risk Mitigation

Major Complications Include:

• Mechanical: arterial injury (2-3%), pneumothorax (3% subclavian), hemothorax 4, 7
• Infectious: catheter-related bloodstream infections (3%) 7
• Thrombotic: DVT (2% subclavian, 9% femoral), pulmonary embolism 7

Risk Reduction Strategies:

• Subclavian CVCs have lower DVT rates than femoral (2% vs 9%, P<0.001) but higher pneumothorax risk 7
• Femoral CVCs may be safer than subclavian during emergency trauma resuscitations 7
• Tunneled catheters have cuff that induces fibrosis, inhibiting organism migration and reducing infection 2

Emergency Situations

When IV access cannot be obtained emergently, intraosseous access is the preferred alternative route 1, 5

• All IV medications can be administered intraosseously 1
• Onset of action and drug levels comparable to venous administration 1