What are the benefits and indications for placing a central venous catheter (central line)?

Benefits and Indications for Central Venous Catheters

Central venous catheters provide critical venous access for administering high-osmolarity solutions, vasopressors, parenteral nutrition, chemotherapy, and for hemodynamic monitoring—with specific device selection based on anticipated duration of therapy and clinical indication. 1

Primary Clinical Benefits

Central lines offer several distinct advantages over peripheral access:

• Delivery of caustic medications: Central lines safely deliver high-osmolarity solutions (>850 mOsm/L), vesicants, and vasopressors that would cause peripheral vein damage 2, 1
• Hemodynamic monitoring: Central venous pressure (CVP) and central venous oxygen saturation (ScvO2) monitoring at the superior vena cava-right atrial junction predicts return of spontaneous circulation and guides resuscitation 2, 1
• Rapid drug delivery: Peak drug concentrations are higher and circulation times shorter compared to peripheral IV access, particularly important during cardiac arrest 2
• Reliable long-term access: Enables extended therapy for parenteral nutrition, chemotherapy, and hemodialysis when peripheral veins are inadequate 2, 1

Specific Indications by Duration

Short-Term Access (Days to Weeks)

• Non-tunneled polyurethane catheters via internal jugular or subclavian vein for hospitalized patients requiring continuous infusions, vasopressor support, or CVP monitoring 2, 1
• Critical care applications: Fluid resuscitation, multiple medication infusions, blood product administration, and hemodynamic monitoring in ICU patients 3, 4

Medium-Term Access (Up to 3 Months)

• PICCs or Hohn catheters for prolonged parenteral nutrition in hospitalized or home-based patients, though PICCs have limitations for self-care due to arm positioning 2
• Intermediate chemotherapy regimens or extended antibiotic therapy requiring reliable venous access 5

Long-Term Access (>3 Months)

• Tunneled catheters (Hickman, Broviac, Groshong) for home parenteral nutrition requiring daily access—these are preferable to totally implantable ports for frequent use 2, 1
• Totally implantable ports for intermittent long-term therapy such as chemotherapy cycles where daily access is not required 2
• Hemodialysis access via internal jugular vein (never subclavian, which causes central venous stenosis) 1

Key Clinical Decision Algorithm

Choose central line when:

1. Peripheral access is inadequate or impossible 6, 4
2. High-osmolarity solutions (>850 mOsm/L) are required—peripheral PN is limited to ≤850 mOsm/L for short periods only 2
3. Vasopressor therapy is needed, particularly for prolonged duration or high doses 7
4. CVP monitoring or ScvO2 measurement is clinically indicated 1
5. Therapy duration exceeds 5 days for peripherally compatible infusions 2
6. Vesicant or irritant chemotherapy administration is planned 2

Avoid PICCs when:

• Duration <5 days (inappropriate per MAGIC criteria) 2
• Long-term home parenteral nutrition is planned (higher thrombosis risk, difficult self-care) 1
• In critically ill patients when <14 days of use expected (non-tunneled CVCs preferred) 2

Site Selection Priorities

Preferred sites in order of infection risk:

1. Subclavian vein: Lowest infection risk but avoid in hemodialysis patients due to stenosis risk 1
2. Internal jugular vein: Right-sided preferred for straighter path and fewer mechanical complications 1
3. Femoral vein: Relatively contraindicated for parenteral nutrition due to highest infection and thrombosis risk 2, 1

Critical Technical Requirements

• Ultrasound guidance is mandatory for all central venous catheterizations—strongly reduces complications and improves success rates 2, 1
• Tip position must be at the cavo-atrial junction or lower third of superior vena cava for parenteral nutrition and accurate CVP monitoring 2, 1
• Confirm tip position during procedure when possible, especially with infraclavicular subclavian approach; post-procedure chest X-ray is mandatory when intraoperative confirmation was not performed 2

Common Pitfalls to Avoid

• Do not use femoral access for parenteral nutrition—high contamination and thrombosis risk makes this relatively contraindicated 2
• Avoid high internal jugular approaches—exit sites near the neck are difficult to maintain and increase infection risk 2
• Never use subclavian vein in hemodialysis patients—causes irreversible central venous stenosis that precludes future arteriovenous fistula creation 1
• Do not place PICCs for <5 days duration—rated as inappropriate use; consider ultrasound-guided peripheral IV or midline catheter instead 2
• Avoid left-sided placement when possible—associated with higher malposition, thrombosis, and stenosis rates 1