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Central venous catheter insertion is a standard and, often, the necessary procedure for critically ill patients. Various access techniques and devices were developed for many indications, including total parenteral nutrition administration, dialysis, plasmapheresis, medication administration, and hemodynamic monitoring, and to facilitate further complex interventions such as transvenous pacemaker placement. Central venous access may be attained with various devices, depending on the indication for catheter insertion. Broadly, central venous catheters allow for the administration of vasoactive medications and agents known as venous irritants. Still, catheters are used to perform dialysis or plasmapheresis or as a conduit to insert additional devices for more complex procedures. This activity reviews central venous catheter insertion and highlights the role of the interprofessional team in managing patients who undergo this procedure. Objectives: Identify the indications and contraindications for central venous catheter insertion. Describe the technique involved in central venous catheter insertion. Review the common complications of central venous catheter insertion. Outline the importance of interprofessional team collaboration, communication, and care coordination to enhance the care of patients requiring central venous catheter insertion to improve outcomes. Access free multiple choice questions on this topic.

A central venous catheter (CVC) is an indwelling device inserted into a large, central vein (most commonly the internal jugular, subclavian, or femoral) and advanced until the terminal lumen resides within the inferior vena cava, superior vena cava, or right atrium. These devices and the techniques employed to place them are synonymous with "central line", “central venous line” (CVL), or  "central venous access." The placement of a CVC was first described in 1929.[1] Over the following decades, central venous access rapidly developed into an essential experimental instrument for studying cardiac physiology and an indispensable clinical tool in treating many disease processes.[2] Various access techniques and devices were developed for many indications, including total parenteral nutrition administration, dialysis, plasmapheresis, medication administration, and hemodynamic monitoring, and to facilitate further complex interventions such as transvenous pacemaker placement.[1][3][4][5][6][7] Despite these advancements, the procedure has remained relatively unchanged since the advent of the (now universally employed) Seldinger technique in the 1960s.[8] A notable exception is the adjunct of ultrasound guidance, which has recently become the standard of care for CVCs placed in the internal jugular vein, owing to associated decreases in complications and an increase in first-pass success.[5][9][10][11][12][13] Some controversy persists about the merits of specific site selection (e.g., which vein) and the relative associated complication rates of CVCs placed in different central veins. However, there is broad consensus that today, in the modern era, the competency to establish and manage a central venous catheter is an indisputably essential skill set for clinicians involved in the care of critically ill patients. The purpose of this article is to review the indications, contraindications, techniques, complications, and management of centrally placed venous catheters.

Numerous potential complications can occur during the procedural placement of a central venous catheter but also due to the indwelling equipment. Procedural complications include the following: Arrhythmias – typically ventricular or bundle branch blocks due to guidewire irritation of the atria or ventricles Arterial puncture Pulmonary puncture with or without resultant pneumothorax Bleeding – hematoma formation, which can obstruct the airway Tracheal injury Air emboli during venous puncture or removal of the catheter[32] Post-procedural complications include the following: Catheter-related bloodstream infections – bacterial or fungal[33] Central vein stenosis Thrombosis Delayed bleeding with multiple attempts in a coagulopathic patient[32][34]

After a CVC placement, nurses are charged with maintaining, monitoring, and utilizing central venous catheters. The bedside nurse must be adept at recognizing complications such as infections, hematoma, thrombosis of the catheter, and signs of pneumothorax and bleeding. Nurses are also responsible for ensuring that the site is maintained in a clean and sterile fashion. Beyond the immediate complications of the procedure itself, nursing must be immediately aware of any ongoing issues and delayed complications. Their role in the interprofessional team is of monumental importance in maintaining the central venous catheter and recognizing potential complications. Clear communication between all team members is essential to appropriate patient care.[37] The clinician should inform the nurse as soon as the proper placement of the CVC is confirmed, and nursing should wait for this confirmation before using the line to administer medications. The nurse and the clinician should be aware of and track when the line was placed. CVCs are temporary, and complication rates increase when lines are left in too long.

Daily inspection of the access site and device patency should be performed during nursing rounds. In particular, nursing must disinfect injection ports, catheter hubs, and needleless connectors with institutionally approved antiseptics. Intravenous administration sets should be changed regularly per hospital policy. The site should be checked for bleeding, hematoma formation, and cellulitis signs, including erythema, purulent drainage, and warmth.[38] Dressings should be changed if visibly soiled. This must be performed with proper sterile technique. Importantly, any manipulation of the catheter site should be done using a sterile procedure. A bouffant cap, mask, and sterile gloves must be worn to minimize infection. The area should be cleaned with approved antiseptics, allowed to dry, and a sterile occlusive dressing must be replaced.[38] At interprofessional team rounds, there should be a daily discussion about whether or not the central venous catheter is still indicated. If deemed unnecessary for further management, the central venous catheter should be removed expeditiously.[39]

Many potential complications can arise from the placement of central venous catheters. Nursing staff should be aware of the immediate and delayed complications and alert the clinician in charge of the patient’s care.[39] However, clinicians should also be wary of complications and always consider the catheter (as a source) if the patient shows signs of infection.