Central Venous Catheterization

Abstract

Central venous catheterization is frequently required in critically ill patients to facilitate fluid resuscitation; to administer vasoactive agents, sedative agents, antibiotics as well as myriad other medications; as well as to provide access for various dialytic approaches. The most common sites of venous access are the subclavian, internal jugular, and femoral veins. Central venous catheterization is not a benign procedure and may be associated with potentially lifethreatening complications. Femoral venous catheterization is probably associated with the lowest incidence of periprocedural complications in the inexperienced operator. Furthermore, contrary to popular belief, the incidence of catheter-associated sepsis and thromboembolic complications may not be higher with femoral catheters. Femoral catheters, however, should be avoided in patients nursed in a chair or ambulating patients. The presence of a coagulopathy is not a contraindication to central vein catheterization; the rate of complications is related to the expertise of the operator rather than the ability of the patient’s blood to clot. In the hands of the inexperienced, femoral vein catheterization is recommended in the coagulopathic patient. Catheter-associated sepsis is a serious complication in critically ill patients (see Chapter 44); central venous catheters should therefore be inserted under strict aseptic conditions; hand washing, gloves, gown, and extended drapes are mandatory. While the risk of infection is related to the number of ports and manipulations, triple- lumen catheters may limit the number of catheters required (and infections) and are therefore generally recommended. Furthermore, antibiotic-coated catheters and reduce the risk of infection are therefore recommended.