Commonly Used Catheters
TYPE OF CATHETER |
INDICATION FOR USE |
---|---|
NON-TUNNELED LINES |
|
Triple-Lumen Catheter |
Central access/pressors |
Introducer Sheath (e.g. Cordis®) |
Large bore, short length catheter for rapid resuscitation. Can be used to introduce PA catheter or transvenous pacer |
Trialysis Catheter |
2 of 3 lumens are large bore catheters that can be used for dialysis. Third lumen can be used for central access |
Peripherally Inserted Central Catheter (PICC) |
Long term IV medications (e.g. antibiotics, chemotherapy). Usually terminates in SVC, consider for treatment courses >4 weeks |
Midline |
Long term IV medications (e.g. antibiotics). Not as useful as PICC for frequent blood draws. Usually terminates near axilla, consider for treatment courses <4 weeks |
Pulmonary Artery (PA) Catheter (aka Swan-Ganz Catheter) |
Hemodynamic monitoring in cardiogenic/mixed shock |
TUNNELED LINES (more stable and lower infection risk than non-tunneled, usually placed by IR or surgery) |
|
Hickman® Groshong® |
Long-term dialysis, medications, or chemotherapy |
Port-a-cath |
Subcutaneous port attached to catheter; port can be accessed to draw blood or give medications |
Principles of Size and Flow
- Poiseuille equation governing flow: Q = (πPr⁴)/(8ηL).
- Q = flow.
- P = pressure.
- r = radius.
- η = dynamic viscosity.
- L = length.
- Therefore, flow rates of catheters vary by radius of catheter (larger = faster, most important factor), and length (shorter = faster).
- “French” and “gauge” both refer to diameter of catheter. Higher French = larger catheter, lower gauge = larger catheter.
Common Indications for Central Venous Cannulation
- Administration of vasoactive/phlebitic medications (e.g. pressors, chemotherapy, TPN).
- Hemodynamic monitoring (e.g. CvO2, CVP, PA catheters).
- Rapid fluid/blood product resuscitation (e.g. Cordis®).
- Extracorporeal therapies (e.g. hemodialysis, plasmapheresis).
- Introduction of other devices (PA catheters, transvenous pacing wires placed through Cordis®).
Contraindications to Central Venous Cannulation
- Absolute contraindications (select a different site): infection over the site, thrombosis/stenosis of the vein.
- Relative contraindications: coagulopathy (particularly relevant to subclavian lines as this is not an easily compressible site), inability to tolerate requisite positioning. See site-specific sections for further detail.
Site Selection
Location |
Advantages |
Disadvantages |
---|---|---|
Femoral |
|
|
Internal Jugular |
|
|
Subclavian |
|
|
Procedural Technique
Preparation
- Obtain informed consent.
- Gather your central line insertion kit. Necessary supplies that are sometimes not within these kits and need to be obtained:
- Sterile gloves, gown, hair cover, mask+face shield, chlorhexidine, 1% lidocaine, large Tegaderm, biopatch, sterile tubing (for your manometry column), angiocatheter, sterile ultrasound probe cover + sterile ultrasound gel, at least 4 extra saline flushes, sterile caps for central line ports.
- Optimal patient positioning depends on location of the line - see site-specific sections for further detail.
- Turn the cardiac monitor towards you and increase the monitor volume. An increase in heart rate could signal ectopy from your guidewire, and a drop in pitch could signal desaturation concerning for pneumothorax.
- Perform a time out and confirm allergies.
- Perform hand hygiene and put on sterile personal protective equipment.
Ultrasound and Local Anesthetic
- Chlorhexidine prep the site.
- Place sterile drape, place sterile ultrasound probe cover, and organize your equipment on your sterile field.
- Flush each port of your central line with sterile saline and then cap each port to prevent air entrainment.
- Flush your manometry tubing with sterile saline and leave your sterile flush attached.
Initial Cannulation
- See site-specific sections for anatomical detail and approach.
- Identify your target vein using ultrasound (veins are compressible, arteries are pulsatile. For additional confirmation, color Doppler should confirm flow moving in opposite directions in vein vs artery).
- Create small wheal with local anesthetic. Continue to anesthetize deeper tissues/muscles, visualizing your needle tip with ultrasound.
- While either a finder needle or angiocatheter needle can be attached to a syringe and used to puncture the vein, the angiocatheter allows ease of use and can be readily hooked up to manometry tubing.
- Steady your dominant hand and elbow holding the syringe and angiocatheter needle. Following your needle tip with ultrasound, advance your needle while continuously aspirating. Once you have confirmed you are in the vein by ultrasound and blood return, flatten your angle and advance your catheter fully over the needle.
- Hold the catheter with one hand and withdraw the needle with the other. Cover the angiocatheter with your thumb to prevent air entrainment.
- Attach your manometry tubing, aspirate a small amount of blood into the tubing, raise your tubing in the air, and remove your flush to ensure you are in a low-pressure vessel (column of blood should drop and flow should be non-pulsatile).
Seldinger Technique
- Thread your guidewire through your angiocatheter. Length of guidewire used depends on your site of access. NEVER LET GO OF THE GUIDEWIRE!
- Remove your angiocatheter over the guidewire while keeping hold of the wire.
- Use scalpel to make a 3-4mm incision in the skin over the guidewire. Ensure that you do not cut the wire (point sharp end of scalpel away) and ensure your cut is contiguous with the needle tract (i.e. there is no “skin tag”).
- Pass dilator 3-4cm over the guidewire to dilate the subcutaneous tissue and into the vessel. Remove dilator. Have sterile gauze ready in case of bleeding.
- Pass catheter over the guidewire - wire will exit out of the brown port (uncap this port if needed). NOTE: Do not let go of the wire at any point.
- Once catheter has been advanced into the vein, remove the guidewire.
Securing the Catheter & Post-procedure
- Aspirate each port to ensure blood return and flush each line again with sterile saline. Recap each port to prevent air entrainment.
- Suture in place, add biopatch, and apply Tegaderm.
- If internal jugular or subclavian line, order STAT chest xray to confirm line placement. In addition, can consider sending a blood gas from the line to ensure pO2 is consistent with venous cannulation.
- Discard all sharps and garbage, and write a procedure note.
Darouiche RO, Wall MJ Jr, Itani KM, et al. Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med 2010;362(1):18-26.
Parienti JJ, Mongardon N, Megarbane B, et al. Intravascular Complications of Central Venous Catheterization by Insertion Site. N Engl J Med 2015;373(13):1220-9.
Pronovost P, Needham D, Berenholtz S, et al. An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. N Engl J Med 2006;355(26):2725-2732.