CHAPTER 27

### KEY POINTS

• The subclavian approach is preferred for placement of central venous catheters (CVCs).

• Real-time ultrasound may reduce the mechanical complications associated with CVC insertion.

• Chlorhexidine-based skin antiseptic solutions reduce the incidence of catheter-related bloodstream infections as compared to povidone-iodine.

• Almost 50% of hospital-acquired bloodstream infections are caused by staphylococcal species.

• CVCs should not be replaced nor exchanged over a guide wire on a routine basis.

Central venous catheters (CVCs) have become an integral part of delivering care in the modern intensive care unit (ICU). In fact, the CDC estimates that in US ICUs there are 15 million CVC days per year (total number of days patients are exposed to CVCs).1 Indications for placement of CVCs include invasive hemodynamic monitoring, administration of vasoactive drugs, administration of caustic agents (eg, chemotherapy), administration of parental nutrition, renal replacement therapy, large bore venous access for rapid administration of fluids, and long-term venous access. This chapter will focus on the use of CVCs in the ICU setting. Thus, long-term tunneled catheters used for hemodialysis and peripherally inserted central catheters (PICC) will not be discussed.

### PLACEMENT OF CENTRAL VENOUS CATHETERS

The clinical presentation often dictates the type of catheter to be inserted. For example, a patient with a hemodynamically significant gastrointestinal hemorrhage may only require a single lumen, large bore CVC for volume resuscitation in addition to a peripheral IV, whereas a neutropenic patient with septic shock may require a triple lumen CVC in order to simultaneously administer vasoactive drugs and antibiotics. Importantly, most evidence suggests that the number of catheter lumens does not affect the rate of CVC infectious complications.2,3 Once the type of catheter has been selected, an anatomic site for insertion needs to be determined. The optimal anatomical location for insertion of CVCs has been a matter of debate for many years. In 2001, Merrer and colleagues published a study of 289 patients who were randomized to have their CVCs inserted in either the femoral or subclavian vein.4 Patients with femoral vein catheters had a dramatically higher incidence of infectious complications (19.8% vs 4.5%; p < 0.001) as well as thrombotic complications (21.5% vs 1.9%; p < 0.001) as compared to patients with subclavian catheters. The overall sum of mechanical complications (arterial puncture, pneumothorax, hematoma or bleeding, air embolism) was similar between the two groups. To date, there are no randomized trials comparing subclavian versus internal jugular catheters with regard to infectious complications, though observational studies suggest a lower rate of infectious complications with subclavian catheters and a similar rate of mechanical complications.5,6 A recent Cochrane review on comparison of central venous access sites in 2007 did suggest that subclavian catheters had lower rates of colonization (defined as culture tip with >103 colony-forming units) and major infectious complications (ie, clinical sepsis with or without bacteremia) when compared to the femoral site.7 As a result of these and other8 studies, the CDC recommends that, if not contraindicated, the subclavian vein should be used for the insertion of nontunneled CVCs in adult patients in an effort to minimize infection risk.

### INFRACLAVICULAR SUBCLAVIAN APPROACH

Prior to the insertion of an infraclavicular subclavian CVC, a small rolled up towel should be placed between the shoulder blades to move the vascular structures more anterior. After the subclavian area has been ...

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