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KEY POINTS

  • he subclavian and internal jugular approaches are preferred for the placement of central venous catheters (CVCs).

  • Real-time two-dimensional ultrasound reduces the mechanical complications associated with CVC insertion.

  • A bundled approach including education on CVC insertion and maintenance, use of maximal sterile barriers, and chlorhexidine-based skin antiseptic solutions reduces the incidence of catheter-related bloodstream infections.

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

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

INTRODUCTION

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 United States 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 parenteral 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.

SELECTION OF INSERTION SITE

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 to simultaneously administer vasoactive drugs and antibiotics. Most evidence suggests that the number of catheter lumens does not affect the rate of infectious complications; however, current Infectious Diseases Society of America (IDSA) guidelines do recommend using a CVC with the minimum number of ports or lumens deemed necessary for the management of a given patient (Category IB recommendation).2–4 Once the type of catheter has been selected, an anatomic site for insertion needs to be determined. The optimal anatomical location for the insertion of CVCs has been a matter of debate for many years. In a 2001 study, 289 patients were randomized to have CVCs inserted in either the femoral vein (FV) or the subclavian vein (SCV).5 Patients with FV 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 SCV catheters. The overall sum of mechanical complications (arterial puncture, pneumothorax, hematoma or bleeding, air embolism) was similar between the two groups. To date, there is no randomized trial comparing SCV versus internal jugular (IJ) catheters with regard to infectious complications. Though most observational studies suggest a lower rate of infectious complications with SCV catheters and a similar rate of mechanical complications,6,7 a recent study comparing incidence of CVC-related bloodstream ...

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