Central venous catheterization
In medicine, central venous catheterization (CVC or central venous line) is "placement of an intravenous catheter in the subclavian, jugular, or other central vein for central venous pressure determination, chemotherapy, hemodialysis, or hyperalimentation.". A catheter is placed into a large vein in the neck, chest or groin. This is inserted by a physician when the patient needs more intensive cardiovascular monitoring, for assessment of fluid status, and for improved of intravenous infusions of medications or fluid therapy. The most commonly used veins are the internal jugular vein, the subclavian vein and the femoral vein. This is in contrast to a peripheral catheterization which is usually placed in the arms or hands.
How to insert
- hand washing
- full-barrier precautions during the insertion
- cleaning the skin with chlorhexidine
- avoiding the femoral site if possible
- removing unnecessary catheters
If after the insertion the chest radiography shows that the vertical distance from the CVC tip to the carina is more than 55 mm, the line may have been inserted too far.
Ultrasonographic guidance may reduce complications.
How to remove
If an air embolism occurs, positioning the patient in the left lateral decubitus or Trendelenburg positions may help. Administering intravenous fluids and supplmenental oxygen may help. The air can be aspirated with a new central venous or pulmonary arterial catheter. More details are available.
27% to 67% of patients may have catheter-associated deep vein thrombosis. A meta-analysis found that "anticoagulant prophylaxis is effective for preventing all catheter-associated deep vein thrombosis in patients with central venous catheters. The effectiveness for preventing symptomatic venous thromboembolism, including pulmonary embolism, remains uncertain."
If the central line needs to remain for drug administration, then thrombolysis may be used. If the line is no longer needed, the catheter is removed after 3-5 days of anticoagulation. Clinical practice guidelines by the American College of Chest Physicians agree for neonotes (ACCP states the recommendation is a "Weak recommendation, low or very low-quality evidence, Grade 2C") , but anticoaguation is not specified for adults. Anticoagulation should be continued for at least 3 months.
Air embolism may occur when a catheter is removed - see section above on removal.
Embolism of catheter fragment
A catheter fragment may embolize. This may be due to pinch-off syndrome (catheter constricted between clavicle and first rib), catheter removal, catheter disconnection, and catheter rupture . This may manifest at catheter malfunction, arrhythmia, pulmonary symptoms, or septic syndromes.
All catheters can introduce bacteria into the bloodstream, but CVCs are known for occasionally causing Staphylococcus aureus and Staphylococcus epidermidis sepsis. The incidence of staphylococcal infections is decreasing.
A patient with a central line, fever, and no obvious cause of the fever may have catheter-related sepsis. A meta-analysis found "Paired quantitative blood culture is the most accurate test for diagnosis of IVD-related bloodstream infection. The cultures are compared for number of colonies with line infection indicated by 5:1 ratio (CVC versus peripheral). However, most other methods studied showed acceptable sensitivity and specificity (both >0.75) and negative predictive value (>99%)".
Quantitative cultures are not commonly available. Alternatively, paired qualitative cultures in which time to positivity is assessed with line infection indicated by cultures that are positive 2 hours before peripheral cultures.
This analysis did not include Gram stain and acridine-orange leucocyte cytospin test (AOLC) of 100 microliters of catheter blood (treated with edetic acid) which one group of investigators proposes. 
The American Centers for Disease Control and Prevention recommends again routine culturing of central venous lines upon their removal. However, the three cited studies do not directly address the validity of this practice.
Generally, antibiotics are used, and occasionally the catheter will have to be removed. In the case of bacteremia from staphylococcus aureus, removing the catheter without administering antibiotics is not adequate as 38% of such patients may still develop bacterial endocarditis.
Prevention of complications
A "chlorhexidine gluconate–impregnated sponge (CHGIS) in intravascular catheter dressings may reduce catheter-related infections" whereas changing unsoiled dressings every 3 versus every 7 days may not matter according to a factorial randomized controlled trial. 
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