Strict indication:
A central access is indicated if it is necessary to infuse solutions and medications that have an irritating effect on veins as well as for high-calorie infusions, particularly in the context of parenteral nutrition. The infusion of circulatory and cardiac medications with a short half-life, especially catecholamines, typically requires the placement of a central venous catheter. The lack of options for creating a peripheral infusion port is a mandatory indication as well. The indication for creating a central venous access should be weighed against the associated potential complications and risks. Arterial catheters are needed for blood gas analysis and continuous blood pressure monitoring. In patients with acute lung failure, placing both kinds of catheters is typically unavoidable. Peripheral indwelling catheters, compared to central venous catheters, generally present a much lower risk of infection and intervention. Thanks to their shorter lengths, they also offer a higher infusion volume over time, even with the same lumen.

Puncture sites:
The primary puncture site for placing an arterial catheter is the radial artery. If that should not be possible, it should be placed in the femoral artery. The brachial artery should only be considered if no other options are available. Catheters are placed with the Seldinger wire technique, using sterile precautionary measures. The primary puncture sites for a central line are the left internal jugular vein and the subclavian vein bilaterally. If possible, puncturing the femoral vein should be avoided for hygienic reasons, while the right internal jugular vein should be saved for the potential placement of ECMO cannulas. The complication rate of central access catheters can be reduced with ultrasound control. Ultrasound should therefore be used for any procedure involving the placement of a central line. The number of central line lumina should be as small as possible. Lumina that are not used must be continuously perfused with 5 mL/h of NaCl. Changing a central line by using an existing Seldinger wire is prohibited!

Procedure:

1. Assistance from a second person wearing personal protective equipment (PPE)

2. Perform hand hygiene

3. Disinfection of work surfaces with wipes

4. Optimal patient positioning

5. If necessary, hair removal with a clipper

6. Skin disinfection with octeniderm, minimum exposure time 1 minute

7. Open catheter kit and place items on work surface without touching the sterile areas

8. Perform hand hygiene

9. Put on sterile gown and sterile gloves

10. Area covered with sterile drapes, repeated skin disinfection

11. Sterile placement of the central line on the sterile catheter kit

12. Local anaesthesia

13. Venipuncture with the Seldinger method without pre-puncture; in the case of ultrasound-guided puncture, the probe is kept in a sterile sheath that also covers the cable. Catheter placement with Alphacard

14. Aspiration and flushing of all lumina with NaCl, sterile closure of all lumina

15. Attach catheter with central line tape; sutures should only be used if attachment by tape is contraindicated

16. Every newly created central line should be checked with x-ray imaging as soon as possible if there is no expertise for position control by ultrasound. Retract the catheter if its end is located in the right atrium.

17. After placing the central line, perform a pulmonary ultrasound to rule out pneumothorax (see SOP 3.5.2 Chest ultrasound - pneumothorax)

Complications associated with placing a central venous catheter:
• Puncture of the apical pleura and lung with pneumothorax (subclavian and internal jugular vein)
• Haemothorax and haemomediastinum
• Puncture of arterial vessels (carotid artery, subclavian artery, vertebral artery) with risk of bleeding, formation of a false aneurysm, arteriovenous fistula
• Puncture of lymphatic vessels with chylothorax and chylomediastinum
• Catheter misplacement (e.g. in the pleural space, resulting in “infusion thorax” - pleural effusion)
• Nerve injuries (brachial plexus, vagus nerve, phrenic nerve, cervical plexus, stellate ganglion)
• Catheter infection and sepsis
• Thrombosis
• Triggering extrasystoles when advancing the Seldinger wire or the catheter into the right atrium or ventricle
• Air embolism

Handling:
A separate (or arterial) access should be used for blood samples and transfusions

Catheter care:
• Avoid unnecessary manipulation at the catheter
• Aseptic conditions for injections and blood samples via the catheter
• Sterile dressing
• Daily inspection of the puncture site (signs of inflammation) and dressing change
• Reduce connection pieces and three-way stopcocks to a minimum; change every 24 hours.
• When disconnecting the central line from the infusion system, apply spray disinfectant to the
catheter connector before reconnecting.
• Use the plugs of three-way stopcocks only once
• Control of biochemical infection parameters -> catheter change

If an infection-related catheter change is necessary, submit the catheter tip–removed under sterile conditions–for microbiological analysis.
Changing the central line with the Seldinger wire in the same place is not permissible.

Central line removal:
Any central line that is no longer needed should be removed immediately. Central lines are not changed routinely. Any indwelling central lines must be changed in case of skin redness, other signs of inflammation or blocked lumina. Venous catheters that had to be placed in emergency conditions without adequate antiseptic measures should be changed as quickly as possible.

Ventilation and intensive care therapy for COVID-19
Manual for all medical practitioners. Working with ventilated critical pathogen spectrum patients
Kremeier, Peter; Pulletz, Sven; Woll, Christian; Oczenski, Wolfgang; Böhm, Stephan
2021, 138 pages, DIN A4