Central venous catheterization
Theo van den Herik VTS (ECC) and Kris Gommeren DVM, MSc, PhD, Dipl. ECVIM-CA (Internal Medicine), Dipl. ECVECC
Central venous catheters
Central venous catheters (CVC) are catheters that reach into the cranial or caudal vena cava and are typically placed in either the external jugular or femoral veins. Central venous catheters exist as single lumen or multi-lumen catheters that allow simultaneous venous access for different purposes, such as:
Failure to properly place or care for a central venous catheter poses significant patient risk. Catheter-related complications must be avoided as much as and detected as early as possible. The number of complications associated with peripheral venous catheter is relatively low, but catheter-related complications associated with central venous catheters occur more frequently and may be more severe. This may be partially explained by the higher frequency of peripheral line placement. Conversely, central venous catheters are less frequently placed, and patients for which these catheters are placed often have multiple conditions predisposing them to complications (e.g., immunodeficiencies, coagulopathies).
Research performed in human medicine on catheter-related complications suggests protocol-based placement and control of the venous and arterial lines significantly reduced morbidity, mortality, and cost.1 Similarly studies in veterinary medicine are lacking, yet a similar effect could be expected.
Instructions for midline or central venous line placement
2% Chlorhexidine solution
10 × 10 cm sterile gauzes
Bandage 5 cm
16G needle or #11 scalpel blade
10 mL syringe
Central venous catheter “Seldinger technique”
Fill the 10 mL syringe and three-way stopcock with 0.9% saline.
Select the vein where the central line will be placed :
Measure how far the central catheter should be advanced into the vein:
Widely shave the area around the vein.
Clean the site with the 2% chlorhexidine solution.
Perform proper hand hygiene and wear sterile gloves.
Catheter placement (video 91.1)
Cover the head or medial side of the femur with a sterile cover just to the opening in the skin.
Temporary occlude the vein and determine its location and trajectory.
Create a small skin opening using the 16G needle or a #11 scalpel blade (fig. 91.1a).
Place the catheter into the vein in the direction of the heart, ensuring blood enters the catheter hub (fig. 91.1b).
Remove the stylet from the catheter.
Feed the guidewire through the needle.
Remove the catheter, ensuring the guidewire remains partially within the vein.
An assistant may apply gentle pressure with sterile gauze at the insertion site to prevent excessive blood loss.
The dilator is fed over the guidewire in order to enlarge the opening in the skin and vein.
Remove the dilator over the guidewire, still ensuring the guidewire stays in place.
Place the central venous catheter over the guidewire as measured previously, aiming for the tip to be located at the 4th intercostal space or as high as possible in the medial saphenous vein. Ensure the guidewire remains accessible before advancing the catheter (fig. 91.2a).
Remove the guidewire, and close the catheter port.
Use a syringe, partially filled with 0.9% NaCl to draw up blood, ensuring all air is removed from the catheter.
Attach a one-way valve or a three-way stopcock to the port.
Cap the port(s) with Combi-Stoppers.
Suture the catheter to the skin (fig. 91.2b).
Adhesive spray can be used on the shaved skin.
Create a square with tape around the insertion site (fig. 91.3).
Place pieces of tape over the catheter wings.
Cover the taped square with a transparent film, leaving the insertion opening visible.
Wrap the intravenous catheter with multiple layers of bandage, ensuring both the catheter and the connection with extension line are covered and protected.
Make sure the extension set runs caudally for ease of manipulation after the procedure.
Label all ports that will be used, clearly indicating their purpose.
Central venous catheters should be thoroughly checked twice daily and whenever a problem occurs. The insertion site should be clean and dry. The insertion site can be cleaned with chlorhexidine solution to reduce the risk of catheter-related infections, although this requires removal of the protective foil. Immediate action should be taken in case of swelling, erythema, hardening of the vein, presence of moisture at the insertion site, pain upon vein palpation or during injection, or abnormal colour and thickness of the skin. In case of strong suspicion (e.g., newly developed and otherwise unexplained hyperthermia) or evidence of infection the central venous line should be removed as early as possible. In such cases it is recommended to perform a bacterial culture of the catheter tip or alternatively of a swap from the insertion site. Upon removal, the insertion site can be cleaned and locally treated with an antibiotic ointment or solution.
All central venous catheter ports should be flushed every four to six hours with normal saline. Heparin solutions were previously advocated but have been found to be associated with several complications such as interactions with other medications, thrombocytopenia secondary to the excessive use of heparin, coagulopathies, thrombosis syndrome, and immunologic reactions.2
Described complications include phlebitis, extravasation of drugs and fluids, catheter or skin infection, air embolism, hemorrhage, and hematomas.
Complication-related problems depend on catheter composition, catheter placement, catheter maintenance, frequency of catheter manipulation and patient-related factors.
Infection, trauma, poor vein quality, coagulopathies are all reasons to consider other vascular access locations or options.
1Guzman Ramos PJ, Fernandez Perez C, et al. Incidence of and associated factors for bacterial colonization of intravenous catheters removed from dogs in response to clinical complications. J Vet Intern Med 32:1084-1091, 2018.
2Less and less use is being made to flush catheters with heparin solutions; normal saline is used instead. Complications were regularly seen with heparin flush, such as interactions with other medications, thrombocytopenia because of use of heparin, increased bleeding tendencies, thrombosis syndrome and allergic reactions.
Central venous catheterization
Video 91.1 Central venous catheterization placement.mp4