- Administration of vesicant or irritant medications that either damage smaller peripheral veins, or would be destructive to local tissue if a peripheral IV failed and the medication extravasated during infusion
- Total parenteral nutrition
- Poor peripheral IV access
- CVC may be preferential to PICC in many scenarios because PICC is associated with 5% rate of DVT compared to only 1% with CVC. CVC and PICC have the same rate of catheter related blood stream infections. 1
- Situations to consider CVC over PICC include2
- GFR < 45, to preserve future AV fistula sites
- Severe illness
- Access needed < 14 days
- Renal replacement therapy, plasmapheresis, or apheresis
- Transvenous pacing
- Mixed venous O2 monitoring or CVP monitoring
- Pulmonary artery catheter placement
- Thrombus of target vessel
- Always check for 100% compressibility of the target vein.
- Review previous vascular ultrasound reports and procedure notes for signs of DVT or stenosis
- Infection over the target vessel
- Severely agitated patient
- Consider IO placement and sedation prior to placing a CVC in an uncooperative patient
- Coagulopathy ³
- Most studies have not shown that coagulopathy does not increase the risk of CVC complications in experienced operators. Despite this, the general consensus is to attempt to correct coagulopathies prior to elective CVC (platelets > 50,000, INR < 2.0).
- The need for urgent/emergent placement may require cannulation despite the presence of a coagulopathy. The patient and/or family should be consented and it the increased risk should be documented.
- Pro Tip: For patient with high risk of bleeding, use the micro puncture kit, which has a 21 gauge needle instead of the standard 18 gauge needle.
- Pro Tip: If placing a CVC in a patient with marked uremia (BUN > 60), consider Desmopressin 0.3mcg/kg immediately before the procedure. The effect only lasts an hour or so, and this transient activation of platelets only works once. Additional doses within the same day are ineffective.
- Coagulopathy is a contraindication to a subclavian vein CVC since this is a non-compressible source of bleeding.
- Inability to tolerate ipsilateral pneumothorax
- If a patient is in severe respiratory distress and/or maximum ventilator support, then an iatrogenic pneumothorax would likely be deadly. In these scenarios, consider femoral CVC.
- If the patient has unilateral lung disease (e.g. pneumothorax, hemothorax, unilateral lung transplant), attempt to place the CVC on the side of the bad lung to prevent injuring the good lung.
- IVC filter
- Avoid femoral CVC because, theoretically, a wire could become entangled in the IVC filter.
- Simonov, Michael, et al. “Navigating venous access: A guide for hospitalists.”Journal of Hospital Medicine 7 (2015): 471-478.
- Eisen LA, Narasimhan M, Berger JS, et al. Mechanical complications of central venous catheters. J Intensive Care Med 2006; 21:40.
- Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous Image guided Interventions