Central venous lines (CVL) play an important role in accessing the central venous system, particularly in patients requiring prolonged treatments such as chemotherapy, parenteral nutrition, or antibiotic therapies. These devices, inserted into large-caliber veins (internal jugular, subclavian, femoral), guarantee a high venous flow rate thanks to their precise positioning at the junction of the superior vena cava and the right atrium.

The placement of a central venous catheter is a delicate procedure, performed under radiological control for optimal positioning. It requires rigorous asepsis and constant monitoring to avoid complications such as infections or thrombosis. For nurses, mastering insertion techniques, associated care, and recognizing at-risk situations is essential for the patient's well-being.

This guide details the key principles of CVCs, the types of catheters (CVC, port catheter, implantable catheters), the insertion techniques and the skills required for effective use in a hospital or home setting.

Fundamental Principles of Central Venous Access

Anatomical and physiological understanding

Central venous lines use large-caliber veins, such as the internal jugular vein, the subclavian vein, or the femoral vein, to insert a central venous catheter. These central veins connect to the superior vena cava, carrying blood directly to the right atrium of the heart. This configuration allows for rapid and effective administration of treatments.

The size and depth of these veins, combined with the near absence of valves, promote both the passage and correct positioning of the central catheter, while reducing the risk of obstruction. A perfect mastery of this anatomy is essential to ensure correct catheter placement and limit complications related to its use.

Clinical indications

The placement of a central venous line is indicated in many major clinical situations. These indications include:

• The administration of chemotherapy in patients with cancer.
• Parenteral nutrition requiring a durable device.
• Prolonged antibiotic treatments.
• The monitoring of central venous pressures or rapid, large-volume infusions.

It is also recommended in cases where peripheral venous access is difficult or impossible to use, or for certain repeated blood samples. Each indication should be subject to a rigorous evaluation of risks and benefits by the care team.

Risks and complications

Despite their usefulness, central venous catheters present risks that it is essential to be aware of and prevent. Catheter-related infections are the most frequent and dreaded complication, with the potential to evolve into serious systemic infections.

Other risks include:

• Venous thrombosis associated with the presence of the catheter.
• The risk of pneumothorax during puncture of the subclavian vein.
• Cardiac arrhythmias if the catheter is incorrectly positioned.

To minimize these complications, rigorous monitoring of the insertion site, meticulous aseptic care, and systematic radiological control are essential.

Types of central venous lines

PICC Line

The PICC Line, or peripherally inserted central catheter, is inserted into a deep vein in the arm, usually above the elbow crease, such as the basilic or cephalic vein. This type of central venous catheter is guided to the cavoatrial junction, ensuring reliable access for long-term infusions, often up to six months.

It can be equipped with one or more lights and is held in place by a fixation system such as Stat-Lock or Grip-Lock. The dressing must be changed sterilely and regularly to limit the risk of infection.

Implantable port (Port-a-Cath)

The implantable port, also called Port-a-Cath, is a type of central catheter fully implanted under the skin. It consists of a metallic reservoir connected to a central venous catheter inserted into a central vein such as the internal jugular vein or the subclavian vein. This device is particularly appreciated for its discretion and comfort, offering durable central venous access without the need for daily care at an exposed insertion site.

It is frequently used in oncology for chemotherapy or parenteral nutrition, thus reducing the risk of infections related to the access site.

Peripherally inserted central catheter (PICC or Broviac)

The peripherally inserted central catheter, commonly called Broviac (but also Hickman or Groshong depending on the models), is a tunneled central venous catheter. It is inserted into central veins such as the internal jugular vein or the subclavian vein. This type of catheter is designed for prolonged treatments, with part of the device passing under the skin before reaching the central vein, which reduces the risk of infection at the entry point.

It is widely used in pediatrics and for patients requiring intensive and prolonged treatments, such as certain chemotherapy or parenteral nutrition protocols.

Integration and care techniques

Sterile insertion technique

The placement of a central venous catheter must be performed under strictly sterile conditions to minimize the risk of infection. This involves careful hand washing with a hydroalcoholic product, wearing sterile gloves, a mask, a gown, and a cap. The puncture site is prepared by a rigorous 5-step antisepsis, with application of a suitable antiseptic and complete drying.

The use of a sterile field is essential before insertion, which is often performed under ultrasound guidance and radiological control. Orienting the bevel of the needle at approximately 10-30 degrees during vein penetration allows for precise insertion and minimizes venous trauma.

Wound dressing management

The dressing at the insertion site must be performed using strict aseptic techniques. After each manipulation, the old dressings should be carefully removed, a new antisepsis should be performed, moving from the center to the periphery, and then a sterile transparent semi-permeable dressing should be applied.

This type of dressing allows for visual monitoring of the central venous site without having to remove it frequently. The frequency of dressing changes depends on the protocol in place, but should not be too close together to limit contamination, unless there are signs of infection or detachment.

Administration of medications and solutions

Administration via a central catheter involves connection to a sterile closed system, often using a secure connector. Lines must be systematically purged before and after the passage of solutions, using sterile 0.9% NaCl syringes, to prevent clot formation and maintain patency. Some multi-lumen catheters allow for the simultaneous co-administration of incompatible treatments.

Rigorous flow control, correct line identification, and adherence to infusion protocols are essential for patient safety.

Prevention of healthcare-associated infections

Preventing infections associated with central venous catheters relies on a set of strict measures: hand washing before any manipulation, careful antisepsis of the site and connections, use of sterile equipment, and minimization of openings in the venous circuit. Regular monitoring of the insertion site to detect redness, pain, exudate, or swelling is essential.

If infection is suspected, the medical team should be alerted early and appropriate tests should be performed, including bacterial cultures of the catheter. Continuing education and adherence to best practices are essential to reduce the risk of infection and ensure optimal health for patients with central venous lines.

Communication with patients

Explanation of procedures

It is essential to take the time to clearly explain to patients the nature and procedure of inserting a central venous catheter. By detailing the different steps, the medical reasons justifying this intervention, as well as the benefits and potential associated risks, you help to establish a climate of trust.

An explanation adapted to their level of understanding also helps to reduce their anxiety and prepare them mentally for the procedure.

Managing expectations and concerns

Patients with central venous lines may have legitimate concerns about pain, limitations in their daily activities, or the risk of infection. Your role is to listen attentively to their concerns, answer their questions with empathy, and provide clear and factual information. By communicating transparently, you help the patient better manage their expectations and collaborate more actively in their care pathway.

Training on home care

An important part of preventing complications iseducating patients about home care. It's vital to teach them how to recognize signs of infection or catheter malfunction, the need to avoid unauthorized manipulation of the device, and good hygiene practices.

Informing the patient about the importance of keeping check-up appointments and reporting any anomalies helps to improve the effectiveness of monitoring and to guarantee the safety of patients with a central venous line.

Skills specific to the use of different routes

Role in parenteral nutrition

Parenteral nutrition requires reliable central venous access, capable of supporting the infusion of hyperosmotic solutions over the long term. Devices such as tunneled central venous catheters (CVCs), PICC Lines or implantable ports such as Port-a-Cath are preferred for this function. Their secure implantation and rigorous maintenance are essential to prevent complications such as thrombosis or infections. These devices guarantee continuous and adapted administration of essential nutrients to the patient, especially when the digestive tract is deficient or impractical.

Role in chemotherapy

In the context of cancer treatments, central catheters play a fundamental role. They allow the administration of cytotoxic drugs, which are often corrosive and require stable, deep, and long-lasting venous access. This helps reduce the risk of complications such as phlebitis.

Implantable ports, such as Port-a-Cath, are particularly appreciated for their comfort and discretion, making repeated infusions less burdensome for the patient. Mastering the specificities of these devices, from their placement to their removal, is essential to ensure safe and effective care for cancer patients.

Role in chronic pain management

Central venous lines are also essential in the management of severe chronic pain. They facilitate the administration of powerful analgesics on a continuous or intermittent basis. Through central venous access, controlled infusions allow for optimal control of pain in patients suffering from intractable pain, while avoiding multiple peripheral venipunctures.

To ensure appropriate care, nurses must master the specificities of these catheters, in particular to adjust the dosage, prevent potential complications and offer personalized follow-up to each patient.

Conclusion

Central venous lines are essential devices in nursing care. They allow the administration of complex treatments such as chemotherapy, parenteral nutrition, or the management of chronic pain. Their implementation and maintenance require an in-depth knowledge of anatomy, the use of rigorous sterile techniques, and constant vigilance to prevent risks of infection.

As a nurse, mastering these specific skills is essential to guarantee the safety and comfort of your patients. Do not hesitate to deepen your knowledge and scrupulously apply best practices in order to optimize the quality of care.

FAQ

What are the main indications for central venous access?

The placement of a central venous line is primarily indicated for the administration of heavy and prolonged treatments such as:

• Chemotherapy
• Parenteral nutrition
• Long-term antibiotic therapy
• Administration of blood or blood products
• Pressure monitoring
• Fast filling
• Cases of impossible or difficult peripheral venous access

What contraindications should I be aware of before inserting a central venous catheter?

The major contraindications to the placement of a central venous catheter include:

• Active infection at the site
• Major coagulation disorders
• Skin alterations (burns, irradiation)
• History of phlebitis
• Anatomical malformations
• Severe thrombocytopenia
• Presence of implanted material

Furthermore, the absence of an indication also constitutes a contraindication.

What are the essential gestures and precautions for handling and maintaining a central venous catheter?

To manipulate a central venous catheter, it is essential to maintain rigorous hygiene:

• Wash hands thoroughly
• Wearing sterile gloves
• Use sterile equipment
• Disinfect the site with alcoholic chlorhexidine

It is important to avoid any resistance during injection, to handle devices gently, and to monitor for signs of infection.

The dressing must remain aseptic and be changed according to the protocol in effect.