SAMS 5100 Page 1 of 5

Intravenous Catheters for the Critical Care Patient: Not Just a Peripheral Issue
SAMS 5100: Introduction to Emergency and Critical Care

Learning Goals from lecture and lab:
1) methods to obtain vascular access and indications for each method.
2) how Poiseuilles Law applies to fluid therapy
3) differences between catheters used for emergency versus ICU
4) indications, uses and drawbacks to central catheters (jugular versus PICC lines)
5) differences between over the needle, through the needle, and Seldinger placement
techniques
6) potential catheter-related complications and how to properly handle a catheter so as to avoid
contamination of the site.

Vascular access

Vascular access is essential for treatment of emergency and critical patients. Vascular access is
needed to facilitate fluid therapy and to administer medications, nutrition, blood products, etc.
Intravenous access is the route of choice under most circumstances. Most commonly,
intravenous catheterization is achieved via direct percutaneous insertion. In patients that are in
shock and have circulatory collapse, veins may be collapsed and nearly impossible to cannulate.
As such, additional techniques for placement are needed. Other methods include 1) a facilitation
procedure to make insertion of the catheter through the skin easier, 2) a mini-cutdown to allow
visualization of the vein for easier catheterization, and 3) an emergency cutdown for
visualization of the vessel and placement of a venotomy (hole in the vein) allowing the catheter
to be slid directly into the vein. These methods are especially useful in emergencies when the
patient has cardiovascular collapse and cannulation with a large bore (diameter) catheter is
required. One of these methods should be employed if attempts at percutaneous catheterization
have failed or are likely to fail and the patient requires immediate vascular access.

In some patients, percutaneous and cutdown techniques may not be feasible due to severe
circulatory collapse, patient size (tiny puppies and kittens, birds), or peripheral venous
thrombosis. In such cases, intraosseous catheters can be placed in the femur, ilium, or humerus.
Most fluids and drugs administered via intravenous routes can be given via intraosseous route.

Because of difficulty in maintaining sterility, venous catheters placed via facilitation or cutdown
techniques are best replaced as soon as possible with another catheter. Intraosseous catheters are
also not used long term under ideal circumstances due to sterility and catheter bandaging issues.

Subcutaneous and intraperitoneal fluid administration routes are not appropriate means of access
for treatment of critical care patients.

Choosing a catheter
Catheters are available in a wide array of lumen sizes, lengths and materials. We can make use of
more than just the single lumen short peripheral catheter for treatment of our patients. In
choosing the appropriate indwelling catheter for your patient, first consider whether you have a
stable or unstable patient. Is the catheter needed emergently? Is the patient ready to arrest? How
long does the proposed catheter take to place? Can the patient tolerate needed restraint or
sedation for proposed catheter? Is the patient hypocoagulable or thrombocytopenic?
SAMS 5100 Page 2 of 5
What are your therapeutic goals? Is the catheter for emergency treatment or maintenance and
monitoring? Do you need central access or will peripheral access do? Do you anticipate frequent
blood sampling? Will you administer hypertonic, phlebitis-associated, multiple or incompatible
infusions? Do you anticipate long or short term use?

Are there contraindications to placement in any site? How accessible is the proposed catheter
site? Is there trauma or skin infection at a proposed site? Will the patient have bandages, casts or
surgery that may preclude appropriate catheter care? Is there significant risk of infection at the
site due to vomiting, diarrhea, polyuria or skin infection or wounds? Is there a high risk for
thrombosis such as in small veins, veins crossing joints or in patients with increased clotting
tendencies (hypercoagulable)?

Peripheral versus central catheters
For unstable patients and emergency treatment, short peripheral catheters are the first choice
due to mechanics of fluid flow through vessels as defined by Poiseuilles Law:

Q= rate of flow
Q = Pr
4
P= pressure difference between ends
8l r = radius
l = length of vessel
= viscosity of blood/fluid

Rate of flow is directly proportional to the fourth power of the radius of the catheter and
inversely proportional to the length of the catheter. Therefore, the wider and shorter the catheter,
the faster the flow. If these cannot be inserted quickly via a percutaneous technique, cutdown
access or intraosseus access should be considered.

Central catheters are the catheters of choice for long term therapy, hypertonic infusions, TPN,
multiple or incompatible infusions, for routine blood sampling, and for central venous pressure
monitoring (CVP). I routinely recommend a central (usually multi-lumen) catheter for critical
patients such as those with severe disease including sepsis, septic shock, septic or bile peritonitis,
severe pancreatitis or diabetic ketoacidosis (DKA), oliguric (low urine production) renal failure,
and shock unresponsive to fluid boluses. Central catheters are made of soft, flexible material (eg,
polyurethane or silicone) which is less thrombogenic and less irritating to the vessel and likely
more comfortable for the patient. Some are antibiotic or anticoagulant impregnated and most are
radiopaque. Long term use (days to weeks) is possible with appropriate care. Since these
catheters are located in a central vessel, blood flow is relatively rapid at the tip, allowing
administration of hypertonic or viscous solutions such as TPN. These catheters also facilitate
frequent blood sampling with minimal distress to the patient.

There are two primary types of central catheters. One is the jugular catheter and the other is the
Peripherally Introduced Central Catheter or PICC line (pronounced as pick). In theory, PICC
lines can be inserted into any peripheral vessel and advanced into the central venous circulation.
Typically, they are placed in the saphenous veins and enter the caudal vena cava. Why chose one
over the other? Jugular catheters should be chosen if Central venous pressure (CVP, a measure of
vascular volume) measurements are needed. To ensure accurate CVP measurements, the
catheter should be long enough such that it ends just in front of the right atrium. Measure prior to
placement you can always make the catheter a little shorter but you cant make it grow once
SAMS 5100 Page 3 of 5
its in! Although caudal caval catheters can be used to trend CVP, they do not give accurate
absolute numbers. A PICC catheter is preferred over a jugular catheter in patients with hypo- or
hypercoagulability. Obviously, trauma or infection at the insertion area would preclude
placement at that site. Frequent diarrhea or polyuria may make PICC lines a less optimal choice.

Catheters are available in several lengths and sizes and all have some additional means of
shortening length. Catheters are also available in single, double, and triple lumens.

Catheter Materials

Catheters come in a variety of materials that vary in their stiffness, reactivity and
thrombogeneity. These characteristics influence ease of handling, insertion, and tendency for
phlebitis and thrombosis. Stiff catheters are easier to insert, but are prone to kink at the insertion
site and cause phlebitis due to the stiff catheter end rubbing against the inside of the vessel.
Flexible catheters require a stylet to pass but are less problematic once placed.

Material Reactivity Stiffness Thrombogenicity
Teflon 2+ 4+ 2+
Polyether based polyrurethane 1+ 2+ 1+
Polyester based polyurethane 2+ 3+ 2+
Polyvinyl chloride 4+ 3+ 3+
Polyethylene 3+ 3+ 3+
Polypropylene 3+ 3+ 3+
Silicone 1+ 1+ 1+
From Dibartola, Fluid Therapy in SA practice, 2nd ed, 2000

Catheter Placement
Catheter placement techniques include over the needle, through the needle and modified
Seldinger.

Over the needle catheters are most commonly used for peripheral placement of short, stiff
catheters. This method is quick and easy.

Placement of through-the-needle catheters is used primarily for central lines, especially long
catheters made of flexible material. This method involves percutaneous venipuncture with a
large bore needle followed by threading the catheter into the vessel through the center of the
introducer needle. These catheters are easy to place but require a considerably larger introducer
needle than the catheter which passes through it. As such, placing through-the-needle catheters in
some hypotensive or edematous patients can be more difficult. Some patients will experience
minor bleeding after placement of through- the-needle catheters since the catheter is smaller than
the hole through which it was introduced. Some through-the-needle catheters have peel away
SAMS 5100 Page 4 of 5
needles that can be removed, allowing the entire length of the catheter to be placed in the vessel
with the catheter base sutured directly to the skin. Other through-the-needle catheters have
needles that cannot be removed. To secure the catheter, the catheter and needle are backed out of
the skin slightly and enclosed in a plastic needle guard. The needle guard is then secured to the
patient using tape, suture, and bandaging. This type of catheter is prone to backing out of the
vessel, inadvertent removal, and kinking where it exits the skin. Protective bandages are also
bulky since they must incorporate and stabilize the needle guard. Be sure to look at these
catheters in lab.

Seldinger technique is also called the over the wire technique. This method is used to place an
assortment of central lines and arterial catheters, especially soft, flexible catheters that need a
stylet to introduce. The Seldinger technique looks complicated, but is actually very easy once
practiced. Seldinger technique has the benefit of being able to use a small introducer catheter
compared to the size of the indwelling catheter.


Catheter management
All catheters should be placed using aseptic technique. Using poor technique during placement,
handling the catheter with contaminated hands afterwards, or allowing the catheter site to
become wet, dirty, or contaminated will shorten its usable life. As such, we practice strict
handwashing and gloving prior to placement or manipulation of any catheter.

Central catheters should be placed using STRICT sterile technique. The site should be sterilely
clipped, prepped and draped and sterile gloves should be worn to place the catheter. After
placement, hands are washed and gloved prior to handling the catheter. If gloved hands have
touched other parts of the patient or equipment (including pumps, floors, etc), new gloves should
be donned prior to handling the catheter. The bandage and insertion site should be checked at
least twice daily. In the average patient, the bandage should be changed once daily.

Complications
Complications related to indwelling catheters include hemorrhage, phlebitis, thrombosis,
thromboembolism, air embolism, catheter embolism, infection, and extravasation of drugs and
fluids. The embolic and thrombotic complications are more commonly seen with central lines.
Also, be aware that central catheters are long and the wires are springy it is very easy to
contaminate the catheter or wire if it uncoils and hits you, the patient or another non-sterile area.
Always be aware of the location of the catheter and all its parts.

Extravasation of drugs and fluids from the vein or around the catheter is a common
complication. This occurs secondary to puncture by stiff catheters or introducer needles.
Extravasation is marked by swelling, pain, redness, heat, bruising, and in severe cases,
oozing of the skin, necrosis and sloughing. The type and amount of extravasated fluid
dictates the magnitude of the reaction. In central catheters, fluid can also extravasate into
the chest or pelvis/abdomen, if the vein is punctured, usually by aggressive manipulation of
the stylet or wire.

Thrombosis is especially common in peripheral catheters. Trauma induced by the catheter
rubbing against the vascular endothelium can cause thrombus formation. Animals at risk
for thrombosis, such as patients with Cushings disease and those with certain types of
SAMS 5100 Page 5 of 5
protein loss, may also form clots at sites of catheters. This can be especially dangerous if
large clots form around central lines, as the clots can dislodge and move into the heart or
lungs (pulmonary thromboembolism). The incidence of thrombosis may increase with
prolonged dwell-time of the catheters, and is not uncommon in many critically ill patients,
including horses, who may experience thrombosis of one or both jugular veins.


Phlebitis is inflammation of the vessel at the catheter site. This can be caused by
mechanical trauma, chemicals (drugs), or infection at the catheter site. Thrombophlebitis is
inflammation and clot formation at the site of inflammation. Signs of
phlebitis/thrombophlebitis include tenderness or pain, a hard ropey feel on palpation of
the vessel, redness, swelling, and pain upon flushing of the catheter. Mechanical damage is
minimized by choosing catheters made of soft and non-thrombogenic materials and
securing the catheter adequately to prevent excessive in-and-out motion. Drugs such as
hypertonic solutions (hypertonic saline, >5% Dextrose) or valium (or other drugs dissolved
in propylene glycol) can be irritating to the endothelium. Dilution and a limited duration of
administration may help prevent phlebitis.

Infection is most often caused by migration of surface skin bacteria along the catheter into
the catheter site and vein. Proper hand hygiene (hand washing and gloving) is a must to
prevent contamination of fluid lines and hubs. Signs of infection are similar to those of
phlebitis, and the two can be difficult to differentiate. Fever, leukocytosis and exudates
may help identify an infection. Catheter infection should be suspected in any animal with a
catheter and an unexplained fever, even if the site looks okay. The catheter should be
removed and cultured.

Air embolism can occur if large quantities of air are accidentally infused into the
circulation, especially if the fluid bag contains a lot of air and is forced in via a rapid
infuser (pressure bag). Catheter embolism occurs most commonly with through the needle
catheters when the catheter is lacerated by the tip of the introducer needle.