Lines and Catheters

Hospital Medicine Editor: Manasa Atyam, MD
Reviewed by: Chase J. Webber, DO
Secton Editor: Marium Hashemi

General Guidance

  • Primary goals of line/catheter management:
    • Know why it was placed
    • Know where it is going (venous, arterial, potential space)
    • Know what needs to happen before it can be removed
  • Key principle: lines should only be placed when medically necessary and removed as medically appropriate 
  • Infection risk: all foreign objects risk introducing microbes during placement or becoming a nidus for growth 
  • Note: this chapter does not include additional forms of invasive monitoring devices (i.e., Swan Ganz catheters), surgical/procedural drains, or support devices (i.e., endotracheal tubes, ventricular assist devices, etc.) as these typically require subspecialty consultation/management

Urinary Catheters

  • Indications: 
    • Surgery, immobilization, urinary retention 
    • Strict I/O monitoring (critical illness, diuresis) 
    • Open sacral/perineal wounds with incontinence 
  • Key Management Points: 
    • Chronic foleys: exchange on admission 
    • Duration of use: biggest CAUTI risks; assess daily for need 
    • Obstruction concerns: urgent urology consult 
    • Consider coude catheter for difficult placement (especially BPH) 
  • Removal Criteria: 
    • Ability to void independently (with PVR follow-up) 
    • Resolution of placement indication 
  • Alternatives: 
    • Purewick catheter 
    • Condom catheter 
  • Complications: 
    • Traumatic placement 
    • CAUTI

Central Venous Catheter (CVCs)

  • Types of Central Access: 
    • Non-tunneled CVCs: internal jungular (IJ), subclavian, femoral 
    • Peripherally Inserted Central Catheters (PICCs): single lumen (most patients) vs double lumen (ICU, chemo, TPN)
    • Tunneled/Indwelling catheters: Hickman lines, ports (placed by IR/surgery for long-term intermittent access)
  • Indications: 
    • Vasoactive infusions (pressors, inotropes) 
    • Long-term antibiotics, TPN 
    • Inability to obtain peripheral access 
    • Caustic agent administration (chemotherapy, certain antibiotics) 
  • Insertion Complications by Site: 
    • Femoral: highest infection risk 
    • Subclavian: pneumothorax risk 
    • All sites: arterial cannulation, air embolism, thrombosis, malposition 
  • Removal Criteria: 
    • Discontinuation of agents requiring central access 
    • Transition to comfort care 
    • Concern for CLABSI 
  • Alternatives: 
    • Peripheral IV access (consider ultrasound-guided) 
  • What Medicine Residents Place: 
    • IJ, femoral CVCs (subclavian typically avoided on floors) 
    • PICCs (often placed by IR or PICC team)

Arterial Lines

  • Indications: accurate blood pressure measurement, frequent arterial blood draws (ABG)
  • Potential complications: arterial occlusion (spasm, thrombus), with resultant ischemia, hematoma formation
  • Criteria for removal: resolution of placement criteria

Feeding Tubes

  • What Medicine Residents Can Do: 
    • Place dobhoff (nasogastic/nasoenteric) tubes 
    • Replace mature G-tubes (tract already established) 
  • Troubleshooting: 
    • Malposition/not functioning: EGS consult 
    • Skin breakdown: wound consult 
  • G-tube Study Protocol: 
    • Administer 30 mL Gastrogaffin via tube (resident often must push) 
    • Obtain KUB
  • When to Escalate to IR/Surgery: 
    • New G-tube or GJ-tube placement 
    • Immature tract complications 
    • Complex repositioning
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