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Indications for and complications of central venous catheters Author

Indications for and complications of central venous catheters

Author
Michael Young, MD

Section Editor
Scott Manaker, MD, PhD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS

Disclosures

Last literature review version 19.3: Fri Sep 30 00:00:00 GMT 2011 | This topic last updated: Thu Nov 11 00:00:00 GMT 2010 (More)

INTRODUCTION — Insertion of a central venous catheter (CVC) in a human was first reported by Werner Forssman, a surgical intern, who described canalizing his own right atrium via the cephalic vein in 1929. A technique that facilitates catheter placement into lumens and body cavities was subsequently introduced by Sven-Ivar Seldinger in 1953 [1]. Insertion of a CVC using the Seldinger technique has revolutionized medicine by allowing the central venous system to be accessed safely and easily [2].

CVCs are now common among critically ill patients. More than five million central lines are inserted each year in the United States alone [3]. Multi-lumen central venous catheters have become ubiquitous in the intensive care unit (ICU). New catheter designs and standardization of insertion techniques have reduced complication rates.

Indications, strategies to prevent complications, mechanical complications, and catheter removal are discussed here. The placement of CVCs and CVC-related infectious and thrombotic complications are discussed separately. (See “Placement of central venous catheters” and “Diagnosis of intravascular catheter-related infections” and “Prevention of intravascular catheter-related infections” and “Pathogenesis of and risk factors for central venous catheter-related infections” and “Catheter-induced upper extremity venous thrombosis”.)

INDICATIONS — Common indications for placement of a CVC include:

  • Hemodynamic monitoring — A CVC permits measurement of the central venous pressure and the venous oxyhemoglobin saturation. In addition, it provides a conduit for insertion of a pulmonary artery catheter. (See “Insertion of pulmonary artery catheters”.)
  • Administration of medications — Many medications (eg, vasopressors, chemotherapy, TPN) are administered by a central venous catheter because they can cause phlebitis when given through a peripheral intravenous catheter.
  • Transvenous cardiac pacing.
  • Plasmapheresis, apheresis, hemodialysis, or continuous renal replacement therapy.
  • Poor peripheral venous access.

Volume resuscitation does not require a CVC if sufficient peripheral intravenous access can be obtained (eg, 14- or 16-gauge intravenous catheters). In fact, peripheral intravenous catheterization may be preferable because a greater flow rate can be achieved through a shorter catheter, assuming the catheters are of equal diameter. As an example, the maximal flow rate through a 16-gauge catheter whose length is 2.5 inches, is twice the maximal flow rate through the 16-gauge port of an eight inch CVC [4]. When a CVC that is 8.5 French or larger (ie, an introducer) is used, the intravenous tubing becomes the rate limiting factor, not the CVC. With rapid infusion devices, flow rates up to one liter per minute are possible. (See “Treatment of severe hypovolemia or hypovolemic shock in adults”.)

PREVENTING COMPLICATIONS — Central venous catheterization should be performed with the patient carefully positioned, using sterile conditions and topical analgesia. An experienced operator, ultrasound guidance, and nursing supervision are preferable, if available.

Infection — In a large, prospective cohort study, the following five steps (sometimes called the Pronovost checklist) reduced CVC-related bloodstream infections when instituted together [5]. (See “Prevention of intravascular catheter-related infections”, section on ‘Catheter teams and use of checklist’.)

  • Hand hygiene — An alcohol sanitizer or antimicrobial soap should be used immediately prior to donning sterile gloves.
  • Chlorhexidine skin antisepsis — A chlorhexidine solution should be applied by back and forth rubbing for at least 30 seconds. The solution should be allowed to air dry for at least two minutes and should not be wiped or blotted. Chlorhexidine appears preferable to a povidone-iodine solution [6].
  • Maximal barrier precautions — All operators should wear a mask, cap, sterile gown, and sterile gloves. In addition, a sterile full-body drape should be placed on the patient.
  • Avoid insertion into the femoral vein — Insertion of a CVC into the subclavian vein is associated with the lowest risk of infection, followed by the internal jugular vein. In one trial, 289 patients were randomly assigned to undergo central venous catheterization at the subclavian site or the femoral site [7]. There were fewer CVC-related infections among patients who had a CVC inserted in their subclavian vein (5 versus 22 percent).
  • Remove unnecessary CVCs — A daily review of CVC necessity should be performed, with prompt removal of unnecessary CVCs.

Additional interventions that may reduce CVC-associated bloodstream infections include antibiotic impregnated CVCs, nursing supervision during insertion, and increased attention to ongoing catheter care after insertion:

  • Antibiotic impregnated CVCs — A meta-analysis of 11 randomized, controlled trials (2603 catheters) found that CVCs impregnated with chlorhexidine-silver sulfadiazine were less likely to cause bloodstream infection (odds ratio 0.56, 95% CI, 0.37-0.84) [8]. However, this finding has not been universal [9].
  • Nursing supervision — In a prospective cohort study, the patient’s nurse used a check list defining best-practice to monitor the procedure, and was empowered to stop the procedure if best-practice was violated [10]. Over a six month period, the CVC-related bloodstream infection rate decreased from 11 to zero infections per 1000 catheter days.
  • Vigilant catheter care — A prospective audit of post-insertion catheter care was conducted over a 28-day period (721 catheter-days) [11]. There were 323 breaches in catheter care and four catheter-related bloodstream infections (5.5 infections per 1000 catheter-days). The major breaches included dressings that were not intact (158 breaches per 1000 catheter-days) and incorrectly placed caps (156 breaches per 1000 catheter-days). This study suggests that there is substantial opportunity to better standardize and improve the maintenance of CVCs. Such care should also target earlier recognition of potentially infected catheter sites.
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Mechanical — Factors associated with fewer mechanical complications (eg, bleeding, blood vessel injury, pneumothorax) include increased operator experience, fewer insertion attempts, and ultrasound guidance.

Operator experience — It is unknown how many CVCs should be inserted by an operator each year to maintain his or her skills. But, experience is clearly important. In one prospective cohort study, operators who had previously inserted more than 50 CVCs were more likely to be successful at inserting subsequent CVCs, with fewer complications [12].

Recognition of the importance of operator experience has prompted many hospitals to require that a certain number of successful CVC insertions be performed before an operator can place CVCs without supervision. In addition, some centers use simulation labs with mannequins or have rotations through their cardiac catheterization lab to allow operators to receive highly supervised practice inserting CVCs [12,13].

Limiting attempts — The number of attempts is also related to the likelihood of a mechanical complication. In a prospective cohort study, the incidence of mechanical complications was six fold higher when insertion was attempted more than three times, compared to successful insertion on the first attempt [14]. It is, therefore, reasonable for an operator to seek assistance if a CVC cannot be successfully inserted after three attempts [15].

Ultrasound guidance — Real-time two-dimensional ultrasound guidance is superior to blind, landmark-guided techniques, particularly when used during CVC insertion into the internal jugular vein [16-23]. This was best demonstrated by a meta-analysis of 18 studies (1646 patients) that compared CVC placement guided by landmarks versus two-dimensional ultrasound [18]. Ultrasound guidance markedly reduced insertion failures in both adults (adjusted relative risk 0.14, 95% CI 0.06-0.33) and infants (adjusted relative risk 0.15, 95% CI 0.03-0.64) when the CVC was inserted in the internal jugular vein. In addition, the risk of complications was reduced approximately two-fold. The benefit of ultrasound to guide subclavian and femoral vein placement was uncertain. Despite the apparent benefit of using two-dimensional ultrasound guidance for IJ insertion, routine use of Doppler to identify blood flow does not appear to be beneficial for subclavian line insertion [18,24,25].

Confirm position — A newly placed CVC is frequently used before it has been confirmed by a chest radiograph that it is correctly positioned. This is most common in the operating room and in emergent situations. Failure to confirm the position can be problematic since clinician judgment does not consistently predict catheter malposition or other mechanical complications, especially with less experienced operators [26].

A promising technique has been developed that uses a right atrial electrocardiogram (ECG) to confirm that a CVC has been accurately inserted. A randomized trial the compared CVC insertion using this technique to CVC insertion without it, found that use of the technique improved the rate at which CVCs were correctly positioned (96 versus 76 percent) [27].

COMPLICATIONS — Numerous complications are associated with central venous catheter (CVC) placement. The most common are listed in the table (table 1).

Published rates of cannulation success and complications vary according to the anatomic site and operator experience. As an example, one review described an overall complication rate of 15 percent [28], while an observational cohort study of 385 consecutive CVC attempts over a six month period found that mechanical complications occurred in 33 percent of attempts [29]. Complications included failure to place the catheter (22 percent), arterial puncture (5 percent), catheter malposition (4 percent), pneumothorax (1 percent), subcutaneous hematoma (1 percent), hemothorax (less than 1 percent), and asystolic cardiac arrest (less than 1 percent).

Most mechanical complications (eg, pneumothorax) are detected at the time of catheter insertion. In contrast, infectious and thrombotic complications usually occur later. Mechanical complications at the time of catheter insertion are most common after attempted insertion in the subclavian (SC) vein [29]. Despite this, SC insertion may be preferred in experienced hands since the rate of mechanical complications is largely operator dependent [28].

Infection and thrombosis — Common complications of an indwelling CVC include infection and thrombosis. These are discussed separately. (See “Diagnosis of intravascular catheter-related infections” and “Prevention of intravascular catheter-related infections” and “Pathogenesis of and risk factors for central venous catheter-related infections” and “Catheter-induced upper extremity venous thrombosis”.)

Arrhythmia — Ventricular dysrhythmias and bundle branch block are well recognized complications during central venous access procedures. Periprocedure arrhythmias are universally the result of guidewire or catheter placement into the right heart. Limiting the depth of guidewire insertion to less than 16 cm avoids this complication [30-32]. Catheter migration up to 3 cm is common with patient movement and repositioning and may cause delayed symptoms.

Vascular injury — Arterial puncture is noted in 3 to 15 percent of central venous access procedures [28]. Immediate recognition and management of arterial puncture usually prevents subsequent complications. Once an arterial stick is suspected, the needle is immediately withdrawn and direct but nonocclusive pressure applied to the site continuously for 15 minutes to prevent hematoma formation. Unrecognized arterial cannulation with subsequent dilation and catheter placement is associated with life-threatening hemorrhage and neurologic complications [33,34]. Late recognition of arterial cannulation increases the risk of hemorrhagic complications that may require surgical intervention. Measuring intraluminal pressure with a transducer prior to dilation aids in recognizing arterial puncture if location is unclear [28,33].

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Pulmonary complications — Free aspiration of air into the syringe may occur with pleural puncture but is often the result of incomplete seal of the syringe and needle. Suspected pleural puncture should prompt close attention for signs or symptoms of cardiopulmonary distress due to pneumothorax. Pleural puncture can quickly evolve into tension pneumothorax with hemodynamic collapse, especially in patients receiving positive pressure ventilation. The need for emergency intravenous access may require continued attempts at the same or alternative locations. Avoid contralateral supradiaphragmatic access attempts in close succession due to the potential for bilateral pneumothoraces. Hemothorax, hydrothorax and chylothorax occur in a small fraction of torso cannulations.

Venous air embolism — Central venous access procedures create a risk for venous air embolism [35]. Air is easily entrained into the vascular space when a needle or catheter is left open to the atmosphere. Fatal doses of air measuring as little as 20 mL can be aspirated in seconds through a large bore catheter [36,37]. Upright positioning, hypovolemia, spontaneous inhalation during instrumentation, and inattention to catheter seals increase the risk for entraining air. Trendelenburg positioning, Valsalva maneuver, prompt needle/catheter occlusion, and tight intravenous connections help to avoid this complication [35,38].

Affected patients can suffer cardiovascular and pulmonary symptoms including tachyarrhythmias, chest pain, cardiovascular collapse, dyspnea, coughing, hypoxemia, and respiratory distress. Symptoms contemporaneous with central line insertion or manipulation are highly suspicious for venous air embolism. Left lateral decubitus and Trendelenburg positioning to trap the air in the right ventricular apex is often recommended but has not been rigorously studied. Supportive measures including fluid resuscitation and adrenergic agents should be used as needed. One hundred percent inspired oxygen may speed air resorption.

CATHETER REMOVAL — Venous air embolism and bleeding are the complications most likely to occur when the CVC is removed.

Venous air embolism is a serious and poorly recognized complication of central venous catheterization. Venous air embolism can occur at the time of CVC insertion, while the catheter is in place, or at the time of catheter removal [39-41]. Patients should be placed in the supine position prior to CVC removal to decrease the risk of air embolism. The CVC should be removed during exhalation, when intrathoracic pressure is greater than atmospheric pressure. Air can be entrained into the venous circulation as the intrathoracic pressure decreases below atmospheric pressure if the CVC is removed during inspiration (see “Air embolism”).

Firm pressure should be applied for at least one minute following removal and the wound should be dressed with dry sterile gauze. The tip of the catheter should be cut off using sterile scissors and sent for culture if a CVC-related infection is suspected. (See “Diagnosis of intravascular catheter-related infections”.)

SUMMARY AND RECOMMENDATIONS

  • Common indications for central venous catheter (CVC) insertion include hemodynamic monitoring, administration of medications, plasmapheresis, apheresis, hemodialysis, and continuous renal replacement therapy. In addition, a CVC may be necessary in patients with poor peripheral venous access. (See ‘Indications’ above.)
  • We recommend that a protocol be used in all patients who require a CVC (Grade 1B). One protocol proven to reduce CVC-associated blood stream infections includes hand hygiene, chlorhexidine skin antisepsis, maximal barrier precautions, avoiding femoral vein insertion, and prompt removal of unnecessary catheters. (See ‘Infection’ above.)
  • Increased operator experience, fewer insertion attempts, and ultrasound guidance are associated with fewer mechanical complications. (See ‘Mechanical’ above.)
  • CVCs can be inserted into the internal jugular, external jugular, subclavian, femoral, or brachial vein (table 2). The optimal site is determined by operator preference, operator experience, patient anatomy, and clinical circumstances. (See “Placement of central venous catheters”.)
  • Numerous complications are associated with CVC placement (table 1). Mechanical complications (eg, pneumothorax) tend to be detected at the time of catheter insertion, whereas infectious and thrombotic complications usually occur later. Venous air embolism and bleeding are the complications most likely to occur when the CVC is removed. (See ‘Complications’ above and ‘Catheter removal’ above.)
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