Complications of central venous catheters and their prevention
- Michael P Young, MD
Michael P Young, MD
- Professor of Medicine
- Geisel School of Medicine at Dartmouth
Insertion of a central venous catheter 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 . Insertion of a central venous catheter using the Seldinger technique has revolutionized medicine by allowing the central venous system to be accessed safely and easily .
Central venous catheters are now common among critically ill patients. In the United States, over 15 million catheter days/year are recorded in the intensive care unit alone . Multilumen central venous catheters have become ubiquitous in the intensive care unit. New catheter designs, standardization of insertion techniques, use of ultrasound guidance, and subsequent central line management have reduced complication rates.
Mechanical complications associated with central venous catheter placement and removal and strategies to these prevent complications are discussed here. The placement of central venous catheters and infectious and thrombotic complications are discussed separately. (See "Overview of central venous access", section on 'Indications' and "Diagnosis of intravascular catheter-related infections" and "Catheter-related upper extremity venous thrombosis" and "Epidemiology, pathogenesis, and microbiology of intravascular catheter infections".)
Numerous complications are associated with central venous catheter placement. The most common are listed in the table (table 1).
Published rates of cannulation success and complications vary according to the anatomic site, the use of ultrasound guidance, and operator experience. As an example, one review described an overall complication rate of 15 percent , while an observational cohort study of 385 consecutive central venous catheter attempts over a six-month period found that mechanical complications occurred in 33 percent of attempts . 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). In the past decade, the mechanical complication rate and failure rate have significantly decreased with the use of ultrasound-guided cannulation, especially for catheter insertion using the internal jugular site. The advantage of using ultrasound guidance is less well established when using the femoral or subclavian vein approach . (See "Principles of ultrasound-guided venous access".)
- SELDINGER SI. Catheter replacement of the needle in percutaneous arteriography; a new technique. Acta radiol 1953; 39:368.
- Higgs ZC, Macafee DA, Braithwaite BD, Maxwell-Armstrong CA. The Seldinger technique: 50 years on. Lancet 2005; 366:1407.
- CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 http://stacks.cdc.gov/view/cdc/5916/ (Accessed on February 06, 2014).
- McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003; 348:1123.
- Eisen LA, Narasimhan M, Berger JS, et al. Mechanical complications of central venous catheters. J Intensive Care Med 2006; 21:40.
- Brass P, Hellmich M, Kolodziej L, et al. Ultrasound guidance versus anatomical landmarks for subclavian or femoral vein catheterization. Cochrane Database Syst Rev 2015; 1:CD011447.
- Parienti JJ, Mongardon N, Mégarbane B, et al. Intravascular Complications of Central Venous Catheterization by Insertion Site. N Engl J Med 2015; 373:1220.
- Boyd R, Saxe A, Phillips E. Effect of patient position upon success in placing central venous catheters. Am J Surg 1996; 172:380.
- Tripathi M, Dubey PK, Ambesh SP. Direction of the J-tip of the guidewire, in seldinger technique, is a significant factor in misplacement of subclavian vein catheter: a randomized, controlled study. Anesth Analg 2005; 100:21.
- Lefrant JY, Muller L, De La Coussaye JE, et al. Risk factors of failure and immediate complication of subclavian vein catheterization in critically ill patients. Intensive Care Med 2002; 28:1036.
- Oliver WC Jr, Nuttall GA, Beynen FM, et al. The incidence of artery puncture with central venous cannulation using a modified technique for detection and prevention of arterial cannulation. J Cardiothorac Vasc Anesth 1997; 11:851.
- Bowdle A. Vascular complications of central venous catheter placement: evidence-based methods for prevention and treatment. J Cardiothorac Vasc Anesth 2014; 28:358.
- Mirski MA, Lele AV, Fitzsimmons L, Toung TJ. Diagnosis and treatment of vascular air embolism. Anesthesiology 2007; 106:164.
- Roberts S, Johnson M, Davies S. Near-fatal air embolism: fibrin sheath as the portal of air entry. South Med J 2003; 96:1036.
- Laskey AL, Dyer C, Tobias JD. Venous air embolism during home infusion therapy. Pediatrics 2002; 109:E15.
- Heckmann JG, Lang CJ, Kindler K, et al. Neurologic manifestations of cerebral air embolism as a complication of central venous catheterization. Crit Care Med 2000; 28:1621.
- Flanagan JP, Gradisar IA, Gross RJ, Kelly TR. Air embolus--a lethal complication of subclavian venipuncture. N Engl J Med 1969; 281:488.
- Toung TJ, Rossberg MI, Hutchins GM. Volume of air in a lethal venous air embolism. Anesthesiology 2001; 94:360.
- Gordy S, Rowell S. Vascular air embolism. Int J Crit Illn Inj Sci 2013; 3:73.
- Kander T, Frigyesi A, Kjeldsen-Kragh J, et al. Bleeding complications after central line insertions: relevance of pre-procedure coagulation tests and institutional transfusion policy. Acta Anaesthesiol Scand 2013; 57:573.
- Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006; 355:2725.
- Chaiyakunapruk N, Veenstra DL, Lipsky BA, Saint S. Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis. Ann Intern Med 2002; 136:792.
- Parienti JJ, du Cheyron D, Timsit JF, et al. Meta-analysis of subclavian insertion and nontunneled central venous catheter-associated infection risk reduction in critically ill adults. Crit Care Med 2012; 40:1627.
- Veenstra DL, Saint S, Saha S, et al. Efficacy of antiseptic-impregnated central venous catheters in preventing catheter-related bloodstream infection: a meta-analysis. JAMA 1999; 281:261.
- Kalfon P, de Vaumas C, Samba D, et al. Comparison of silver-impregnated with standard multi-lumen central venous catheters in critically ill patients. Crit Care Med 2007; 35:1032.
- Lai NM, Chaiyakunapruk N, Lai NA, et al. Catheter impregnation, coating or bonding for reducing central venous catheter-related infections in adults. Cochrane Database Syst Rev 2013; :CD007878.
- Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 2004; 32:2014.
- Shapey IM, Foster MA, Whitehouse T, et al. Central venous catheter-related bloodstream infections: improving post-insertion catheter care. J Hosp Infect 2009; 71:117.
- Ramakrishna G, Higano ST, McDonald FS, Schultz HJ. A curricular initiative for internal medicine residents to enhance proficiency in internal jugular central venous line placement. Mayo Clin Proc 2005; 80:212.
- Barsuk JH, Cohen ER, Nguyen D, et al. Attending Physician Adherence to a 29-Component Central Venous Catheter Bundle Checklist During Simulated Procedures. Crit Care Med 2016; 44:1871.
- Britt RC, Novosel TJ, Britt LD, Sullivan M. The impact of central line simulation before the ICU experience. Am J Surg 2009; 197:533.
- Wu SY, Ling Q, Cao LH, et al. Real-time two-dimensional ultrasound guidance for central venous cannulation: a meta-analysis. Anesthesiology 2013; 118:361.
- Soni NJ, Reyes LF, Keyt H, et al. Use of ultrasound guidance for central venous catheterization: a national survey of intensivists and hospitalists. J Crit Care 2016; 36:277.
- Abood GJ, Davis KA, Esposito TJ, et al. Comparison of routine chest radiograph versus clinician judgment to determine adequate central line placement in critically ill patients. J Trauma 2007; 63:50.
- Hourmozdi JJ, Markin A, Johnson B, et al. Routine Chest Radiography Is Not Necessary After Ultrasound-Guided Right Internal Jugular Vein Catheterization. Crit Care Med 2016; 44:e804.
- Ely EW, Hite RD, Baker AM, et al. Venous air embolism from central venous catheterization: a need for increased physician awareness. Crit Care Med 1999; 27:2113.
- Catheter-related infection
- Catheter-induced thrombosis
- Vascular injury
- Pulmonary complications
- Venous air embolism
- PREVENTING COMPLICATIONS
- Mechanical problems
- - Appropriate operator experience
- - Limiting attempts
- - Ultrasound guidance
- - Confirm catheter positioning
- - Preventing air embolism
- SUMMARY AND RECOMMENDATIONS