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Central venous catheters: Overview of complications and prevention in adults

Central venous catheters: Overview of complications and prevention in adults
Literature review current through: Jan 2024.
This topic last updated: Apr 11, 2023.

INTRODUCTION — A variety of complications are associated with central venous catheters, including those associated with catheter insertion and immediate access-related issues, as well as longer-term (>1 week) complications such as catheter malfunction, central vein stenosis or thrombosis, and catheter-related infection. The number and severity of complications increase with catheter size, multiple catheter implantations, and a longer catheter dwelling time.

An overview of complications related to central venous catheters and strategies for management and prevention are reviewed. Selection, placement, and management of central venous catheters are reviewed separately. (See "Central venous access in adults: General principles" and "Routine care and maintenance of intravenous devices".)

The placement and general management of hemodialysis access catheters are provided elsewhere. (See "Central venous catheters for acute and chronic hemodialysis access and their management".)

INCIDENCE — Numerous complications are associated with central venous catheter placement. The most common are listed in the table (table 1). The rate of mechanical complications is largely operator dependent and most (eg, pneumothorax) are detected at the time of catheter insertion [1]. Infectious and thrombotic complications usually occur later than mechanical complications.

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 [1], while an observational cohort study of 385 consecutive central venous catheter attempts over a six-month period reported mechanical complications in 33 percent of attempts [2]. 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 cardiac arrest (less than 1 percent). A later study examining the complications of central venous catheters by insertion site noted that 2.1 percent of patients had mechanical complications during insertion, 0.5 to 1.4 percent experienced bloodstream infections, and 0.5 to 1.4 percent developed deep vein thrombosis attributable to the central venous catheter [3]. The rate of mechanical complications is significantly decreased with the use of dynamic ultrasound-guided venous access. (See "Central venous access in adults: General principles", section on 'Use of ultrasound' and "Basic principles of ultrasound-guided venous access".)

There are many considerations when choosing the venous access site. Mechanical complications are more common after attempted insertion in the subclavian vein compared with the internal jugular approach and are least common for the femoral vein [2,3]. However, the subclavian approach is associated with fewer bloodstream infections and symptomatic thrombosis [3]. Nevertheless, to avoid future complications (eg, central vein stenosis), the subclavian site should be avoided when placing central catheters in those with chronic kidney disease (stage 3b or higher) and is also avoided for the placement of hemodialysis catheters (algorithm 1). (See "Central venous access: Device and site selection in adults", section on 'Benefits/risk for specific sites' and "Central venous catheters for acute and chronic hemodialysis access and their management", section on 'Access site'.)

PLACEMENT-RELATED ISSUES — The nature of access-related catheter complications depends upon the site of insertion (table 2). Dynamic ultrasound-guided puncture of the vein with imaging of the wire in the vein prior to dilation and catheter placement along with fluoroscopic guidance of the wires and catheter increases technical success rates and reduces mechanical complication rates [4]. The proper positioning of the catheter should be confirmed prior to use. (See "Central venous access in adults: General principles", section on 'Confirming catheter tip position' and "Central venous catheters for acute and chronic hemodialysis access and their management", section on 'Catheter positioning'.)

Access-related complications for large-bore tunneled catheters are similar to those seen with the placement of nontunneled central venous catheters. However, because of the larger caliber of tunneled catheters, complications may be more severe. Adding to the challenges, many patients have a history of prior central venous catheterization, especially of the internal jugular veins. The resulting scarring can lead to stenosis and chronic occlusion and inability to cannulate the vein. (See 'Central venous obstruction' below.)

Pneumothorax — Pneumothorax is a serious complication. Central venous catheterization (internal jugular, subclavian sites) is the most common cause of iatrogenic pneumothorax [5-9]. The incidence of central access-related pneumothorax varies with access site and the presence of underlying risk factors such as lung disease, failed initial access, operator inexperience, and setting (elective, emergency) [5,10,11].

The internal jugular approach is associated with a low rate of pneumothorax. One study of hemodialysis catheters suggested a rate of less than 0.1 percent [12]. In a review of ultrasound-guided catheter placement by interventional radiologists, the incidence was zero [13]. The subclavian site is associated with a higher rate of pneumothorax (2.3 versus 0.1 percent in one study [14]).

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, particularly in patients receiving positive pressure ventilation necessitating chest tube placement. (See "Thoracostomy tubes and catheters: Placement techniques and complications".)

The need for emergency intravenous access may require continued attempts at the same or alternative locations. However, it is important to avoid contralateral supradiaphragmatic access attempts in close succession due to the potential for bilateral pneumothoraces.

Venous air embolism — Air embolism is a rare but potentially lethal complication associated with central venous access [15].

Most modern dialysis catheter kits incorporate diaphragms into the peel-away sheaths that prevent significant air embolism [16]. While older series suggest an air embolism rate of approximately 1 percent [17], later series suggest that the rate of air embolism is even lower [12]. One review reported only 15 cases over a 15-year period, with over 11,000 catheter insertions, an incidence of 0.14 percent [18].

Venous air embolism can occur at the time of central venous catheter insertion, during catheter use, or at the time of catheter removal [19-21]. Air is easily entrained into the vascular space when a needle or catheter is left open to the atmosphere. Upright positioning, hypovolemia, spontaneous inhalation during instrumentation, and inattention to catheter seals increase the risk for entraining air. Placement of a patient in Trendelenburg position, if possible, may reduce the risk of air embolization and is generally recognized as a good clinical practice when placing a catheter.

The effect of venous air embolization depends upon the rate and volume of air introduced into the venous circulation [22-24], though the minimum volume of air that is lethal to humans has not been established. The lethal dose for humans has been theorized to be 3 to 5 mL/kg [25].

When it occurs, venous air embolism is often poorly recognized. Affected patients can suffer cardiovascular and pulmonary symptoms including tachyarrhythmias, chest pain, coughing, dyspnea, hypoxemia, respiratory distress, and cardiovascular collapse. Symptoms such as these in association with central line insertion, manipulation, or removal are highly suspicious for venous air embolism. (See "Air embolism", section on 'Clinical features'.)

Left lateral decubitus and Trendelenburg positioning to trap the air in the right ventricular apex are often recommended but have not been rigorously studied. Supportive measures including fluid resuscitation and adrenergic agents should be used as needed. One hundred percent inspired oxygen may increase the speed of air resorption [26]. (See "Air embolism", section on 'Treatment'.)

Arterial injury — A possible complication associated with central venous access is inadvertent needle puncture of an associated artery (eg, common femoral artery, carotid artery, subclavian artery) instead of the targeted vein. Arterial puncture is noted in 3.7 to 12 percent of all central venous access procedures [27-30]. The consistent use of ultrasound during central catheter placement decreases the incidence of vascular injury but does not eliminate it.

While serious blood loss associated with central venous catheter placement is uncommon, hematomas that form after inadvertent arterial puncture can compress associated structures, and in the case of inadvertent carotid puncture, can obstruct the airway and be life-threatening [31]. It remains unclear when or if coagulation defects should be corrected prior to elective central venous catheter placement [32]. (See "Central venous access in adults: General principles", section on 'Patients with coagulopathy and/or thrombocytopenia'.)

Immediate recognition and management of arterial puncture usually prevents subsequent complications. Unrecognized arterial puncture with subsequent dilation of the arteriotomy and catheter placement, particularly of large-bore catheters (ie, >7 French), can lead to life-threatening bleeding into the chest, retroperitoneum, or thigh, depending on the access site [33]. Late recognition of arterial catheterization increases the risk of hemorrhagic or thrombotic complications, which may require surgical intervention. Accidental catheterization of the carotid or subclavian artery by a large-bore catheter (>7 French) can cause arterial thrombosis, hemorrhage, stroke, pseudoaneurysm, or death [28]. (See "Vascular complications of central venous access and their management in adults", section on 'Inadvertent arterial puncture'.)

Arrhythmia — Ventricular dysrhythmias and bundle branch block are well-recognized complications during central venous access procedures. Periprocedural 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 [34-36]. Catheter movement of up to 3 cm is common with patient movement, and repositioning may cause delayed symptoms. Nontunneled central venous catheters positioned deep into the right atrium or catheters placed in the right ventricle increase the risk for dysrhythmias and cardiac perforation, although cardiac perforation is a rare event [37].

CATHETER-RELATED INFECTION — Infection is a common complication of indwelling central venous catheters. Symptoms vary depending on the access site and the location and severity of the infection. Infections can present locally or systemically. (See 'Local infection' below and 'Systemic infection' below.)

Incidence by type of catheter — All intravascular catheters are associated with risk of infection (table 3). (See "Intravascular catheter-related infection: Epidemiology, pathogenesis, and microbiology" and "Tunneled hemodialysis catheter-related bloodstream infection (CRBSI): Epidemiology, pathogenesis, clinical manifestations, and diagnosis".)

In a systematic review that included 200 studies, the risk of catheter-related blood stream infection per 1000 catheter-days and varied by types of intravascular catheter were as follows [38]:

Peripherally inserted central catheters (PICCs) – 1.1 (95% CI 0.9-1.3)

Cuffed and tunneled central venous catheters – 1.6 (95% CI 1.5-1.7)

Noncuffed central venous catheters

Nonmedicated and tunneled – 1.7 (95% CI 1.2-2.3)

Nonmedicated and nontunneled – 2.7 (95% CI 2.6-2.9)

However, there was no adjustment for severity of illness. Therefore, a particular type of catheter could be associated with an increased risk of infection if it was preferentially used in more severely ill or vulnerable patients.

Increasingly, use of central venous catheters outside the intensive care unit (ICU) and use of peripherally inserted central catheters (PICCs) in the outpatient setting makes comparison of infection risk across catheter type challenging. PICCs have been associated with a lower rate of blood stream infection compared with centrally inserted catheters in studies conducted largely among outpatients [38-40]; studies among inpatients have demonstrated infection rates comparable with those of other central venous catheters [41-44]. In a study of 251 PICCs placed in 115 hospitalized patients, of whom 42 percent had an ICU stay during the study period, the rate of catheter-related bloodstream infection was 2.1 per 1000 catheter-days, similar to rates seen with central venous catheters placed in the internal jugular or subclavian veins (2 to 5 per 1000 catheter-days) [44].

Catheter-related bacteremia and infections in patients on hemodialysis occur at a rate ranging from 0.6 to 6.5 episodes per 1000 catheter-days and are associated with significant morbidity and mortality [45,46]. The relative risk of bacteremia in dialysis patients using hemodialysis catheters is estimated to be approximately 10 times higher than the risk of bacteremia in patients with arteriovenous (AV) fistulas [47]. In the Hemodialysis (HEMO) study, 7.6 percent of all patients had catheters used for vascular access, yet this group comprised 32 percent of all study patients hospitalized with access-related infection [48]. For these reasons, AV access (AV fistula, AV graft) for hemodialysis is preferred to the use of tunneled hemodialysis catheters [49,50]. (See "Approach to the adult patient needing vascular access for chronic hemodialysis".)

Local infection — Local infections include those affecting the catheter exit site, or in the case of tunneled catheters, the tunnel itself.

Exit-site infection — An exit-site infection is defined as localized inflammation at the site of insertion and, in the case of a tunneled catheter, the portion of the catheter external to the cuff. It is characterized by localized erythema, crusting, and a minimal amount of exudate. Most exit-site infections are not associated with bacteremia.

Most exit-site infections are culture-positive for staphylococcal strains and respond to local measures, such as use of topical antimicrobials (eg, mupirocin). Catheter removal is usually not necessary.

For worsening local inflammation or increased exudate, systemic antibiotics are necessary. Catheter removal may also be needed if symptoms worsen or the patient doesn't respond to local measures [49,51-54].

Catheter tunnel infection — Catheter tunnel infection can also occur and is defined as an inflammation within the tunnel proximal to the cuff but with a negative blood culture. These manifest with erythema and tenderness overlying the tunnel and possibly with purulent drainage from the access site. Treatment consists of catheter removal in addition to appropriate antibiotics. Once these measures are instituted, the infection usually clears quickly.

Systemic infection — Systemic manifestations can include fever, chills, malaise, or hemodynamic instability as signs of bacteremia and sepsis, or with endocarditis or septic emboli.

The frequency of catheter-related bacteremia is less for tunneled compared with nontunneled catheters. The most important risk factor for tunneled catheter-related bacteremia is longer duration of catheter use [55,56]. Other risk factors in dialysis patients include a history of previous catheter-related bacteremia, recent surgery, diabetes mellitus, iron overload, immunosuppression, and hypoalbuminemia [57]. (See "Central venous access: Device and site selection in adults", section on 'Factors influencing catheter selection' and "Intravascular catheter-related infection: Epidemiology, pathogenesis, and microbiology".)

Clinical features and diagnosis – Catheter-related bloodstream infection should be suspected in any patient with a catheter and symptoms or signs of sepsis, infective endocarditis, or septic embolism particularly when there is no clinical evidence for an alternative source of infection [58,59]. Fever and/or chills are nonspecific but are the most sensitive clinical manifestations of catheter-related bacteremia. Catheter-related bacteremia can also result in metastatic infections such as vertebral bone or disc space infections [46]. (See "Intravascular non-hemodialysis catheter-related infection: Clinical manifestations and diagnosis", section on 'Clinical Manifestations' and "Tunneled hemodialysis catheter-related bloodstream infection (CRBSI): Epidemiology, pathogenesis, clinical manifestations, and diagnosis", section on 'Clinical manifestations'.)

Whenever a bloodstream infection is suspected, blood cultures should be drawn. The diagnosis of catheter-related bloodstream infection is based on blood cultures (obtained prior to initiation of antibiotic therapy) of the same organism from at least two blood samples, one from the catheter and one from a peripheral site. In hemodialysis patients, obtaining peripheral blood cultures may not be possible, either because their peripheral veins cannot be accessed or because an existing vein needs to be preserved for future fistula or graft creation [60-62]. (See "Intravascular non-hemodialysis catheter-related infection: Clinical manifestations and diagnosis", section on 'Collecting specimens for culture' and "Tunneled hemodialysis catheter-related bloodstream infection (CRBSI): Management and prevention", section on 'Obtain blood cultures before antibiotics'.)

Treatment – Empiric antibiotic therapy (table 4) is initiated once blood cultures are obtained and tailored to their results [63-65]. The duration of treatment is based on the severity of clinical manifestation, infecting organism and whether the catheter has been removed. When possible, catheters should be removed in cases of systemic infection. Treatment of intravascular catheter-related infection is reviewed separately. (See "Intravascular non-hemodialysis catheter-related infection: Treatment".)

CENTRAL VENOUS OBSTRUCTION — There is a strong correlation between central venous cannulation and the development of central vein obstruction [66,67]. Venous cannulation creates an area of vessel injury that, upon healing, leads to an area of fibrotic stenosis [68-70]. Repeated cannulation at the same site reinjures the vessel. Points within the vessel that are repeatedly chafed by the catheter may also be injured and subsequently stenose [71]. Progressive vein stenosis ultimately leads to venous thrombosis. The classification (figure 1) and etiologies of thoracic central venous obstruction are reviewed separately. (See "Overview of thoracic central venous obstruction".)

Central vein stenosis — Central vein stenosis is associated with access of the internal jugular and subclavian veins, but also occurs with catheters that have been inserted peripherally. The risk for central vein stenosis appears increased with placement in the left internal jugular or subclavian vein versus the right internal jugular or femoral vein, longer catheter dwell time, and the use of dialysis catheters versus smaller, more flexible catheters [72]. An additional issue that affects hemodialysis catheters is that the rapid blood flows associated with hemodialysis create areas of turbulent flow beyond the tip of the catheter, which stimulates endothelial proliferation [67]. Stagnation of flow at the catheter insertion site can also occur if the diameter of the catheter is large relative to the diameter of the cannulated vessel. (See "Overview of thoracic central venous obstruction", section on 'Etiologies' and "Central vein obstruction associated with upper extremity hemodialysis access".)

The incidence is variable and is reported to occur in 20 to 40 percent of patients with chronic catheters, but is likely under-reported, since many patients are asymptomatic [68]. A 50 percent rate of vein stenosis has been cited for hemodialysis catheters that have been placed into the subclavian vein. In one study of 57 patients following hemodialysis catheter placement, 28 percent of patients developed central vein thrombus, and 14 percent developed brachiocephalic vein stenosis at a mean of 21 days (range 7 to 59 days) [73]. The odds of a central vein stenosis increased by 38 percent with each additional catheter placement. Because of the implications of catheter-associated central venous stenosis and thrombosis for future, permanent upper extremity arteriovenous (AV) fistula creation, placement of hemodialysis catheters into the subclavian vein is be avoided [49,50]. (See "Central venous catheters for acute and chronic hemodialysis access and their management", section on 'Access site'.)

Most central vein stenoses are asymptomatic. Central vein stenoses are sometimes detected incidentally in association with catheter placement. When symptoms occur, patients may complain of upper extremity edema, variable levels of pain, and venous collateral formation. When the superior vena cava (SVC) is involved, patients may experience symptoms associated with SVC syndrome such as headaches, facial edema, dyspnea, and hoarseness [74]. Hemodialysis patients with a functioning AV fistula or graft may also present with elevated venous pressures on dialysis and prolonged bleeding after needle removal. Among dialysis patients, a previously asymptomatic stenosis may manifest after the creation of a hemodialysis AV fistula in the ipsilateral extremity [67]. The high flow into the accessed vessel exceeds the rate at which blood can flow across the stenotic lesion, leading to venous congestion. (See "Catheter-related upper extremity venous thrombosis in adults", section on 'Clinical presentation' and "Clinical features, diagnosis, and classification of thoracic central venous obstruction", section on 'Clinical features'.)

Duplex ultrasound typically establishes the diagnosis, but advanced venous imaging may also be used, particularly if intervention is being considered (algorithm 2). (See "Catheter-related upper extremity venous thrombosis in adults", section on 'Diagnostic evaluation' and "Clinical features, diagnosis, and classification of thoracic central venous obstruction", section on 'Diagnosis'.)

Asymptomatic central vein stenosis should not be treated. Prophylactic treatment has been associated with progression to significant symptoms, as opposed to observation [75]. Percutaneous transluminal angioplasty can be performed to dilate areas of stenosis that are associated with symptoms on the ipsilateral arm [76]. Lesions that recur following angioplasty can be treated with endovascular stents. However, the outcomes of central vein stenosis associated with hemodialysis catheters treated with angioplasty or stenting is not favorable, as most vessels re-stenose or occlude altogether. (See "Central vein obstruction associated with upper extremity hemodialysis access", section on 'Treatment' and "Endovenous intervention for thoracic central venous obstruction".)

Catheter-related venous thrombosis — Catheter-related venous thrombosis is a common complication of indwelling central venous catheters and is estimated to contribute to 10 percent of all deep vein thromboses (DVT) in adults [77,78]. The majority of catheter-related DVT occurs in the upper extremities. Risk factors include malignancy, previous venous thrombosis, intensive care unit admission, hypercoagulability, and infection [79,80]. (See "Catheter-related upper extremity venous thrombosis in adults", section on 'Epidemiology and risk factors' and "Peripherally inserted central catheter (PICC)-related venous thrombosis in adults", section on 'Incidence and risk factors'.)

Symptoms are variable and depend upon the location, extent, and duration of thrombosis. Extremity pain and edema are frequently observed, though many are asymptomatic [81,82]. For patients with symptoms, duplex ultrasound is the initial diagnostic test of choice and has high sensitivity and specificity [83]. Magnetic resonance or computed tomographic venography are alternatives when operator dependency or anatomy limit ultrasound examination. Catheter-based venography may be appropriate if endovenous intervention is anticipated [84-87]. (See "Clinical features, diagnosis, and classification of thoracic central venous obstruction", section on 'Diagnosis'.)

For patients confirmed with catheter-related venous thrombosis, anticoagulation is initiated per DVT protocol [88-90]. Routine removal of the catheter is not recommended, unless the catheter is no longer needed [91]. Prophylactic anticoagulation to prevent catheter-associated vessel thrombosis is generally not recommended, even in patients with a prior history of deep vein thrombosis. (See "Catheter-related upper extremity venous thrombosis in adults", section on 'Treatment' and "Catheter-related upper extremity venous thrombosis in adults", section on 'Thrombosis prevention' and "Overview of thoracic central venous obstruction", section on 'Management'.)

CATHETER MALFUNCTION — Catheter malfunction manifests when a catheter does not allow adequate flow. The mechanism of the obstruction may be mechanical (kinking of the catheter, tight suture around the catheter, or the catheter pushed against the vessel wall) or thrombotic (intraluminal thrombus, mural thrombus, or a fibrin sheath).

For hemodialysis catheters, low flow rates and high pressures during dialysis may indicate a significant occlusion, and flow rates can become too low (<300 mL/minute) to sustain the prescribed dialysis session [92,93]. Differentiation between a mechanical or thrombotic etiology cannot usually be made on clinical grounds alone. (See "Malfunction of chronic hemodialysis catheters".)

Catheter malposition is common, often leading to catheter malfunction [49]. For a tunneled hemodialysis catheter, in general, the right internal jugular vein is the best location due to the venous anatomy, allowing for a more direct path from the venous puncture site to the right atrium. A right-sided approach is also associated with lower rates of catheter malfunction and other more severe complications [94]. (See "Central venous catheters for acute and chronic hemodialysis access and their management", section on 'Access site'.)

CATHETER LOSS — The decision-making surrounding removal or retention in patients experiencing catheter-related complications can be challenging. While catheter removal may be preferred, the available catheter may be necessary for ongoing treatment (eg, hemodialysis), medication, or fluid administration (eg, parenteral nutrition).

Catheter removal — Indications for immediate catheter removal include sepsis, hemodynamic instability, persistent bacteremia despite 72 hours of specific antimicrobial therapy, metastatic infection, suppurative thrombophlebitis of the access vein, and catheter tunnel infection [60].

After removal of a tunneled catheter, placement of a temporary, nontunneled catheter is the best option. A new, tunneled catheter can be inserted once negative blood cultures are obtained. (See "Intravascular non-hemodialysis catheter-related infection: Treatment", section on 'Catheter removed'.)

Occasionally, a catheter may become stuck and may require intervention (endovascular or surgical) for retrieval [95].

Catheter replacement — If continued central venous access is required, replacement of the catheter at a new site, rather than exchange over a wire, reduces the incidence of catheter infection. (See "Routine care and maintenance of intravenous devices", section on 'Catheter dwell time and replacement'.)

For treating catheter infection, the success rate of an antibiotic lock (in conjunction with systemic antibiotics) depends on the infecting organism. (See "Intravascular non-hemodialysis catheter-related infection: Treatment", section on 'Catheter salvaged' and "Central venous catheters for acute and chronic hemodialysis access and their management", section on 'Access, flushing, and catheter locking'.)

PREVENTING COMPLICATIONS — Patients are best served by vascular access placed by an adequately experienced operator or a vascular access team. An experienced operator, ultrasound guidance, and the involvement of nursing during catheter placement reduces complications. Even in the absence of a specialized vascular access team, the rate of complications can be reduced by using a comprehensive prevention strategy. (See "Routine care and maintenance of intravenous devices", section on 'Catheter teams and use of checklist'.)

Appropriate operator experience — It is unknown how many central venous catheters should be inserted by an operator each year to maintain skills. However, experience is clearly important. In one prospective cohort study, operators who had previously inserted more than 50 central venous catheters were more likely to be successful at inserting subsequent central venous catheters with fewer complications.

Recognition of the importance of operator experience has prompted many hospitals to require that a certain number of successful central venous catheter insertions be performed before an operator can place central venous catheters without supervision. In addition, simulation training for central line placement has been shown to have small-to-moderate benefits on reducing complications [96]. Some centers use simulation labs with mannequins or have rotations through their cardiac catheterization lab to allow operators to receive highly supervised practice inserting central venous catheters [97,98].

Mechanical problems — Factors associated with fewer mechanical complications (eg, bleeding, blood vessel injury, pneumothorax, failure to cannulate the vein) include site of insertion, fewer insertion attempts, patient body habitus, and use of ultrasound guidance.

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 with successful insertion on the first attempt. It is, therefore, reasonable for an operator to seek assistance if a central venous catheter cannot be successfully inserted after three attempts to cannulate the vein or to insert the catheter [99]. We define an attempt as each time the hollow needle is inserted in search of the vein or each attempt to dilate the vein or thread the catheter over the guidewire.

Limiting wire/catheter length – Judicious guide wire control can help avoid arrhythmias during catheter placement, and appropriate catheter length can help avoid subsequent arrhythmia. If the patient becomes symptomatic, manipulation of the wire away from the ventricles will typically resolve the issue. One author has recommended that no more than 20 cm of wire/catheter be inserted from the right internal jugular vein during central venous catheter insertion [100]. Direct visualization of the wire/catheter under fluoroscopy is also useful.

Ultrasound guidance – Real-time two-dimensional ultrasound guidance is superior to blind, landmark-guided techniques and recommended whenever equipment and experience are available, particularly for central venous catheter insertion into the internal jugular vein. Ultrasound-guided venous access is reviewed in detail elsewhere. (See "Basic principles of ultrasound-guided venous access".)

Confirm catheter positioning – A newly placed central venous catheter is frequently used before it has been confirmed by a chest radiograph or ultrasound to ensure that it is correctly positioned. It is especially common in the operating room and in emergency situations for clinicians to use central lines prior to placement conformation by imaging. 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 [101]. There is evidence that a chest radiograph may not be mandated after uncomplicated ultrasound-guided right internal jugular vein cannulation [102]. However, ultrasound may be more sensitive than chest radiograph to detect some catheter placement associated complications, especially pneumothorax [103]. (See "Central venous access in adults: General principles", section on 'Confirming catheter tip position'.)

Preventing air embolism – Venous air embolism is a serious and poorly recognized complication of central venous catheterization, especially with large-lumen catheters. Health care-associated intravascular air embolism leading to patient death or serious injury is preventable and is considered a "never" event by the Centers for Medicare and Medicaid Services (CMS) and the National Quality Forum. Venous air embolism can occur at the time of central venous catheter insertion, while the catheter is in place, or at the time of catheter removal [19-21].

Trendelenburg positioning, Valsalva maneuver, prompt needle/catheter occlusion, and tight intravenous connections help to avoid this complication during central venous catheter placement [15,104]. Prior to central venous catheter removal, patients should be placed in the supine position. The central venous catheter should be removed during exhalation, when intrathoracic pressure is greater than atmospheric pressure. Firm pressure should be applied for at least one minute following removal. Furthermore, placement of an occlusive petroleum-based product dressing after removal of a nontunneled catheter may prevent the passage of air through a persistent catheter tract [105].

Infection control measures — Measures to prevent catheter-related infection include the following [106]:

Maximal barrier precautions – During catheter placement, 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. (See "Central venous access in adults: General principles", section on 'Aseptic technique'.)

Avoid insertion into the femoral vein – Compared with insertion of a central venous catheter into the internal jugular or subclavian vein, a femoral venous access site may be associated with a higher risk of infection (2.7 versus 1.3 per 1000 catheter-days) [107]. As described above, subclavian venous catheterization is avoided in patients who require hemodialysis. (See "Central venous access: Device and site selection in adults", section on 'Benefits/risk for specific sites'.)

Hand hygiene – Strict adherence to universal care strategies, including hand hygiene and the use of aseptic no-touch techniques during dressing changes or when handling the catheter, remain the most important measures for the prevention of catheter-associated infections (table 5) [39,108,109]. (See "Routine care and maintenance of intravenous devices", section on 'Universal care strategies'.)

Chlorhexidine skin antisepsis – During routine catheter care and handling, using a chlorhexidine solution is preferable to a povidone-iodine solution [110]. 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. (See "Routine care and maintenance of intravenous devices", section on 'Skin antisepsis'.)

Daily evaluation – For temporary catheters, daily evaluation should be performed to confirm the ongoing need for the catheter. In one study, catheter duration greater than four days increased the risk of catheter-related bloodstream infections in almost a linear fashion over time [111].

Remove unnecessary central venous catheters – A daily review of central venous catheter necessity should be performed, with prompt removal of unnecessary central venous catheters.

Protocols — Compliance with measures to prevent complications is a challenging problem [112,113]. To help avoid complications, we recommend use of a protocol for all patients who require a central venous catheter.

In an early prospective audit of postinsertion catheter care conducted over a 28-day period (721 catheter-days), 323 breaches in catheter care occurred [114]. 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 suggested the need for standardized care and maintenance of central venous catheters, and earlier recognition of potentially infected catheter sites.

The largest study evaluating a protocol to prevent catheter-related infection involved 103 intensive care units in Michigan and over 375,000 catheter-days. The intervention consisted of five evidence-based procedures that are strongly recommended by the United States Centers for Disease Control and Prevention guidelines [106,113]. These included:

Hand washing

Full barrier precautions during insertion of central venous catheters

Chlorhexidine for skin disinfection

Avoidance of the femoral insertion site

Removal of catheters when no longer indicated

Following implementation of the evidence-based intervention, the mean rate of catheter-related blood stream infection per 1000 catheter-days decreased from 7.7 at baseline to 1.4 at 16 to 18 months. The rate of infection fell continuously during this period (incidence-rate ratio 0.62 in the first three months and 0.34 at 16 to 18 months).

Compliance with infection control practices for prevention of central venous catheter-related blood stream infection was evaluated in a survey of infection control coordinators at 516 Veterans Administration (VA) and non-VA hospitals in the United States for the period March 16 through August 1, 2005 [112]. There were two main findings:

The rate of compliance was significantly higher at VA hospitals for maximal sterile barrier precautions (84 versus 71 percent), the use of chlorhexidine at the insertion site (91 versus 69 percent), and the composite of these two approaches plus avoidance of routine central venous catheter replacement (62 versus 44 percent).

Use of these preventive measures was higher in hospitals with a certified infection control professional, a higher safety culture score, and participation in an infection prevention collaborative.

The relatively low rate of compliance is important since the rate of central venous access-related blood stream infection can be significantly reduced by implementation of such infection prevention measures.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Venous access".)

SUMMARY

Mechanical complications – Numerous complications are associated with central venous catheters (table 1). Mechanical complications (eg, pneumothorax, arterial injury, arrhythmia) tend to be detected at the time of catheter insertion, whereas infectious and thrombotic complications usually occur later. Venous air embolism can occur during catheter placement, with catheter use, or during catheter removal. (See 'Placement-related issues' above.)

Infectious complications – Infectious complications continue to be common. Measures to prevent catheter-related infection include the following appropriate infection control measures: proper hand hygiene, skin antisepsis, maximal barrier precautions, and timely removal of catheters when their use is no longer required. (See 'Infection control measures' above.)

Preventive strategies – The use of ultrasound guidance, increased operator experience, proper catheter length, and fewer insertion attempts are all associated with fewer mechanical complications associated with the placement of central venous catheters. Appropriate site selection and avoidance of subclavian catheters, particularly in hemodialysis patients, helps prevent stenotic and subsequent thrombotic complications. The use of catheter teams and protocols also helps to prevent complications. (See 'Preventing complications' above.)

ACKNOWLEDGMENT — The editorial staff at UpToDate would like to acknowledge Jesse Jacob, MD, and Robert Gaynes, MD, who contributed to an earlier version of this topic review.

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Topic 8180 Version 25.0

References

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