The incidence and risk of central venous catheter malpositioning: a prospective cohort study in 1619 patients

Central venous catheters are used in various hospital wards. An anterior-posterior chest X-ray is usually obtained soon after cannulation to assess the location of the catheter tip. This prospective clinical study was designed to determine the radiographic catheter tip position after central venous cannulation by various routes, to identify clinical problems possibly associated with the use of malpositioned catheters and to make a cost-benefit analysis of routine chest X-ray with respect to catheter malposition. A total 1619 central venous cannulations were recorded during a three-year period with respect to patient data, information about the cannulation procedures, the radiographic catheter positions and complications during clinical use. The total incidence of radiographic catheter tip malposition, defined as extrathoracic or ventricular positioning, was 3.3% (confidence interval 25 to 4.3%). Cannulation by the right subclavian vein was associated with the highest risk of malposition, 9.1%, compared with 1.4% by the right internal jugular vein. Six of the 53 malpositioned catheters were removed or adjusted. No case of malposition was associated with vascular perforation, local venous thrombosis or cerebral symptoms. We conclude that the radiographic incidence of central venous catheter malpositioning is low and that clinical use of malpositioned catheters is associated with few complications. However, determination of the catheter position by chest X-ray should be considered when mechanical complications cannot be excluded, aspiration of venous blood is not possible, or the catheter is intended for central venous pressure monitoring, high flow use or infusion of local irritant drugs.     

Central venous catheters for children with malignant disease: surgical issues

The use of long-term central venous catheters has eliminated the fear and pain of repeated venopunctures for children with malignant disease, but problems still exist for the surgeon. Issues include choice of catheter, site and technique of placement, prevention of infection and accidental displacement, and removal. Five years' experience with 102 catheter placements in 81 children with leukemia or malignant tumors has been reviewed. These catheters remained in place an average of 318 days (32,481 patient days), maintained at home under close nursing supervision. Six months after the last entry in this series, 14 catheters are functioning and 35 patients have died with catheters intact. Fifty-three catheters have been removed because of completion of treatment (29), infection (10), dislodgement (11), and other reasons (3). In these immunocompromised patients, infectious episodes were common (186 episodes) but only ten episodes required removal of the catheter for control (1/3,248 days of use). Central venous catheters are of great help in treatment of children with malignant disease, and with careful attention to detail complications can be minimized. The advantages of central venous catheters are so great that almost all parents now agree to their use from the time the diagnosis is made, despite the possible problems with maintenance, dislodgement, and infection.     

Conversion of temporary hemodialysis catheters to tunneled hemodialysis catheters

PURPOSE: To determine the feasibility and clinical outcomes of conversion of temporary to tunneled hemodialysis catheters using the same venous insertion site. METHODS: Data from 42 patients with existing temporary hemodialysis catheters referred for placement of tunneled hemodialysis catheters were retrospectively reviewed. In these patients, the temporary catheter was exchanged for a peel-away sheath, and a tunneled catheter was inserted using the existing venous access site. Technical success, procedural complications, and clinical outcomes were evaluated. Hemodialysis records were reviewed to assess catheter patency during a 30-day follow-up period. RESULTS: The study group consisted of 20 males and 22 females (mean age: 58 years). All 42 temporary catheters were successfully converted to tunneled hemodialysis catheters without immediate procedure-related complications. Follow-up data were available for 32 patients (total: 3038; median 71 catheter days). Nine catheters were removed for infection, yielding a catheter infection rate of 0.30/100 catheter days; three catheters were removed for blood flow <200 ml/min. 13 patients had catheters removed when catheters were no longer needed. Three patients died with working catheters. The patency rate was 72% at 30 days, with four catheters functioning at the end of the study period. CONCLUSION: Conversion of a temporary hemodialysis catheter to a tunneled hemodialysis catheter using the same venous insertion site is a safe procedure that avoids complications associated with venotomy and allows conservation of other central venous access sites. Patency and infection rates in these catheters are comparable to several studies of catheter exchange and de novo placement of tunneled hemodialysis catheters.     

Field 6. Safety practices for haemodynamic procedures (administration of vasoactive drugs, vascular and cardiac catheterization). French-speaking Society of Intensive Care. French Society of Anesthesia and Resuscitation

Arterial and central venous catheterizations and their use for continuous infusion of vasoactive drugs could lead to serious adverses events that could be life threatening. The incidence of human errors related patient adverses events could be decreased by the uses of algorithms and procedures. Concerning the continuous infusion of vasoactive drugs, the name of drug and its concentration should be clearly notified. The use of modern pump and noncompliant pipe could reduce the frequency bolus infusion and their related haemodynamic alterations. Reasonable procedure could reduce the arterial and central venous catheters related complications. Subclavian and radial sites should be preferred for central venous and arterial catheter insertion, respectively. The use of real time echographic guidance could facilitate the catheter insertion. These catheters should be removed when they are not indicated. Concerning the pulmonary artery catheter, the balloon tip should be inflated with visual control of the pulmonary artery pressure. Its removal is recommended within the first five days.     

A clinical study of thrombus formation associated with central venous catheterization

Septic complication is one of the major problems associated with central venous catheterization. Thrombi produced around a catheter are regarded to a predisposing factor. However, few reports have focused on thrombus formation in clinical settings. We studied prospectively thrombus formation associated with central venous catheterization in 56 patients. Thrombus formation was identified in 39 cases (70%). In most cases, this thrombi formed around a catheter and were released into stream when the catheter was removed. However, complications attributable to the thrombi, such as pulmonary embolism were not observed. Then we tested four materials of catheters including vinylchloride, vinylchloride coated with heparine, polyurethane, and silicone to compare the incidence of thrombus formation. Thrombi were found regardless the catheter material when they were placed for more than 10 days. Cultures of blood, catheter tips and parts of catheters placed under the skin were performed to clarify the relation between thrombus formation and catheter-related sepsis. Positive culture was obtained only five cases but they were all associated with thrombus formation. These results suggest that central venous catheterization frequently results in thrombus formation, which would lead to catheter-related spesis.     

Urokinase in the treatment of occluded central venous catheters in children

Urokinase was used to clear occluded silastic central venous catheters in 14 pediatric patients. The catheters, which had been placed into a neck vein and tunnelled out through the skin of the anterior chest wall, were being used for either long-term parenteral nutrition or chemotherapy. Occluded catheters that could not be cleared by simple flushing with heparinized saline were filled with a solution of urokinase, which was left in place for 2 hours before the catheter was flushed a second time. Twenty-one occluded catheters were managed in this way over a period of 14 months. There were no allergic reactions or bleeding complications. Twelve of the 21 occluded catheters were immediately cleared. Three catheters ruptured during attempted flushing maneuvers but were patent after repair. Two catheters remained partially occluded. Only four catheters were removed because of persistent occlusion. When simpler techniques fail, urokinase instillation appears a safe and effective alternative to the more common practice of removing occluded central venous catheters in children.     

A review of 560 Hickman catheter insertions

Indwelling, cuffed, tunnelled, central venous (Hickman) catheters are increasingly being used for venous access and the administration of chemotherapy for oncological patients. This paper reviews the technical problems associated with the percutaneous insertion of these catheters and the complications arising from their use. Five hundred and sixty catheters were inserted; 31.3% had complications at insertion, most commonly precipitation of an arrhythmia (13.9%). Arterial puncture occurred in 3.8% and pneumothorax in 1.6%. Catheters remained in place for a median period of 91 days. Forty percent of catheters were removed electively on completion of treatment; 30.2% required removal because of complications, which included sepsis, migration, thrombosis and blockage. Twenty percent of patients died with their catheter in place, 8.5% were still in situ and 1.6% were removed because of patient non compliance. Sepsis remains the commonest, long term complication, with staphylococcus epidermidis being the organism isolated most frequently. There were no catheter-related deaths.     

Glomerulonephritis associated with chronic infection from long-term central venous catheterization

There have been few reports on immune complex-mediated glomerulonephritis associated with chronic infection from long-term central venous catheterization in adulthood. We report here on a 13-year-old boy with nephritis who exhibited glomerulonephritis that had been induced by the long-term use of central venous catheters, and its resolution after extraction of the central venous catheter. A diagnosis of glomerulonephritis associated with chronic infection caused by long-term central venous catheterization was made, based on the absence of clinical findings after removal of the catheter, hypocomplementemia, pathology findings resembling membranoproliferative glomerulonephritis, and detection of Staphylococcus epidermidis from culture of the removed catheter culture. For clinicians using long-term central venous access for parenteral feeding, rapid catheter exchange is necessary for patients with fever of unknown origin.     

Tamponamento cardíaco: uma complicação rara da cateterização venosa central – relato de um caso clínico

The extensive use of central venous catheters (CVC) in a hospital environment leads to increased iatrogenic complications, as more catheters are used enclosed and its maintenance is prolonged. Several complications are known to be related to central venous catheter, of which the uncommon cardiac tamponade (CT), hardly recognized and associated with high mortality.We present a clinical case, with favorable outcome, of a patient who developed a CT 17 days after CVC placement, and try to reflect on the measures that can be taken to reduce its incidence, as well as the therapeutic approaches to practice in the presence of a suspected CT.     

Venous access. Preoperative, operative, and postoperative dilemmas

The past two decades have seen a tremendous increase in the use of central venous catheters and its associated complications. The increased sophistication that physicians now have with regard to nutritional and metabolic needs has escalated the use of central venous catheters. As the acquired immunodeficiency syndrome epidemic grows, so too will the number of patients with infections and metabolic complications, many of whom will have conditions severe enough to benefit from the use of central venous catheters to deliver antimicrobial drugs and other supportive intravenous therapy. Our ability to sustain patients with short-bowel syndrome also relies critically on central venous access. Likewise, treatment of patients with leukemias and certain solid tumors frequently requires placement of these catheters. Central venous catheters are essential for bone marrow transplantation. Efforts to minimize the risks associated with placement of a central venous catheter by more frequent use of catheter exchange rather than another venipuncture should be encouraged when possible. Techniques to prevent arrhythmia during overinsertion of guide wires are also important. Vigilant searches for, and prompt treatment of, catheter-related sepsis and central vein thrombosis are critical. Better prophylaxis against the development of catheter-related sepsis and catheter-related thrombosis is also needed. Further prospective investigations should be performed, however, to define precisely cost-effective methods of detection and duration of therapy for patients with both catheter-related sepsis and catheter-related thrombosis. Further advances in the technology and management of catheters need to continue to meet these ongoing challenges.     

Central venous catheters in neonates less than 3500 g—results of a prospective study

In this prospective study we analysed 336 consecutive central venous catheters in neonates less than 3500 g. A protocol standardizing the technique of insertion, the care of the catheter, the preparation of solutions and weekly bacteriological screening was applied to all catheter insertions. Mechanical complications were observed in 15 (6%), catheter dislodgement (5%), obstruction (8%), perforation (2%) and caval vein thrombosis (0.6%). Routine bacteriological cultures of feeding solutions and infusion devices showed a contamination rate of 3.5% and 2%. Skin swab and catheter tip cultures after catheter removal demonstrated positive results in 6% and 4.7%, but catheter related sepsis occurred in only 2.3%. Staphylococcus epidermidis was found in 81% of all positive bacterial cultures. Four point seven per cent of catheters were removed for suspected infection though only one third of them produced a bacteriological growth. We conclude that the risk of mechanical complications and contamination of central venous catheters in neonates can be minimized by the use of a standardized protocol.     

Multiple purpose central venous access in infants less than 1,000 grams

The use of central venous catheters in low birthweight infants has been associated with a high rate of infectious and mechanical-related complications. We reviewed our experience with multipurpose central venous catheters in infants less than 1,000 g to determine the rate of catheter-related sepsis and mechanical catheter malfunction. From October 1981 to August 1984, 20 infants (average weight 778 g) underwent placement of 22 central venous Broviac catheters. In addition to parenteral nutrition, antibiotics, aminophylline, and replacement fluids were infused. Total catheter days were 961, with an average of 44 days per catheter. Primary catheter sepsis occurred with two catheters (9%). Mechanical complications occurred with six catheters (exposed cuff, 1; catheter break, 2; catheter reposition, 1; catheter thrombosis, 1; dehiscence of cutdown site, 1). The incidence of catheter-related sepsis was acceptably low. The high incidence of mechanical catheter malfunction (6/22, 27%) resulted in minimal morbidity to the infant and could have been avoided by better operative technique, proper positioning intraoperatively, and meticulous care of the catheter post-operatively. We conclude that multipurpose long-term central venous access can be safely utilized with the Broviac catheter in infants less than 1,000 g.     

The anterior jugular venous system: variability and clinical impact

The anterior jugular venous system, with its interconnections to the subclavian and deep jugular veins, provides a collateral venous network across the midline of the neck area, which is especially important in unilateral occlusion of an innominate vein. We illustrate the variability of this system and its clinical impact on catheterization by three cases of landmark-guided central venous cannulation. Case 1: Cannulation of the left internal jugular vein with a central venous catheter and of the left innominate vein (LIV) with a pulmonary artery catheter resulted in correctly positioned catheter tips. However, these catheters were actually not placed in the innominate vein but coursed through the jugular venous arch. Case 2: Cannulation of the left subclavian vein was complicated by resistance of guidewire advancement at 13 cm. Occlusion of the LIV and enlargement of the jugular venous arch were present. Case 3: Insertion of a pulmonary artery catheter and a central venous catheter through the LIV. The pulmonary artery catheter was correctly placed. The tip of the central venous catheter was mistakenly positioned in the left anterior jugular vein. We describe the normal anatomy of the anterior jugular venous system and its role as a major collateral. Correct placement of central venous catheters may be possible via the anterior jugular venous system. Conversely, central venous catheters malpositioned in the anterior jugular vein can increase the risk for complications and should be removed.     

Early identification of bacteria leading to central venous catheter contamination

Catheter-related bloodstream infections (CRBSI) are a common problem in patients after central venous catheterization. Using DNA analysis we compared bacteria found on the tip of central venous catheters removed because of clinical signs of CRBSI with bacteria found on needle, dilator, and guidewire used for insertion of these catheters. In five of seven central venous catheters removed because of clinical signs of CRBSI, bacteria on the catheter tip were genetically identical to bacteria found on the insertion device, proving that catheter contamination in these cases was caused by contacting bacteria during the initial puncture. These findings may be important for antibiotic prophylaxis or therapy in patients at risk for CRBSI. IMPLICATIONS: In five of seven central venous catheters removed because of clinical signs of catheter-related blood infections, DNA analysis showed bacteria found on the catheter tip to be identical with bacteria found on the puncture kits used for insertion of these catheters.     

An unusual complication of a central venous catheter in a neonate

The use of central venous catheters in neonates is associated with early and late complications. It is recognized that catheter tip migration and perforation of a viscus can occur at any time with a potentially fatal outcome. We present a case in which the successful placement of a central line was followed 2 weeks later by a sudden respiratory deterioration necessitating intubation and ventilation. The catheter tip had eroded through the wall of a pulmonary artery and a bronchus into the bronchial tree. The report highlights the serious morbidity arising from the use of central venous lines in neonates and stresses the importance of X-rays in establishing the correct position of all catheters. A sudden change in the condition of a patient should raise the suspicion of a catheter-related problem.     

Central venous catheter associated thrombosis of major veins: thrombolytic treatment with recombinant tissue plasminogen activator.

OBJECTIVE--Major thromboses can occur in the venous system in association with central venous catheters. This usually necessitates removal of the catheter. METHODS--The effectiveness of low dose recombinant tissue type plasminogen activator (rt-PA) in combination with heparin was assessed in patients with central venous catheter associated thrombosis. RESULTS--In five patients, all suffering from cancer, a 5-7 day continuous infusion resulted in complete lysis of the thrombus without complications in three. In the other two patients moderately severe haemorrhage was observed with only partial lysis, of the thrombus. CONCLUSIONS--The infusion of heparin and rt-PA is potentially effective in thrombosis related to use of central venous catheters, but the risk of haemorrhage is not inconsiderable.     

The use of the internal mammary vein for central venous access

Purpose: To describe the use of the internal mammary vein as an alternative access for central venous catheters.Methods: We performed a retrospective review of patients who underwent placement of central venous catheters via the internal mammary vein. Patient demographics, indication for venous access, technical success, catheter type, dwell time and indication for exchange or removal were recorded.Results: Placement of central venous catheters via the internal mammary vein was attempted in 11 patients including 8 children (4 males, mean age 5.7 years) and 3 adults. The most common indication was parenteral nutrition in patients with intestinal failure (7/11). Initial needle access of the vein was successful in all patients. Catheter placement was successful in 9 and unsuccessful in 2 patients due to occlusion of the superior vena cava. There were no immediate complications. A total of 20 catheters of various sizes (3–14.5 French) and lengths (8–23 cm) were either placed (n = 12) or exchanged (n = 8). The most common indications for catheter exchange were poor function and malposition (7/8). Four catheters were removed for infection and 4 were accidentally removed. The mean dwell time was 141 days (range 0–963 days) per catheter for a total of 2829 catheter days. The total mean dwell time per patient, including primarily placed and exchanged catheters, was 314 days (range 5–963 days).CONCLUSIONS: The internal mammary vein may provide a safe alternative route for patients who have lost their traditional access veins.     

Intraperitoneal fluid therapy: an alternative to intravenous treatment in a patient with limited vascular access

We describe a 58-year-old female with Crohn's disease and short bowel syndrome after repeated intestinal resections, with only 90 cm of small intestine left. She had been dependent on vascular access for total parenteral nutrition for 16 years. Due to intravascular complications after numerous long-term central venous catheters, her vascular accessibility became limited. During the course of a year she was fed enterally through a gastrostomy, but required supplementary fluid therapy through peripheral venous route. Because of extremely limited venous access, we decided to implant an intraperitoneal catheter for administration of crystalloid fluid. The first intraperitoneal catheter had to be removed because of a postoperative infection, but after antibiotic treatment, a second intraperitoneal catheter was implanted without complications, through which the patient is now fully provided with crystalloid fluid (Ringer's acetate). Abdominal ultrasound examination shows good absorption of the fluid, and for the first time in 16 years the patient does not need intravascular access. We suggest that intraperitoneal administration of fluid may be an alternative for patients with limited vascular access.     

Management of central venous catheters using a wire introducer

The wire introducer method is a satisfactory technique for management of central venous catheters if bacteriologic monitoring of the removed catheter is used to determine whether the introduced catheter should be allowed to remain. The data indicate that when central venous catheters become infected, they do so through the whole length of the catheter, from subcutaneous tunnel to intravascular tip. An intravenous catheter which produces negative cultures can be safely changed by the introducer method aseptically. An infected catheter must be removed as soon as the diagnosis is apparent, since the replacement catheter will be seeded by the colonized tract. Blood specimens drawn through central venous lines do not reflect the status of the line itself but rather the presence or absence of systemic bacteremia.     

Clinical evaluation of percutaneous insertion and long-term usage of a new cuffed polyurethane catheter for central venous access.

A new, long-term venous access catheter was evaluated in clinical practice and the insertion time, complication rate and prospective follow-up recorded. Fifty novel polyurethane catheters (Cuff-Cath) were inserted in 48 patients, for cytotoxic chemotherapy in 36, long-term total parenteral nutrition in five and miscellaneous indications in seven. All catheters were inserted by a percutaneous technique under local anaesthesia. The mean insertion time was 18 min. There were three insertion complications; failure to cannulate, pneumothorax and malposition. Seven catheters required removal (sepsis in five, subclavian vein thrombosis in two) and one catheter fell out. Total catheter days to date has been 6607 (mean 132, range 18-831 days). Eleven catheters are still in use a mean of 154 days (range 38-490 days) after insertion. Furthermore, a new technique has been described which prevents inadvertent displacement. This new catheter combines the mechanical advantages of polyurethane, together with those of a Dacron cuff. Early results suggest that this catheter may be a useful alternative to silicone catheters of the Hickman/Broviac type for long-term central venous access.