危重病患者中心静脉插管相关性感染的前瞻性研究

作者对加强医疗病房收治的危重病患者留置的中心静脉插管相关性感染（ＣＲＳ）进行了研究,以了解其患病率及危险因素。研究结果显示,总共１５１根中心静脉插管中,１３根（８．６％）伴有ＣＲＳ;危重病患者ＣＲＳ的发生率为每天１６．７次／１０００导管。插管时患者存在其它感染灶、插管穿刺部位、插管留置时间、拔管后２４小时内体温下降程度均与明确的ＣＲＳ相关;插管操作时间、拔管时体温、拔管后２４小时内患者体温下降程度均与没有ＣＲＳ呈显著相关。作者认为,危重病患者ＣＲＳ的发生率较高,导管穿刺和留置过程中仔细操作和护理是降低ＣＲＳ发生率的关键。     

Late rupture of central catheter implanted through subclavian route

A 68-year-old woman with a subcutaneous reservoir and central venous catheter implanted in the left subclavian vein for chemotherapy developed a late fracture of the catheter 220 days after implantation, with migration of the distal fragment to the pulmonary artery. After diagnosis of the complication, the distal fragment had to be removed by radiologic intervention and the reservoir was withdrawn. The need for central venous treatments, whether for definitive parenteral nutrition or prolonged antibiotic infusion, pain therapy, chemotherapy or, lately, for hemodialysis has made the placement and use of implantable systems a routine procedure for anesthesiology services. However, such techniques are not free of multiple complications, some of which are serious and which may be caused by poor technique during insertion of the catheter. We consider careful selection of the point of subclavian vein insertion to be important. The scheduling of follow-up chest films is also crucial for ruling out a "pinch-off phenomenon".     

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.     

Competence of the internal jugular vein valve is damaged by cannulation and catheterization of the internal jugular vein

BACKGROUND: Experimental results suggest that the competence of the internal jugular vein (IJV) valve may be damaged when the IJV is cannulated for insertion of a central venous catheter. It has further been hypothesized that the risk of causing incompetence of the proximally located valve might be reduced by using a more distal site for venous cannulation. The present study evaluated these hypotheses in surgical patients. METHODS: Ninety-one patients without preexisting incompetence of the IJV valve were randomly assigned to undergo distal or proximal IJV cannulation (> or = 1 cm above or below the cricoid level, respectively). Color Doppler ultrasound was used to study whether new valvular incompetence was present during Valsalva maneuvers after insertion of a central venous catheter, immediately after removal of the catheter, and, in a subset of patients, several months after catheter removal, when compared with baseline findings before cannulation of the IJV. RESULTS: Incompetence of the IJV valve was frequently induced both by proximal and distal cannulation and catheterization of the IJV. Its incidence was higher after proximal than after distal cannulation (76% vs. 41%; P < 0.01) and tended to be so after removal of the catheter (47% vs. 28%; P = 0.07). Valvular incompetence persisting immediately after removal of the catheter did not recover within 8-27 months in most cases. CONCLUSIONS: Cannulation and catheterization of the IJV may cause persistent incompetence of the IJV valve. Choosing a more distal site for venous cannulation may slightly lower the risk of causing valvular incompetence but does not reliably avoid it.     

Central venous catheter placement using the ECG-guided cavafix-certodyn SD catheter

Study Objective: To evaluate the clinical use of a new ECG-guided central venous catheter with regard to positioning in the superior vena caves (SVC).

Design: Prospective study.

Setting: Operating rooms of a university hospital and a general hospital.

Patients: 89 elective and emergency adult surgical patients requiring central venous catheterization perioperatively.

Interventions: We performed ECG-guided placement of the central venous catheter from several insertion sites. After we observed an intra-atrial p-wave (p-atriale), the catheter was withdrawn 3 cm back into the SVC. Postoperative anterior-posterior chest radiographs were performed for verification of tip localization.

Measurements and Main Results: In all 81 patients who exhibited a p-atriale that reverted to a normal-size p-wave (p-SVC) after withdrawal of the catheter 3 cm, the tip was located in the SVC or the SVC-right atrial junction on the chest radiograph. In 7 of the 8 cases without a p-atriale, the catheter tip was shown to be located at an incorrect position on the chest radiograph. The size of the p-atriale was always at least twice that of the p-SVC.

Conclusions: Use of this wire-conducted intravascularECG signal is a reliable tool for positioning the central venous catheter via various insertion sites. The technique proved to be an inexpensive, easy, and clear method. When a p-atriale is seen, uncomplicated insertions do not require radiologic guidance to control catheter tip position.     

Is a routine chest x-ray necessary for children after fluoroscopically assisted central venous access?

Purpose: The aim of this study was to determine in a pediatric population whether a routine chest x-ray after central venous access is necessary when the central venous catheter is placed with intraoperative fluoroscopy.Methods: This was a retrospective review of the charts of all patients at Children’s Hospital in Denver, Colorado who underwent subclavian or internal jugular central venous catheter placement from January 1, 1998 through December 31, 2001. Age, sex, primary reason for access, access site, number of venipuncture attempts, type of catheter, intraoperative fluoroscopy results, chest x-ray results, location of the tip of the catheter, and complications were analyzed.Results: There were 1,039 central venous catheters placed in 824 patients, 92.6% in the subclavian vein and 7.4% in the internal jugular vein. There were 604 (58.1%) children who had both fluoroscopy and a postprocedure chest x-ray, there were 308 (29.6%) who had only fluoroscopy, there were 117 (11.3%) who had only a postprocedure chest x-ray, and there were 10 (1.0%) who had neither fluoroscopy nor chest x-ray. On completion of the procedure, there were 12 (1.1%) children with misplaced central venous catheters, only 1 (0.1%) when intraoperative fluoroscopy was used. There were 17 (1.6%) complications; 9 (0.9%) were pulmonary (pneumothorax, hemothorax, or an effusion). All children with pulmonary complications experienced clinical signs and symptoms suggestive of the complication after their central venous catheter insertion but before their postprocedure chest x-ray.Conclusions: The number of complications encountered in children who had central venous access of the subclavian vein or internal jugular central vein with intraoperative fluoroscopy was infrequent, the number of misplaced catheters was minimized with intraoperative fluoroscopy, and all children with pulmonary complications showed clinical signs suggestive of pulmonary complications before postoperative chest x-ray. Therefore, children who have had central venous access of the subclavian and internal jugular vein with intraoperative fluoroscopy do not appear to require a routine chest x-ray after catheter placement unless clinical suspicion of a complication exists.     

Competence of the Internal Jugular Vein Valve Is Damaged by Cannulation and Catheterization of the Internal Jugular Vein

Background: Experimental results suggest that the competence of the internal jugular vein (IJV) valve may be damaged when the IJV is cannulated for insertion of a central venous catheter. It has further been hypothesized that the risk of causing incompetence of the proximally located valve might be reduced by using a more distal site for venous cannulation. The present study evaluated these hypotheses in surgical patients.

Methods: Ninety-one patients without preexisting incompetence of the IJV valve were randomly assigned to undergo distal or proximal IJV cannulation (>= 1 cm above or below the cricoid level, respectively). Color Doppler ultrasound was used to study whether new valvular incompetence was present during Valsalva maneuvers after insertion of a central venous catheter, immediately after removal of the catheter, and, in a subset of patients, several months after catheter removal, when compared with baseline findings before cannulation of the IJV.

Results: Incompetence of the IJV valve was frequently induced both by proximal and distal cannulation and catheterization of the IJV. Its incidence was higher after proximal than after distal cannulation (76%vs. 41%;P < 0.01) and tended to be so after removal of the catheter (47%vs. 28%;P = 0.07). Valvular incompetence persisting immediately after removal of the catheter did not recover within 8-27 months in most cases.     

Ultrasonography-guided jugular venous catheter insertion for renal transplant recipients before renal transplantation: a prospective study

AIM: Anatomical landmark technique for central venous catheter insertion preoperatively during renal transplantation may result in serious complications. In this prospective study, we sought to evaluate the results of ultrasonography-guided central venous catheter insertion before renal transplantation. PATIENTS AND METHODS: Since March 2004 routine ultrasonography-guided central venous catheter insertion was performed before the operation for living related renal transplantation. Chest X-ray was used as a control after catheter insertion. Visual pain scale was evaluated after the procedure. We recorded the duration of the procedure, amount of local anesthetic, number of punctures, and complications, namely, hematoma, carotid artery puncture, hemorrhage, and hemo-pneumothorax. RESULTS: Since March 2004, 120 jugular venous catheters were inserted into renal transplant recipients preoperatively. Mean visual pain scale was 2.5 +/- 1.2 cm (range, 0.6-4.1 cm). Mean duration of the procedure was 9 +/- 3 minutes (range, 6-15 minutes); the amount of local anesthetic injected was 1.6 +/- 0.6 mL (range, 0.9-2.3 mL). There was no carotid artery puncture, hemo-pneumothorax, or hematoma. During the study period, 3 of the first 10 catheter insertions required more than 1 puncture, for the rest 1 puncture was sufficient for catheter insertion. There was no bleeding or intravenous fluid leakage from the catheter insertion site. CONCLUSION: Ultrasonography-guided jugular venous catheter insertion is a successful safe method. Routine ultrasonography-guided procedures before renal transplantation avoided the complications related to catheter insertion.     

Late mediastinitis with bilateral hydrothorax after vessel perforation by a central venous catheter

A central venous catheter was inserted into the right internal jugular vein of a 67-year-old woman to provide parenteral nutrition on the 7th day after surgery. Five days later, mediastinitis with bilateral hydrothorax had developed and was causing respiratory failure and systemic inflammatory response syndrome secondary to documented vascular perforation by the catheter. Four factors have been associated with increased risk of perforation: catheter rigidity and diameter, the angle between the tip of the catheter and the vessel wall, and insertion from the left. Three catheter positions have been described as safe when radiologically confirmed: the superior vena cava, the point where the superior vena cava meets the atrium, and the midpoint of the innominate vein. However, it should not be forgotten that a radiograph is 2-dimensional and a single image of a catheter tip can correspond to a variety of locations (superior vena cava, vena innominata, extravascular location, and more). Even when there is clinical and radiologic evidence of catheter positioning, vascular perforation should be suspected in patients with a central venous catheter and bilateral pleural effusion who present respiratory insufficiency and hemodynamic instability.     

Sudden death after central venous cannulation

A previously fit 39-yr-old man was admitted with clinical findings suggestive of septicaemic shock. Afier routine insertion of a central venous catheter he developed electromechanical dissociation. Prolonged efforts to resuscitate the patient were unsuccessful. Post mortem examination showed a cyst arising from the tricuspid valve annulus which had prolapsed into the right ventricular outflow tract. The insertion of a central venous catheter probably caused the cyst to prolapse and cause cardiac arrest with electromechanical dissociation. This unique complication emphasises the importance of not allowing the Sel-dinger wire or central venous catheter to enter the heart during insertion. Correct positioning of central venous catheters during insertion is most safely confirmed by back flow of blood in the catheter and right atrial electrocardiography together with a follow up chest radiograph, rather than relying on the occurrence of cardiac arrhythmias during placement of the Sel-dinger wire or catheter. To avoid excessive lengths of Seldinger wire or catheter being inserted inadvertently during placement, both should be marked along their lengths.     

Femoral Venous Catheterization Is a Major Risk Factor for Central Venous Catheter-Related Bloodstream Infection

Background: Bloodstream infection is a major complication associated with central venous catheters (CVCs). However, there have been few studies of the risk factors for catheter-related bloodstream infection in patients who undergo colorectal surgery (CRS). Purpose: To disclose the risk factors for catheter-related bloodstream infection in CRS. Methods: Catheter-related bloodstream infection was evaluated retrospectively from a database of patients who had undergone CRS. Results: Three hundred-fifty patients received 423 CVCs for a total of 7,760 catheter days. Thirty-nine cases of catheter-related bloodstream infection (5.03 per 1,000 catheter days) were diagnosed. There were no significant differences in background between patients with or without catheter-related bloodstream infection, with the exception of the term of catheter insertion (24.6 ± 7.0 days vs.17.7 ± 0.6 days, P =. 0151). However, univariate analysis using factors of sex, age, insertion difficulty, length of the inserted catheter, term of catheter insertion, administration of chemotherapy, administration of total parenteral nutrition (TPN), kind of disinfectant, degree of surgical insult, and type of catheter revealed that use of a femoral venous catheter was an independent risk factor for catheter-related bloodstream infection (odds ratio [OR] = 3.175; 95% confidence interval [CI], 1.103–9.139; P =. 0322). Conclusions: Use of femoral venous catheters is a major risk factor for catheter-related bloodstream infection in CRS.     

Catheter‐related sepsis in ultrasound‐guided percutaneously inserted long‐term tunnelled central venous catheter: A review of 50 patients

Objective: Ultrasound‐guided percutaneous insertion of a long‐term tunneled central venous catheter (TCVC) is now a very common procedure, but catheter‐related sepsis remains a significant problem. This study aims to review our results concerning this complication. Methodology: Fifty‐seven central venous catheters were inserted into 50 patients percutaneously under ultrasound guidance in Queen Elizabeth hospital for between 1 March 2003 and 30 April 2004. Data was retrospectively collected and analysed from hospital records. Results: This study had a successful placement rate of 100%. The overall complication rate was 31% (18 out of 57), comprised of four mechanical complications (all occurring within 30 days of insertion). There was no complication documented within the first 24 h. Fourteen patients developed infective complications, and of these eight patients were classified as catheter‐related sepsis, all requiring premature removal of their catheters. There were in total 6161 catheter days, with the incidence rate of catheter‐related sepsis of 1.2 per 1000 catheter days. The infecting organisms were heterogeneous, with the majority being Gram‐positive cocci (47%). Our study found that patients who developed neutropaenia within 30 days after insertion were significantly associated with catheter‐related sepsis (P < 0.05). Conclusion: Insertion of TCVC under ultrasound guidance is a safe method with a high success rate. Incidence of catheter‐related sepsis of TCVC under percutaneous guidance was comparable to the open method. Neutropaenia developing within 30 days after ultrasound‐guided percutaneous insertion of central venous catheter may be associated with increased risk of catheter‐related sepsis.     

A checklist to improve the quality of central venous catheter tip positioning

Central venous catheter insertion is a routine procedure performed by anaesthetists in the peri-operative setting. Upper body central venous catheters are usually placed such that their tip lies within the superior vena cava or at the cavo-atrial junction. Positioning the tip ‘too low’ in the right atrium has long been argued against on the basis that it increases the risk of perforation, leading to cardiac tamponade. Positioning the tip ‘too high’ in the brachiocephalic vein or above can also be problematic in that proximal migration can result in extravascular placement of the proximal lumen. Such an incident occurred at our hospital in 2016, resulting in extravasation of a vesicant medication causing tissue necrosis. We undertook a quality improvement project involving a standardised bundle of care and a peri-operative central venous catheter insertion checklist with the aim of reducing the risk of such an incident re-occurring. We conducted a three-month pre-intervention audit (n = 84) in 2016 and a post-intervention audit (n = 84) in 2017. Compared with the pre-intervention audit, the post-intervention audit coincided with a lower rate of central venous catheter tip malpositioning (5.6% vs. 9.2%); and a higher rate of ‘optimal’ central venous catheter tip position in the distal superior vena cava or cavo-atrial junction (45.1% vs. 29.2%). The central venous catheter insertion checklist also substantially improved documentation of sterility measures, insertion depth and post-insertional documentation of tip position on chest radiograph.     

Central venous catheter placement in hemodialysis: evaluation of electrocardiography using a guide-wire

Internal jugular vein cannulation has become a routine and clinically important aspect of medical care in hemodialysis patients. Mismanagement in the location of a central venous catheter may occur in up to 20% of cases. The aim of the study was to evaluate the utility of endocavitary electrocardiography in right internal jugu-lar vein placement of central venous catheters. We examined 327 central venous catheterizations performed in two Dialysis Units; all catheters were positioned using intra-atrial ECG monitoring by guide-wire and after, by catheter filled with NaCl solution. EC-ECG via guide-wire was successful on 321 occasions (98.1%). Correct placement of the catheter was confirmed by EC-ECG via catheter in each case, and by plain chest-X-ray only in the first hundred cases. In 314 patients (98.1%), insertion of the catheter was successful at the first attempt. In 6 catheterizations, no atrial trace was obtained due to atrial fibrillation in 4 cases, and in 2 cases technical error and guide-wire looping into a right jugular vein. Complications as a direct result of guide-wire or catheter placement were not observed. In our opinion this method can be used safely and makes radiological control usually unnecessary. (The Journal of Vascular Access 2001; 2: 45-50).     

Long-term central venous catheters: size and location do matter

BACKGROUND: Right or left side of placement for subclavian vein catheterization for placement of long-term central catheters and size of the catheters has not been analyzed completely. METHODS: The records of 502 consecutive long-term central venous catheters placed in patients while in the operating room over a 1-year period were reviewed and 230 subclavian vein tunneled catheters were analyzed. Technical difficulties in placing the catheters were defined as arterial puncture, guidewire malposition, catheter malposition, need to switch site of access, sheath difficulty, and inability to place the catheter. RESULTS: Three complications were identified (1%) and technical difficulties occurred in 15% of the patients. More difficulty was associated with the insertion of larger triple-lumen catheters than smaller single-lumen catheters (31% vs. 11%, respectively; P < .009). Right subclavian placement was associated with a 24.4% technical difficulty rate versus a 10.4% technical difficulty rate for left subclavian placement (P < .005). CONCLUSIONS: This study supports placing the smallest catheter necessary via the left subclavian vein.     

Catheter rupture and distal embolisation: a rare complication of central venous ports

Central venous access devices placed through a percutaneous subclavian approach may be compressed by neighbouring bony structures, leading to biomaterial fatigue, catheter fracture at the compression site, and possible embolisation of distal fragment into the central veins. The aim of this paper is to review the experience of the authors, including more than 1300 subclavian port placements, carried out during a five-year period, discussing possible causes and therapeutic options of this rare complication. Nine patients out of 1320 (0.68%) experienced this complication during the five-year period of this study. Two patients only showed a retrospective radiologic evidence of the 'pinch-off sign' (e.g. initial compression of the catheter at the costo-clavicular junction). No patients had symptoms from the embolised catheter fragment; the most frequent symptom (8 out of 9 cases) was a painful swelling around the port area during infusion, related to the extravasation of medications or fluids into the subcutaneous tissue. The site of embolised segment varied from azygos vein to right pulmonary artery; however, these findings did not affect the outcome, and all the embolised fragments were successfully retrieved through a transfemoral approach using a radiologic interventional technique. No fatality occurred. The catheter fracture and embolisation of the distal fragment are a well-known complication of subclavian central venous long-term cannulation, whose estimated overall incidence is 0.5-1%. Diagnosis is usually based on the radiologic appearance of the catheter compression (so called 'pinch-off sign'), which is far from being constant; a clinical suspicion can derive from intermittent malfunction, which claims differential diagnosis with the pres-ence of a fibrin sleeve around the tip of the catheter. Once diagnosed, the treatment is always an interventional radiologic approach, which has a very high success rate. When it fails, the possibility to leave the fragment embolised in the central veins, heart or pulmonary arteries, should be considered, being the thoracotomy and open catheter retraction questionable, at present time, in patients who have no symptoms and limited life-expectancy.     

Simple method for measurement of cardiac output by thermodilution after cardiac operation.

Cardiac output by the thermodilution technique was measured by a new No. 2 Fr. transthoracic (2F-TT) thermistor catheter placed at cardiac operation into the pulmonary artery directly through the right ventricular outflow tract. Cold (0 degree C) 5% dextrose in water (D5W) was used as indicator and injected through a percutaneously placed central venous pressure (CVP) catheter in the jugular vein. Comparison to the No. 7 Fr. Swan-Ganz (7F-SG) catheter demonstrated a close correlation (r = 0.87) and almost identical mean thermodilution cardiac output values during 530 determinations in 10 patients. No difficulty was experienced in insertion or removal of the 2F-TT catheter and no bleeding complications were noted. Experiments in six dogs showed that variation in position of the tip of the CVP catheter within the superior vena caval venous system and right atrium was not a critical factor in measurement of thermodilution cardiac output. The thermodilution cardiac output technique in general and the ease of insertion, as well as the small size of the 2F-TT catheter, should make this method especially advantageous in infants and small children.     

Dynamics of thrombophlebitis in central venous catheterization via basilic and cephalic veins

The incidence distribution of thrombophlebitis after central catheterization via basilic and cephalic veins was investigated, using 227 catheters made of various plain or heparin-coated materials and with differing stiffness and surface structures. The platelet-adhesion stimulating properties were measured in vitro. Thrombophlebitis showed similar incidence patterns with all catheter types. The maximum incidence of venous reaction was found one to ten days after catheter insertion (central tendency 3-8 days with a peak at 5 days). After ten days the risk of thrombophlebitis fell significantly. The results supported the view that central venous catheters inserted via basilic or cephalic veins should not be withdrawn or exchanged as prophylaxis against thrombophlebitis, at any rate when long-term catheterization is intended. For conclusive comparisons between catheter materials regarding induction of clinically apparent thrombophlebitis, all the patients in the trial should be catheterized for ten days or more, unless symptoms of venous reaction arise earlier.     

Selective use of preoperative venous duplex ultrasound and intraoperative venography for central venous access device placement in cancer patients

Background Central venous access in cancer patients is often challenging. A history of access is common. Appropriate indications for venous imaging studies are not clearly defined. Methods This study was a retrospective analysis of selective use of preoperative venous duplex ultrasound and intraoperative venography in 248 consecutive cancer patients undergoing central venous access placement. Results Ninety patients had a history of central venous access placement. Eleven had a history of deep venous thrombosis of an upper extremity or central vein. One hundred three underwent preoperative ultrasound. Previous central venous access placement was not associated with an abnormal preoperative ultrasound; however, previous central venous access with deep venous thrombosis was (P=.014). Thirty patients underwent intraoperative venography, of which 18 also had preoperative ultrasound. Fifty percent of patients with an abnormal intraoperative venogram had no abnormal findings on preoperative ultrasound. Conclusions Routine preoperative ultrasound is unnecessary. We advocate then selective use of preoperative ultrasound in those with a history of central venous access associated with deep venous thrombosis. We advocate the use of intraoperative venography when there is difficulty advancing the guidewire or catheter or when preoperative ultrasound is negative despite a history of central venous access with deep venous thrombosis.     

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.