[Central venous catheterization: complications of different placements]

Subclavian Artery Pseudoaneurysm Following Bedside Temporary Hemodialysis Catheter Insertion: A Case Report

A pseudoaneurysm of the subclavian artery following central venous catheter placement is a rare but potentially fatal complication that often requires surgical intervention. However, surgical repair of the subclavian artery remains challenging. Herein, we report the case of a male patient undergoing hemodialysis who developed a pseudoaneurysm of the subclavian artery after a bedside central vein catheter placement. Hemostasis was successfully achieved by selecting the pseudoaneurysm using a microcatheter. At the 10-month follow-up, the pseudoaneurysm was completely excluded, and the patient was in a stable condition. The patient underwent native arteriovenous fistula creation and hemodialysis. Endovascular treatment could be an effective nonsurgical treatment for subclavian artery pseudoaneurysms and has been attempted as a first-line treatment option.

Indian Society of Critical Care Medicine Position Statement for Central Venous Catheterization and Management 2020

Background and Purpose

Short-term central venous catheterization (CVC) is one of the commonly used invasive interventions in ICU and other patient-care areas. Practice and management of CVC is not standardized, varies widely, and need appropriate guidance. Purpose of this document is to provide a comprehensive, evidence-based and up-to-date, one document source for practice and management of central venous catheterization. These recommendations are intended to be used by critical care physicians and allied professionals involved in care of patients with central venous lines.

Methods

This position statement for central venous catheterization is framed by expert committee members under the aegis of Indian Society of Critical Care Medicine (ISCCM). Experts group exchanged and reviewed the relevant literature. During the final meeting of the experts held at the ISCCM Head Office, a consensus on all the topics was made and the recommendations for final document draft were prepared. The final document was reviewed and accepted by all expert committee members and after a process of peer-review this document is finally accepted as an official ISCCM position paper.

Modified grade system was utilized to classify the quality of evidence and the strength of recommendations. The draft document thus formulated was reviewed by all committee members; further comments and suggestions were incorporated after discussion, and a final document was prepared.

Results

This document makes recommendations about various aspects of resource preparation, infection control, prevention of mechanical complication and surveillance related to short-term central venous catheterization. This document also provides four appendices for ready reference and use at institutional level.

Conclusion

In this document, committee is able to make 54 different recommendations for various aspects of care, out of which 40 are strong and 14 weak recommendations. Among all of them, 42 recommendations are backed by any level of evidence, however due to paucity of data on 12 clinical questions, a consensus was reached by working committee and practice recommendations given on these topics are based on vast clinical experience of the members of this committee, which makes a useful practice point. Committee recognizes the fact that in event of new emerging evidences this document will require update, and that shall be provided in due time.

Abbreviations list

ABHR: Alcohol-based hand rub; AICD: Automated implantable cardioverter defibrillator; BSI: Blood stream infection; C/SS: CHG/silver sulfadiazine; Cath Lab: Catheterization laboratory (Cardiac Cath Lab); CDC: Centers for Disease Control and Prevention; CFU: Colony forming unit; CHG: Chlorhexidine gluconate; CL: Central line; COMBUX: Comparison of Bedside Ultrasound with Chest X-ray (COMBUX study); CQI: Continuous quality improvement; CRBSI: Catheter-related blood stream infection; CUS: Chest ultrasonography; CVC: Central Venous Catheter; CXR: Chest X-ray; DTTP: Differential time to positivity; DVT: Deep venous thrombosis; ECG: Electrocardiography; ELVIS: Ethanol lock and risk of hemodialysis catheter infection in critically ill patients; ER: Emergency room; FDA: Food and Drug Administration; FV: Femoral vein; GWE: Guidewire exchange; HD catheter: Hemodialysis catheter; HTS: Hypertonic saline; ICP: Intracranial pressure; ICU: Intensive Care Unit; IDSA: Infectious Disease Society of America; IJV: Internal jugular vein; IPC: Indian penal code; IRR: Incidence rate ratio; ISCCM: Indian Society of Critical Care Medicine; IV: Intravenous; LCBI: Laboratory confirmed blood stream infection; M/R: Minocycline/rifampicin; MBI-LCBI: Mucosal barrier injury laboratory-confirmed bloodstream infection; MRSA: Methicillin-resistant Staphylococcus aureus; NHS: National Health Service (UK); NHSN: National Healthcare Safety Network (USA); OT: Operation Theater; PICC: Peripherally-inserted central catheter; PIV: Peripheral intravenous line; PL: Peripheral line; PVI: Povidone-iodine; RA: Right atrium; RCT: Randomized controlled trial; RR: Relative risk; SCV/SV: Subclavian vein; ScVO₂: Central venous oxygen saturation; Sn: Sensitivity; SOP: Standard operating procedure; SVC: Superior vena cava; TEE: Transesophageal echocardiography; UPP: Useful Practice Points; USG: Ultrasonography; WHO: World Health Organization

How to cite this article

Javeri Y, Jagathkar G, Dixit S, Chaudhary D, Zirpe KG, Mehta Y, et al. Indian Society of Critical Care Medicine Position Statement for Central Venous Catheterization and Management 2020. Indian J Crit Care Med 2020;24(Suppl 1):S6–S30.

[Intravenous lines in transfusion and their medical devices]

Treatment by blood transfusion first requires an intravenous cannula. Professionals remember the optimal diameter for transfusion (16 to 18G). Practices differ according to the department concerned. Neonatology and paediatric wards use precision filters and put in fine cannulas (24G) with the constraint that this restricts transfusion flow rate. In haematology and oncology departments, the state of the patient's veins has to be considered when administering chemotherapy which may be toxic for vascular endothelium and the implantation of a venous port by a critical care anaesthetist may be suggested. Emergency departments use central venous catheters, blood warmers and, exceptionally, intraosseous infusion which is now being used again. Haemodialysis requires repeated vascular access making the creation of arteriovenous fistula necessary. We wanted to have an overview of all the different techniques potentially used in the departments of a health institution. These medical devices are managed by the pharmacies in our institutions.

Safety of Percutaneous Internal Jugular Catheterization in Cancer Patients: Prospective Observational Study

Purpose

To determine predictors for failure and early complications of percutaneous internal jugular catheterization (IJC) in cancer patients.

Methods

Six hundred and thirty consecutive cancer patients who required central venous catheterization were included in a prospective observational study. The rates of failure (defined as the intervention of a second physician and/or failure at initial insertion site) and of early complications were prospectively ascertained. Logistic regression analysis estimated odds ratio (OR) and 95% confidence intervals (95% CI) for independent predictors for failure and early complications of percutaneous IJC.

Results

The failure rate was 6.7%, and the early complication rate was 6.7%. In multivariate analysis, left-side initial catheterization (p<0.01), prior catheterization at the same site (p=0.001) and physician inexperience (p<0.0001) were independently associated with failure. Placement requiring more than one needle pass (p<0.01 for two and p<0.0001 for three and more) and absence of fluoroscopy (p<0.0001) were independently associated with early complications.

Conclusions

Percutaneous IJC is a valid option in the central venous catheterization of cancer patients due to its reliability and safety. Skilled physicians must manage difficult placements. If placement requires more than one needle pass or is made without fluoroscopy, patients must be carefully followed for potential complications.

Percutaneous repair of iatrogenic subclavian artery injury by suture-mediated closure device

Central venous catheterization through internal jugular vein is done routinely in intensive care units. It is generally safe, more so when the procedure is performed under ultrasound guidance. However, there could be inadvertent puncture of other vessels in the neck when the procedure is not performed under real-time sonographic guidance. Closure of this vessel opening can pose a challenge if it is an artery, in a location difficult to compress, and is further complicated by deranged coagulation profile. Here, we discuss the removal of an inadvertently placed catheter from subclavian artery with closure of arteriotomy percutaneously using arterial suture-mediated closure device.

Retrospective comparison of two different approaches for ultrasound-guided internal jugular vein cannulation in hemodialysis patients

Background

Prevalent hemodialysis patients with vascular access consisting of a central venous catheter (CVC) are continuously increasing over the years. Improvement in evolution and CVC placement procedures represents therefore an essential tool to enhance performance and reduce intraoperative and long-term CVC complications. Internal jugular vein (IJV) catheterization techniques are different according to ultrasound probe position in relation to vein axis and to needle direction in relation to ultrasound beam. Lateral in-plane (LIP) approach has been proposed to be advantageous compared to traditional anterior out-of-plane (AOP) technique.

Methods

In this retrospective nonrandomized study we evaluated outcomes of 337 hemodialysis CVCs positioned in our center (Dono Svizzero Hospital) between 2011 and 2016, 237 using the AOP technique and 100 using the LIP approach.

Results

We found no significant differences among considered outcomes (procedure success, arterial puncture, pneumothorax, first-use malfunction, kinking/pinching) between the two approaches.

Conclusions

In our experience AOP and LIP approaches have shown the same outcomes. However, we believe that the LIP technique has potential benefits and it should be considered in the decision process of IJV cannulation.

Repositioning of Misplaced Central Venous Catheter with Saline Injection Under C-Arm Imaging

Malposition of central venous catheter is a well known technical complication. Misplaced catheter often requires reinsertion for proper placement of the catheter in the superior vena cava (SVC) to support safe delivery of care and minimize complications. But reinsertion exposes the patient once again to risks of complications related to the procedure including potential of misplacement. Literature describes only a few techniques for repositioning a misplaced central venous catheter (CVC). We tried old simple method of saline injection with force under image intensifier using hydrostatic force of intravenous fluid to straighten the CVC. We could successfully reposition two misplaced CVC's using this method.

Optimum depth of central venous catheter - Comparision by pere's, landmark and endocavitory (atrial) ECG technique: A prospective study

Context:

Blind insertion of central venous catheter has many implications. Better options should be sought to perform this procedure.

Aim:

To evaluate various options for positioning central venous catheter tip.

Settings and Design:

This is institutional based randomized prospective controlled study.

Materials and Methods:

In this prospective study depth and position of central venous catheter were evaluated in 150 patients in intensive care unit. Three different methods: Pere's, landmark, and endocavitory (atrial) ECG control were used.

Statistical Analysis:

Twoway ANOVA test was applied on SPSS version 16 to test the significant difference between the three groups.

Results:

Patient characteristic and demographic data were similar in the three groups. The average depth of central venous catheter by Pere's, landmark, and endocavitory (ECG) technique were 14.20 ± 0.69 cm, 12.08 ± 0.98 cm, and 8.18 ± 0.74 cm, respectively.

Conclusion:

The correct position of central venous catheter by endocavitory (atrial) ECG appears not only to reduce the procedure related complications but also post procedure manipulation of catheter tip detected by post procedure chest X-ray.

[A rare complication of an internal jugular central venous catheter: pneumothorax, pneumo mediastinum and retro pneumoperitoneum and giant subcutaneous emphysema]

L'association: pneumothorax, pneumo médiastin, retro pneumopéritoine et emphysème sous cutané est connue de longue date comme complication de l'intubation et la ventilation mécanique, de l'endoscopie digestive ou de la chirurgie laparoscopique. En dehors de ce contexte, elle demeure inhabituelle surtout dans le cadre de La pose de voies veineuses centrales puisque le risque encouru est celui d'une brèche pleurale avec pneumothorax, il est surtout lié à la mise en place d'un cathéter central sous-clavier plus que lors de la pose d'une voie centrale par voie jugulaire. Nous rapportons le cas d'une patiente qui a souffert d'un pneumothorax associé à, un pneumo médiastin, un rétro pneumopéritoine et un emphysème sous cutané géant, suite à une tentative de catéthérisation de la veine jugulaire interne par voie postérieure. L'intérêt de cette observation réside dans la rareté exceptionnelle de cette association chez une patiente en ventilation spontanée et dans le mécanisme physiopathologique qu'elle suggère.

Persistent left superior vena cava: A possible contraindication to chemotherapy and total parenteral nutrition in cancer patients

Persistent left superior vena cava (PLSVC) is the most common thoracic venous anomaly. Awareness of this condition may be useful when placement of left-side transvenous subclavian or internal jugular catheters is required. This anomaly may be detected only by chest radiograph following placement of the catheter. The primary endpoints of this study were to analyze the prevalence of PLSVC, measurement of its diameters and the outcome of cancer patients with this anomaly undergoing placement of a long term catheter for nutrition and chemotherapy at the Department of Surgery, of the Second University of Naples, Naples, Italy. A total of 600 consecutive adult patients with hematological or solid tumors admitted to our surgery department for implantation of a central venous catheter (CVC) were considered. The CVC was routinely implanted in the left internal jugular vein under ultrasound guidance. Four cases of PLSVC (0.6% of patients) were observed and confirmed using cine magnetic resonance imaging (MRI). In all cases, the CVC was not removed. Three patients underwent chemotherapy and one patient was subjected to total parenteral nutrition. In the three patients undergoing chemotherapy, dynamic ECG and echocardiography were performed at the end of the treatment. No disturbances of the cardiac rhythm or thrombosis were detected, and heart ejection fraction (EF) was not affected. In conclusion, although PLSVC may be a risky condition, no complications occurred in our study. Thus, PLSVC should not be regarded as a strict contraindication to infusion of chemotherapy or hyperosmolar nutritional solutions. However, further research is needed to confirm our data.

Vertebral artery thrombosis and subsequent stroke following attempted internal jugular central venous catheterization

Complications arising from internal jugular venous catheterization are uncommon. Injury to the carotid artery is reported as one of the more common injuries. Vertebral artery injuries are rare and include pseudoaneurysm formation, arteriovenous fistulas, lacerations, and dissection with thrombus formation. Occasionally, such injuries initially go unnoticed and have the potential to cause catastrophic outcomes, leaving clinicians and families wondering what transpired. A thorough autopsy can not only help discern the cause of death, but also help to bring closure to the family. Here we present a case of an unexpected death 3 days following surgery for idiopathic scoliosis in a 17-year-old male. During the surgical procedure, a right internal jugular venous catheterization was attempted but aborted after several failed tries. Twenty-four hours after the procedure, the patient became obtunded and progressed to brain death. At autopsy, he was found to have a right transmural vertebral artery puncture wound with thrombosis leading to a massive posterior circulatory stroke.

Inadvertent subclavian artery cannulation: endovascular repair using a collagen closure device-report of two cases and review of the literature

Inadvertent line insertion into the subclavian artery is an uncommon complication of subclavian venous catheterisation, and its timely recognition is vital to minimise risk of harm to the patient. We describe the radiographic, computed tomographic (CT), and angiographic findings in two patients and illustrate the subsequent endovascular management using collagen vascular closure devices.

[Internal jugular venous cannulation: what is the best approach?]

OBJECTIVES

The aim of this study was to compare two approaches used for internal jugular venous cannulation: the anterior way, described by English et al. and the posterior way, described by Jernigan et al. The primary endpoint was the rate of success. The secondary endpoints were the related adverse events and the difficulty factors.

STUDY DESIGN

Prospective, randomized open clinical trial.

PATIENTS AND METHODS

The study took place in the vital emergency room, the operating room and the emergency intensive care unit of Ibn Sina University hospital (Rabat, Morocco), between June and September 2010. Hundred and one patients needing a central venous catheter were randomized to undergo one of the two techniques. We compared: demographics, success rates, number of attempts, difficulty factors and adverse events.

RESULTS

The success rate was significantly higher in the posterior group (96% versus 68%, P < 0.001), with fewer attempts (1.3 ± 0.7 versus 2.1 ± 1.3; P < 0.001). There were less pneumothorax, (0 versus 6%) and more accidental arterial punctures (34 versus 25.5%) in the posterior group, but the difference wasn't significant. Finally, none of the difficulty factors were correlated to the failure rate.

CONCLUSION

This study shows that the posterior approach in internal jugular venous cannulation is more efficient than and as safe as the anterior approach.

Complications of 1309 Internal Jugular Vein Cannulations with the Anatomic Landmarks Technique in Infants and Children

Purpose

Report the procedural complications of internal jugular vein (IJV) catheter insertion in infants and children and discuss how to prevent them.

Methods

An observational study was performed from January 2006 to August 2010; 1309 internal jugular vein cannulae were inserted in the operating room by either staff or resident anesthesiologists. Patient age, weight, sex, type of catheter (diameter, lumen number), number of attempts, and complications were recorded. The discussion is focused on how to prevent or reduce internal jugular vein line insertion related complications in infants and children.

Results

1309 IJV cannulae were inserted, 85.63% of catheters placed were successful after one to three attempts. Complications included 12 arrhythmias (0.91%), 25 arterial punctures (1.90%), 16 hematomas (1.22%), 17 device occlusions, breaks or malpositions (1.29%), 11 line-related infections (0.84%), four cases of thrombus (0.31%), two cardiopulmonary arrests (0.15%), two hemothoraces (0.15%), five pneumothoraces (0.38%), and one guidewire winding (0.07%). The complication rates of resident anesthesiologists were significantly higher compared to staff anesthesiologists for both common and rare complications (4.27% versus 2.21%; 0.68% versus 0.07%, respectively). In addition, residents' number of attempts were greater than staff anesthesiologists (1.84 and 1.38, respectively).

Conclusions

The IJV catheterization was feasible in infants and children. To reduce the risk of complications, the procedure should be performed or supervised by staff anesthesiologists; inserting the needle, guidewire, dilator, and the catheter too far should be avoided. It is now commonly accepted that all central venous cannulations should be performed under ultrasound guidance, especially in children.

Iatrogenic vertebral artery pseudoaneurysm due to central venous catheterization

Central venous lines have become an integral part of patient care, but they are not without complications. Vertebral artery pseudoaneurysm formation is one of the rarer complications of central line placement. Presented is a rare case of two pseudoaneurysms of the vertebral and subclavian artery after an attempted internal jugular vein catheterization. These were successfully treated with open surgical repair and bypass. Open surgical repair remains the gold standard of treatment. Endovascular repair of vertebral artery pseudoaneurysms has been described with promising outcomes, but long-term results are lacking. Ultimately, the best treatment of these iatrogenic injuries should start with prevention. Well-documented techniques to minimize mechanical complications, including inadvertent arterial puncture, should be practiced and taught in training programs to avoid the potentially devastating consequences.

[Ultrasound-guided central venous access in adults and children: Procedure and pathological findings]

Central venous line placement is a standard procedure in critical care and peri-operative medicine. This procedure can be associated with severe complications. In contrast to the landmark technique, ultrasound-guided punctures can significantly reduce the rate of complications. Patients with a high risk for difficult vascular access include critical care and emergency patients as well as patients on anticoagulation medication and dialysis. Placement of central venous catheters can be difficult in ventilated patients and if there has been prior surgery in the puncture area. In children and small infants central venous access can also be challenging due to the anatomical relationship in the head and neck region. Puncture techniques are explained briefly by means of ultrasound anatomy. Typical ultrasonographic images visualize pathological findings in order to identify dangers and complications in central venous catheterization.

Carina as a useful and reliable radiological landmark for detection of accidental arterial placement of central venous catheters

Central venous catheters are commonly used in the management of critically ill patients. Their insertion can be challenging in hemodynamically unstable patients and in those with altered thoracic anatomy. Although ultrasound guided insertion can reduce this problem, this facility may not be available in all locations and in all institutions. Accidental arterial puncture is one of the very serious complications that can occur during central venous catheter insertion. This is usually detected clinically by bright color and projectile/pulsatile flow of the returning blood. However, such means are known to be misleading especially in hypoxic and hemodynamically unstable patients. Other recognized measures used to identify arterial puncture would be blood gas analysis of the returning blood, use of pressure transducer to identify waveform pattern and the pressures. In this article, we propose that trachea and carina can be used as a reliable radiological landmark to identify accidental arterial placement of central venous catheters. We further conclude that this information could be useful especially when dealing with post-resuscitation victims and hemodynamically unstable critically ill patients.

[Ultrasound guidance of central venous catheterisation]

Portacath implantation with introduction of a catheter into the superior vena caval system is a commonly performed procedure. Catheterization of the internal jugular vein can be difficult due to anatomical variation, individual patient morphology, or as a result of previous catheterization. Use of 2D ultrasonography facilitates localization of the internal jugular vein and decreases the risks of catheter placement.

[Femoral venous catheterization. Does it really need to be avoided?]

The guidelines to prevent central venous catheter related bloodstream infections (CVCBSI) of the Centers for Disease Control and Prevention (CDC) of 2002, Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias/ Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEMICYUC/SEIMC) of 2004, and the recently published guidelines of the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America (SHEA(IDSA) of 2008 have recommended using the subclavian vein and avoiding the use of the femoral vein. They also recommend considering the use of antiseptic- or antimicrobial-impregnated CVCs for hospital units or groups of patients with a high incidence of CVCBSI. When implementing these guidelines, two questions could be asked: 1) Could the abuse of the subclavian vein and avoiding the use of the femoral vein imply a decrease in the incidence of CVCBSI, but an increase in the rate of mechanical complications as pneumothorax and/or hemothorax? 2) Couldn't antimicrobial-impregnated CVCs be used to prevent CVCBSI when the femoral venous access is used?

Ease of using a dedicated percutaneous closure device after inadvertent cannulation of the subclavian artery: case report

Inadvertent puncture of the subclavian artery is a relatively frequent and potentially disastrous complication of attempted central venous access. Due to its noncompressible location, accidental subclavian arterial cannulation may result in hemorrhage as the sheath is removed. We report a new case of successful percutaneous closure of the subclavian artery which had been inadvertently cannulated, using a closure device based on a collagen plug (Angio-Seal, St. Jude Medical). This was performed in a patient who had received maximal antiplatelet and anticoagulation therapies because of prior coronary stenting in the context of cardiogenic shock. There was no prior angiographic assessment, as arterial puncture was presumed to have been distal to the right common artery and vertebral arteries. No complications were observed in this high-risk patient, suggesting that this technique could be used once the procedure has been evaluated prospectively.

Central venous catheterization--an anatomical review of a clinical skill. Part 2. Internal jugular vein via the supraclavicular approach

The safe and successful performance of a central venous catheterization (CVC) requires a specific knowledge of anatomy in addition to a working knowledge. Misunderstanding the anatomy may result in failure or complications. This review aims to aid understanding of the anatomical framework, pitfalls, and complications of CVC of the internal jugular veins. CVC is common practice amongst surgeons, anesthesiologists, and emergency room physicians during the preparations for major surgical procedures such as open-heart surgery, as well as for intensive care monitoring and rapid restoration of blood volume. Associated with this technique are certain anatomical pitfalls and complications that can be successfully avoided if one possesses a thorough knowledge of the contraindications, regional anatomy, and rationale of the technique.

Central venous catheterization -- an anatomical review of a clinical skill -- Part 1: subclavian vein via the infraclavicular approach

The safe and successful performance of a central venous catheterization (CVC) requires a specific knowledge of anatomy in addition to a working knowledge. Misunderstanding the anatomy may result in failure or complications. This review aims to aid understanding of the anatomical framework, pitfalls, and complications of CVC of the subclavian (SCV). CVC is common practice amongst surgeons, anesthesiologists, and emergency room physicians during the preparations for major surgical procedures such as open-heart surgery, as well as, for intensive care monitoring and rapid restoration of blood volume. Associated with this technique are certain anatomical pitfalls and complications that can be successfully avoided if one possesses a thorough knowledge of the contraindications, regional anatomy, and rationale of the technique.

Complications of central venous catheterization in critically ill children

BACKGROUND

Placement of central venous catheter is essential in the management of critically ill children. The purpose of the present paper was to evaluate the success rate, mechanical and thrombotic complications and risk factors associated with these complications from different central venous access sites in critically ill children.

METHODS

A prospective study was undertaken from February 2000 to March 2005 of 369 central venous catheterizations in children in a pediatric intensive care unit.

RESULTS

The veins most frequently used were femoral vein (45%), subclavian vein (32.2%), and internal jugular vein (22.8%). Mean +/- SD duration of catheterization was 9.5 +/- 6.5 days. The procedure was performed under emergency conditions in 18% of patients with an overall success rate of 92.4%. The success rate was significantly lower in younger patients with subclavian catheterization. Insertion-related complications were noted, including 33 arterial punctures (8.9%), 27 cases of malposition (7.3%), 19 hematomas (5.2%), 12 cases of minor bleeding (3.3%), and three cases of pneumothorax (0.8%), and they were more common in the subclavian vein than in the internal jugular and femoral vein. Multiple attempts and failed attempts significantly correlated with higher incidence of complications. Maintenance-related complications included obstruction (n = 26; 7%), accidental removal (n = 14; 3.8%), central venous thrombosis (n = 8; 2.2%), subcutaneous extravasation (n = 14; 3.8%), dislodgment (n = 1; 0.25%), and extravascular infusion (n = 1; 0.25%). The frequency of catheter maintenance-related complications was significantly higher in femoral catheterizations and increased significantly with an increase in the duration of catheterization. A total of five serious complications were seen (pneumothorax in three, dislodgment in one and extravascular infusion in one) in the present series.

CONCLUSIONS

Central venous catheterization in critically ill children is a relatively safe procedure, with a 1.3% rate of serious complications and no mortality. It seems safer to choose initially the femoral or internal jugular vein instead of the subclavian vein because of high success rate without serious insertion-related complications.

Central venous access

Central venous access plays an important role in the management of an ever-increasing population of patients ranging from those that are critically ill to patients with difficult clinical access. Interventional radiologists are key in delivering this service and should be familiar with the wide range of techniques and catheters now available to them. A comprehensive description of these catheters with regard to indications, technical aspects of catheterization, success rates, and associated early and late complications, as well as a review of various published guidelines on central venous catheter insertion are given in this article.

Percutaneous closure after inadvertent subclavian artery cannulation

Accidental insertion of an arterial sheath is an uncommon but potentially serious complication of jugular venous catheterization. When the subclavian artery is inadvertently cannulated, sheath removal can be complicated by significant hemorrhage due to its incompressible location. We report a case of inadvertent insertion of an 8 French sheath into the subclavian artery, which was successfully removed and the puncture site sealed with a collagen-based vascular closure device (Angio-Seal STS Plus). This averted an otherwise emergent open surgical procedure to remove the sheath and repair the subclavian artery in a high-risk patient.

Iatrogenic vertebral artery injury

Iatrogenic vertebral artery injury (VAI) results from various diagnostic and therapeutic procedures. The objective of this article is to provide an update on the mechanism of injury and management of this potentially devastating complication. A literature search was conducted using PubMed. The iatrogenic VAIs were categorized according to each diagnostic or therapeutic procedure responsible for the injury, i.e., central venous catheterization, cervical spine surgery, chiropractic manipulation, diagnostic cerebral angiography, percutaneous nerve block, and radiation therapy. The incidence, mechanisms of injury, and reparative procedures were discussed for each type of procedure. The type of VAI depends largely on the type of procedure. Laceration was the dominant type of acute injury in central venous catheterization and cervical spine surgery. Arteriovenous fistulae and pseudoaneurysms were the delayed complications. Arterial dissection was the dominant injury type in chiropractic manipulation and diagnostic cerebral angiography. Inadvertent arterial injection caused seizures or stroke in percutaneous nerve block. Radiation therapy was responsible for endothelial injury which in turn resulted in delayed stenosis and occlusion of the vertebral artery (VA). The proximal VA was the most vulnerable portion of the artery. Although iatrogenic VAIs are rare, they may actually be more prevalent than had previously been thought. Diagnosis of iatrogenic VAI may not always be easy because of its rarity and deep location, and a high level of suspicion is necessary for its early detection. A precise knowledge of the surgical anatomy of the VA is essential prior to each procedure to prevent its iatrogenic injury.

Traumatic complications from placement of thoracic catheters and tubes

The volume of critically ill patients requiring stabilization in emergency departments (EDs) throughout the USA has increased from 42 million per year in 1960 to over 92 million in 1990, as reported by Goldstein [Crit Care Clinics 21(1):81-89, 2005] and Rivers et al. [Curr Opin Crit Care 8(6):600-606, 2002]. With the increase in this patient population, the number of procedures, both invasive and noninvasive, performed in the ED to improve clinical outcomes has also increased. Therefore, emergency medicine physicians must add to their repertoire the ability to recognize potentially fatal traumatic complications. This review will provide readers with imaging findings of traumatic complications from placement of thoracic catheters and tubes and briefly discuss pitfalls of performing these procedures. In particular, complications arising from placement of hemodialysis catheters, central venous catheters, Swan-Ganz catheters, chest tubes, nasogastric and feeding tubes, and endotracheal tubes will be reviewed.

Clinical review: vascular access for fluid infusion in children

The current literature on venous access in infants and children for acute intravascular access in the routine situation and in emergency or intensive care settings is reviewed. The various techniques for facilitating venous cannulation, such as application of local warmth, transillumination techniques and epidermal nitroglycerine, are described. Preferred sites for central venous access in infants and children are the external and internal jugular veins, the subclavian and axillary veins, and the femoral vein. The femoral venous cannulation appears to be the most safe and reliable technique in children of all ages, with a high success and low complication rates. Evidence from the reviewed literature strongly supports the use of real-time ultrasound techniques for venous cannulation in infants and children. Additionally, in emergency situations the intraosseous access has almost completly replaced saphenous cutdown procedures in children and has decreased the need for immediate central venous access.

Coronary sinus catheter placement: assessment of placement criteria and cardiac complications

STUDY OBJECTIVES

To evaluate the placement and complications of a coronary sinus (CS) catheter in human subjects.

DESIGN

Sixty-two CS catheters inserted in patients scheduled for coronary artery bypass graft surgery (CABG).

SETTING

University hospital, anesthesia and cardiothoracic surgery departments.

PATIENTS

Sixty-two patients without valvular or concomitant diseases undergoing CABG.

INTERVENTIONS

CS fluoroscopy, measurements of CS flow, CS oxygen saturation, and CS distal tip pressure before incision, after incision, 20 min after aortic cross-clamp release (X-off), 50 min after X-off, 2 h after X-off, 4 h after X-off, and 6 h after X-off.

RESULTS

In 57 patients (92%), we achieved successful CS catheter placement. In five patients (8%), CS catheter positioning was not possible. Of the 57 CS catheters placed, dislocation occurred during the operation in six patients (11%) and postoperatively in three patients (6%). Cardiac complications of CS catheter placement occurred in nine patients (15%). Four patients (6%) acquired hemopericardium. Three of these patients had a small hematoma in the right ventricle. In two other patients, contrast medium appeared in the right ventricular wall during catheterization. No hemodynamic signs of these complications were detected clinically. Irregular heart rhythm was observed in only three patients. CS blood oxygen saturation ranged from 40 to 60%. CS flow amounted to 3% of cardiac output. Variations in CS flow paralleled changes in cardiac output.

CONCLUSIONS

A CS catheter is a useful tool for clinical human cardiac research; however, the placement of a CS catheter can cause minor myocardial damage in > 10% of patients. Importantly, this damage may not be clinically evident, but only observed after thoracotomy. CS oxygen saturation, CS flow, distal tip pressure, and fluoroscopy are reliable tools to assess a safe and correct positioning of the CS catheter.

Central venous catheter techniques in infants and children

PURPOSE OF REVIEW

The placement of central venous catheters is often necessary to facilitate optimal anaesthetic and perioperative management or for the long-term management of chronic underlying diseases. Insertion may be a challenge in selected patients, and the risk of infection, thrombosis, and other complications may result in significant risk factors.

RECENT FINDINGS

Ultrasound visualization of the cervical veins with Valsalva manoeuvres significantly increases the rate and safety of central venous cannulation, and decreases needle passes in paediatric patients even with experienced operators. Pericardial effusion with tamponade is a more frequent phenomenon than generally realized, and accurate location of the catheter-tip position is essential. The femoral venous approach has proved to be safe even in premature babies. Clear guidelines for infection control and the prevention of intravascular catheter-related infections in children have been established; however, the high incidence of nosocomial catheter-related infections requires effective prevention strategies. The impact of antimicrobial-impregnated central venous catheters on the prevention of bloodstream infections in children is not yet clear. Routine use of prophylactic antibiosis (i.e. vancomycin) to prevent catheter-related infection cannot be recommended. Thrombolytic therapy with recombinant tissue plasminogen activator is safe, efficient, well tolerated and effective for lysis of catheter-induced intravascular and intracardiac thrombi even in neonates. Embolized catheter fragments can be retrieved in neonates and children by non-surgical interventions using standard procedures applied by paediatric cardiologists.

SUMMARY

Despite a variety of new techniques, the major problem of central venous catheterization in neonates and children remains the prevention of catheter-related infection and infection control.