Vascular erosion by central venous catheters. Clinical features and outcome

Effectiveness of a nurse-led peripherally inserted central catheter service: A retrospective cohort study

BACKGROUND

A multitude of challenges arises from the growing utilisation of peripherally inserted central catheters (PICCs), including the ability to provide timely, effective and safe insertion, which must be ensured and prioritised in patient care. A nurse-led model of care has become more prevalent as PICCs become extensively needed due to their applications. However, despite their widespread use, such intervention is yet in its inception in Saudi Arabia, and thereby, evaluating the outcomes of this service is of utmost importance to support patient safety initiatives and quality of care.

PURPOSE

This research aims to assess the effectiveness of a nurse-led PICC placement service.

METHODS

A quantitative retrospective cohort design was used. The sample of this study was 333 random subsets of records on PICC insertion for adult patients between 1st April 2019 and 31st March 2023 in a tertiary medical facility in Riyadh, Saudi Arabia.

RESULTS

A nurse-led PICC service demonstrated an overall successful placement of 330 cases (99.1%), out of which 323 PICCs (97%) were successfully inserted under intra-cavitary electrocardiogram (IC-ECG) guidance, while 7 PICCs (2.1%) were successfully inserted with fluoroscopy. The overall complication rate was 2.35 occurrences per 1000 CL days, whereas the complication rate within the first 10 days after PICC insertion was 0.42 per 1000 CL days.

CONCLUSION

A nurse-led model for PICC insertion has remarkably high success rates and low rates of complication, highlighting the pivotal role of a specialised PICC team. This service boasted a commendable track record of achieving a high rate of success in its implementation, implying that a nurse-led PICC service operates effectively to improve the patient experience by delivering timely and high-quality healthcare service.

Total parenteral nutrition pleural effusion after peripherally inserted central venous catheter insertion despite fluoroscopic confirmation

Peripherally inserted central catheters are frequently used for durable central venous access for nutrition. Depending on the medical and surgical history, there are times when a person's vasculature has become scarred or stenotic due to multiple previous vascular devices, catheters, or pacemaker/defibrillator leads, that causes placement of a peripherally inserted central catheter challenging. Choosing the correct catheter and approach must be weighed against invasiveness of the procedure as unforeseen complications can arise. When pleural effusions quickly accumulate after placement of a peripherally inserted central catheter despite using confirmatory image guidance, delayed complications must be thought of, and offending medications and catheter should be removed in a timely fashion to avoid further morbidity and mortality.

Clinical Practices in Central Venous Catheter Mechanical Adverse Events

Background: Over 5 million central venous catheters (CVCs) are placed annually. Pneumothorax and catheter malpositioning are common adverse events (AE) that requires attention. This study aims to evaluate local practices of mechanical complication frequency, type, and subsequent intervention(s) related to mechanical AE with an emphasis on catheter malpositioning. Methods: This is a retrospective review of CVC placements in a tertiary hospital setting from 1/2013 to 12/2013. Pneumothorax and CVC positioning were evaluated on post-insertion chest x-ray (CXR). Malposition was defined as unintended placement of the catheter in a vessel other than the intended superior vena cava on CXR. Catheter reposition was defined as radiographic evidence of a new catheter with removal of the old catheter less than 24hrs after initial placement. Data points analyzed included pneumothorax and thoracostomy rate, CVC malposition frequency, catheter reposition rate, catheter duration, and incidence of complications such as catheter associated venous thrombosis. Result: Among 2045 eligible CVC insertions, pneumothoraces occurred in 14 (0.7%; 95%CI 0.38, 1.17) and malpositions were identified in 275 (13.4%; 95% CI 12.3, 15.3). The proportion of pneumothoraces that required tube thoracostomy was 57%. The proportion of CVCs with malposition that were removed or replaced within 24h was 32.7%. "Malpositioned" catheters that were left in place by the clinical team (n = 185) had an average catheter duration of 8.2 days (95% CI 7.2, 9.3) versus 7.2 days (95% CI 6.17, 8.23) for catheters that were replaced after initial malposition (p = 0.14, t test). The incidence of venous thrombosis in repositioned "malpositioned" catheters was 7.8% versus 4.9% for "malpositioned" catheters that were left in place. Conclusions: Clinically significant catheter malposition and pneumothorax after CVC insertion are low. In this study, replaced and non-replaced "malpositioned" catheters had similar catheter duration and rates of complications, challenging the current dogma of CVC malposition practice.

Central Venous Catheters for Hemodialysis-the Myth and the Evidence

Hemodialysis-central venous catheter (HD-CVC) insertion is a most often performed procedure, with approximately 80% of patients with end-stage kidney disease in the United States initiating kidney replacement therapy through a HD-CVC. Certain adverse events arising from HD-CVC placement, including catheter-related bloodstream infections (CR-BSIs), thrombosis, and central vein stenosis, can complicate the clinical course of patients and lead to considerable financial impact on the health care system. Medical professionals with different training backgrounds are responsible for performing this procedure, and therefore, comprehensive operator guidelines are crucial to improve the success rate of HD-CVC insertion and prevent complications. In this review article, we not only discuss the basic principles behind the use of HD-CVCs but also address frequently asked questions and myths regarding catheter asepsis, length selection, tip positioning, and flow rate assessment.

Percutaneous Route of Life: Chylothorax or Total Parenteral Nutrition-Related Bilateral Pleural Effusion in a Neonate?

Peripherally Inserted Central Catheter (PICC) lines are an essential tool in the management of premature neonates. Pleural effusion (PLE) secondary to the leakage of alimentation into the pleural cavity is an encountered complication of central-line total parenteral nutrition (TPN) administration. Methods: We review a case of a premature neonate who suffered large, bilateral PLE after insertion of an upper extremity PICC line for TPN. Results: Pleural fluid biochemical analysis confirmed PICC line infiltration, predominantly with monocytes, low protein, high triglycerides and high glucose. These results favored TPN leakage over chylothorax. Conclusions: To our knowledge, this is the first case of bilateral PLE due to PICC complication in a neonate, which highlights the importance of chylothorax differential diagnosis, the role of autopsy, and the need for clinical precautions when providing premature neonates with high osmolarity TPN.

Clinical relevance of the left brachiocephalic vein anatomy for vascular access in dialysis patients

INTRODUCTION

Most hemodialysis patients start renal replacement therapy with a central venous catheter (CVC). The left internal jugular vein (LIJV) is the second-choice vein for CVC positioning, after the right IJV. However, to reach the right atrium, the CVC must pass through the left brachiocephalic vein (LBV), which also drains blood from the left arm through the subclavian vein. The purpose of this study is to describe how the anatomy of the central venous system and in particular that of the LBV affects vascular access in hemodialysis patients.

MATERIALS AND METHODS

Three-dimensional (3D) virtual model reconstructions of the central thoracic veins of three hemodialysis patients were obtained from contrast-enhanced computed tomography scans acquired in the venous phase. The images were exported as DICOM files and loaded on open-source software for visualizing and analyzing the medical imaging (3D Slicer, Windows version 4.8.1).

RESULTS

As expected, the 3D reconstructions showed that the LBV has a tortuous path with three main angulations that could be associated with external compression and stenosis. These could determine the difficulties and increased risks of venous injury during CVC placement, and an increased risk of medium to long-term catheter-associated vein thrombosis and stenosis.

CONCLUSIONS

The anatomical features of the LBV indicate that the path of a CVC from the LIJV to the right atrium is tortuous and can easily be complicated by vein injury, negatively affecting the creation of future arterio-venous vascular accesses in the left arm.

Comparing the conventional 15 cm and the C-length approaches for central venous catheter placement

Introduction: The present guidelines recommend placing the catheter tip in the superior vena cava (SVC) above the pericardial cephalic reflection. The aim of this study was to compare the accuracy of two different approaches in locating the tip of the Central venous catheter (CVC) at the suggested vascular zone. Methods: This was an interventional study on two hundred patients undergoing Coronary artery bypass surgery (CABG) operation who required a central venous cannulation. They were randomly assigned into two groups. In the first group catheter placement was applied through using the conventional 15 cm method. In the second group a C-length method was applied for measuring the depth of catheter tip placement from the preoperative chest radiographs. For statistical analysis Chi-square test and T-test were used. Results: In the first group (15 cm) 100% of the patients had their catheters placed below the C-line (Carina line) and the average distance between the catheter tip and the C-line was +4.22±2.10 cm. In the second (C-Length) group 52% of the catheters were below C-line with an average distance of +0.77±0.5 cm. There was a meaningful difference between the two groups in respect to the catheter location depth and zone of placement (P<0.001). Conclusion: The C-Length approach in comparison to the conventional 15 cm approach resulted in a considerable higher number of catheters above the recommended C-line, thus it can provide a more reliable and safe mode for CVC placement in the SVC.

Transoesophageal echocardiographic evaluation of central venous catheter positioning using Peres' formula or a radiological landmark-based approach: a prospective randomized single-centre study

BACKGROUND

The lower superior vena cava (SVC), near its junction with the right atrium (RA), is considered the ideal location for the central venous catheter tip to ensure proper function and prevent injuries. We determined catheter insertion depth with a new formula using the sternoclavicular joint and the carina as radiological landmarks, with a 1.5 cm safety margin. The accuracy of tip positioning with the radiological landmark-based technique (R) and Peres' formula (P) was compared using transoesophageal echocardiography.

METHODS

Real-time ultrasound-guided central venous catheter insertion was done through the right internal jugular or subclavian vein. Patients were randomly assigned to either the P group (n=93) or the R group (n=95). Optimal catheter tip position was considered to be within 2 cm above and 1 cm below the RA-SVC junction. Catheter tip position, abutment, angle to the vascular wall, and flow stream were evaluated on a bicaval view.

RESULTS

The distance from the skin insertion point to the RA-SVC junction and determined depth of catheter insertion were more strongly correlated in the R group [17.4 (1.2) and 16.7 (1.5) cm; r=0.821, P<0.001] than in the P group [17.3 (1.2) and 16.4 (1.1) cm; r=0.517, P<0.001], with z=3.96 (P<0.001). More tips were correctly positioned in the R group than in the P group (74 vs 93%, P=0.001). Abutment, tip angle to the lateral wall >40°, and disrupted flow stream were comparable.

CONCLUSIONS

Catheter tip position was more accurate with a radiological landmark-based technique than with Peres' formula.

CLINICAL TRIAL REGISTRATION

Clinical Trial Registry of Korea: https://cris.nih.go.kr/cris/index.jsp KCT0001937.

Simplified equation for determining proper depth of peripherally inserted central catheter in relation to anatomical landmarks

Background

The aim of this study was to develop a formula guiding the peripherally inserted central catheter (PICC) tip placement based on anatomical landmarks such as the upper arm, clavicle, and sternum as well as the patient’s height, weight, and body mass index.

Methods

Fifty-five patients who were scheduled to have PICCs were included in the study. We measured four distances along the passage of the PICC, which were as follows; the tip of the third finger to the middle of the elbow crease (Distance A), the middle of the elbow crease to the acromion process (Distance B), the acromion process to the sternal head of the clavicle (Distance C), and the sternal head of the clavicle to the end of the xiphoid process (Distance D). The lengths from the elbow creases to their carina bifurcations as determined by fluoroscopy during PICC insertions were recorded and used as reference.

Results

The formula for determining PICC depth based on the four distances was determined by regression analysis. The optimal formula was determined to be 25.3 + 0.5 × (Distance C) + 0.6 × (Distance D) which yielded an R² value of 0.3.

Conclusions

The formula proposed for proper depth of the adult, 25.0 + 0.5 × (clavicle length) + 0.6 × (sternum length) for PICC insertion can be used to place the tip at the carina bifurcation level. The distance from elbow crease to catheter insertion point should be added to the length generated by this formula.

Diagnosis and Management of Pleural Transudates

Various clinical trials have been published on the optimal clinical management of patients with pleural exudates, particularly those caused by malignant tumors, while little information is available on the diagnosis and treatment of pleural transudates. The etiology of pleural transudates is wide and heterogeneous, and they can be caused by rare diseases, sometimes constituting a diagnostic challenge. Analysis of the pleural fluid can be a useful procedure for establishing diagnosis. Treatment should target not only the underlying disease, but also management of the pleural effusion itself. In cases refractory to medical treatment, invasive procedures will be necessary, for example therapeutic thoracentesis, pleurodesis with talc, or insertion of an indwelling pleural catheter. Little evidence is currently available and no firm recommendations have been made to establish when to perform an invasive procedure, or to determine the safest, most efficient approach in each case. This article aims to describe the spectrum of diseases that cause pleural transudate, to review the diagnostic contribution of pleural fluid analysis, and to highlight the lack of evidence on the efficacy of invasive procedures in the management and control of pleural effusion in these patients.

Perforation of the superior vena cava 5 days after insertion of a central venous catheter through the left internal jugular vein

We describe a very rare case of an indwelling central venous catheter (CVC) through the left internal jugular vein that perforated the superior vena cava (SVC) wall postoperatively, although the CVC was placed in the appropriate position preoperatively. Three days after CVC insertion, a chest radiograph showed that the CVC tip had moved from the lower SVC to the upper SVC. Five days after the insertion, computed tomography showed SVC perforation and the resulting hydrothorax. In cases of CVC insertion through the left side, the CVC tip should not be placed in the upper SVC (zone B). Considering individual clinical factors and the indwelling period for the CVC, the left innominate vein (zone C) may be a suitable site for the left-sided CVC tip to reduce the risk of SVC perforation.

When one port does not return blood: two case reports of rare causes for misplaced central venous catheters

We present two cases of misplaced central venous catheters having in common the absence of free blood return from one lumen immediately after placement. The former is a case of right hydrothorax associated with central venous catheterization with the catheter tip in intra-pleural location. In this case the distal port was never patent. In the latter case there was an increased aspiration pressure through the middle port due to a catheter looping. The absence of free flow on aspiration from one lumen of a central catheter should not be undervalued. In these circumstances the catheter should not be used and needs to be removed.

[Unilateral pleural effusion caused by vessel perforation due to peripherally inserted central catheter: Indocyanine green as a diagnostic tool]

A peripherally inserted central catheter (PICC) was inserted into a 44-year-old man to provide parenteral nutrition in a protein-calorie malnutrition secondary to a benign pyloric stenosis. On the fifth day while monitoring the catheter, the patient presented with a massive whitish pleural effusion after undergoing gastric endoscopy in order to treat pyloric stenosis. Chylothorax was initially suspected, and the patient was admitted to a recovery unit. Indocyanine green was administered through the PICC, obtaining a greenish discoloration in the pleural effusion 30 min later. This led to the diagnosis of a pleural effusion caused by a vessel perforation due to the PICC, leading to parenteral nutrition extravasation. Thoraco-abdominal computed tomography was performed, which confirmed an innominate vein perforation due to the PICC. PICC insertion may be associated with severe complications, such as central vessel perforation, and therefore the correct position of a central catheter should be always checked. Intravenous computed tomography contrast is the gold standard for central vascular perforation diagnosis. However if a pleural effusion occurs in this context, it is possible to use a dye, which administered intravenously can lead us to the correct diagnosis in situ. Indocyanine green was used for this purpose in this case.

Acute mediastinitis secondary to delayed vascular injury by a central venous catheter and total parenteral nutrition

Vascular injury caused by a central venous catheter (CVC) has been reported to be a rare complication, especially delayed vascular injury due to CVC has a few cases and it can be fatal because of delayed recognition and more serious complications. A 59-year-old woman with no available medical history was admitted for treatment of ovarian cancer. For the surgery, a triple-lumen CVC was placed through the left subclavian vein. Parenteral nutrition through the CVC was used for postoperative nutritional management in the first postoperative day. On the sixth postoperative day (POD), the patient suddenly complained of dyspnea. The CT revealed bilateral pleural effusion and irregular soft tissue density and air bubble in anterior mediastinum suggesting migration of the distal portion of the CVC into the anterior mediastium. In the intensive care unit (ICU) bilateral thoracentesis and percutaneous drainage were performed. She was discharged from the ICU in 3 days later and transferred to the general ward. This case emphasizes the possibility of the delayed vascular injury related to CVC and some strategies for prevention of vascular injury.

[Bedside prediction of right subclavian venous catheter insertion length]

BACKGROUND AND OBJECTIVE

The present study aimed to evaluate whether right subclavian vein (SCV) catheter insertion depth can be predicted reliably by the distances from the SCV insertion site to the ipsilateral clavicular notch directly (denoted as I-IC), via the top of the SCV arch, or via the clavicle (denoted as I-T-IC and I-C-IC, respectively).

METHOD

In total, 70 SCV catheterizations were studied. The I-IC, I-T-IC, and I-C-IC distances in each case were measured after ultrasound-guided SCV catheter insertion. The actual length of the catheter between the insertion site and the ipsilateral clavicular notch, denoted as L, was calculated by using chest X-ray.

RESULTS

L differed from the I-T-IC, I-C-IC, and I-IC distances by 0.14±0.53, 2.19±1.17, and -0.45±0.68cm, respectively. The mean I-T-IC distance was the most similar to the mean L (intraclass correlation coefficient=0.89). The mean I-IC was significantly shorter than L, while the mean I-C-IC was significantly longer. Linear regression analysis provided the following formula: Predicted SCV catheter insertion length (cm)=-0.037+0.036×Height (cm)+0.903×I-T-IC (cm) (adjusted r(2)=0.64).

CONCLUSION

The I-T-IC distance may be a reliable bedside predictor of the optimal insertion length for a right SCV cannulation.

A Venous Catheter Complication: Venous Perforation and Lung Injury

Central venous catheters are frequently used for different causes, like fluid infusions, haemodialysis, and measurement of central venous pressure. Complications that occur at the time or after the placement of these catheters can give harm to the patient or can cause need for a new attempt. Complications, like malfunction of the catheter, arterial puncture, haemothorax, or pneumothorax, can be seen in 5%-26% of the patients, and early detection is very important. We want to present a venous perforation and lung injury case according to the catheter based upon the literature.

A Rare Case of Port-a-Cath Migration into the Mediastinum

Port-a-cath is commonly used in patients who require frequent administration of intravenous medications. We describe a rare case of port-a-cath migration into the mediastinum 16 months after its insertion.

Clinical guidelines on central venous catheterisation. Swedish Society of Anaesthesiology and Intensive Care Medicine

Safe and reliable venous access is mandatory in modern health care, but central venous catheters (CVCs) are associated with significant morbidity and mortality, This paper describes current Swedish guidelines for clinical management of CVCs The guidelines supply updated recommendations that may be useful in other countries as well. Literature retrieval in the Cochrane and Pubmed databases, of papers written in English or Swedish and pertaining to CVC management, was done by members of a task force of the Swedish Society of Anaesthesiology and Intensive Care Medicine. Consensus meetings were held throughout the review process to allow all parts of the guidelines to be embraced by all contributors. All of the content was carefully scored according to criteria by the Oxford Centre for Evidence-Based Medicine. We aimed at producing useful and reliable guidelines on bleeding diathesis, vascular approach, ultrasonic guidance, catheter tip positioning, prevention and management of associated trauma and infection, and specific training and follow-up. A structured patient history focused on bleeding should be taken prior to insertion of a CVCs. The right internal jugular vein should primarily be chosen for insertion of a wide-bore CVC. Catheter tip positioning in the right atrium or lower third of the superior caval vein should be verified for long-term use. Ultrasonic guidance should be used for catheterisation by the internal jugular or femoral veins and may also be used for insertion via the subclavian veins or the veins of the upper limb. The operator inserting a CVC should wear cap, mask, and sterile gown and gloves. For long-term intravenous access, tunnelled CVC or subcutaneous venous ports are preferred. Intravenous position of the catheter tip should be verified by clinical or radiological methods after insertion and before each use. Simulator-assisted training of CVC insertion should precede bedside training in patients. Units inserting and managing CVC should have quality assertion programmes for implementation and follow-up of routines, teaching, training and clinical outcome. Clinical guidelines on a wide range of relevant topics have been introduced, based on extensive literature retrieval, to facilitate effective and safe management of CVCs.

Dialysis Central Venous Catheter Types and Performance

The choice of both short-term (nontunneled) and long-term (tunneled) central venous catheters (CVCs) for hemodialysis is a difficult one, due to the large number of available catheters, with very different characteristics and cost.

CVC-related complications (in particular infections, thrombosis and inefficient dialysis) can determine ominous consequences and death, with extremely elevated costs due to prolonged hospitalization and expensive procedures. Thus, the correct balance between cost and quality of CVC is required when deciding which kind of CVC should be adopted.

In this regard, the design of CVCs has become a very active area of industrial and clinical research, with the ultimate goal of improving the long-term function of the catheter and of reducing complication rates, because even small improvements in the complication or reintervention rates have a positive impact on individual patient care and cost to society. In this article we review the general features of CVCs, including differences between tunneled and nontunneled CVCs, materials and their compatibility with lock solutions, the implications of straight versus precurved design in nontunneled CVCs, lumen and tip features with their clinical implications, catheter coatings and their effect on infection and thrombosis.

Rare complication of a dialysis catheter insertion

Insertion of a dialysis catheter is a very common procedure in renal medicine, which is associated with one or more complications in ∼15% of patients. Central venous catheter vascular erosion is a rare but serious complication, the incidence appears to be between 0.4 and 1% which can be difficult to diagnose, leading to increased morbidity and mortality. We report a case of a persistent left-sided superior vena cava (PLSVC) and a possible central venous catheter vascular erosion following insertion of a left-sided internal jugular dialysis catheter. We discuss the mechanisms, diagnosis and measures to limit vascular erosion and also briefly discuss PLSVC.

Emergent Median Sternotomy for Mediastinal Hematoma: A Rare Complication following Internal Jugular Vein Catheterization for Chemoport Insertion-A Case Report and Review of Relevant Literature

Mediastinal hematoma is a rare complication following insertion of a central venous catheter with only few cases reported in the English literature. We report a case of a 71-year-old female who was admitted for elective chemoport placement. USG guided right internal jugular access was attempted using the Seldinger technique. Resistance was met while threading the guidewire. USG showed a chronic clot burden in the RIJ. A microvascular access was established under fluoroscopic guidance. Rest of the procedure was completed without any further issues. Following extubation, the patient complained of right-sided chest pain radiating to the back. Chest X-ray revealed a contained white out in the right upper lung field. She became hemodynamically unstable. Repeated X-ray showed progression of the hematoma. Median Sternotomy showed posterior mediastinal hematoma tracking into right pleural cavity. Active bleeding from the puncture site at RIJ-SCL junction was repaired. Patient had an uneventful recovery. Injury to the central venous system is the result of either penetrating trauma or iatrogenic causes as in our case. A possible explanation of our complication may be attributed to the forced manipulation of the dilator or guidewire against resistance. Clavicle and sternum offer bony protection to the underlying vital venous structures and injuries often need sternotomy with or without neck extension. Division of the clavicle and disarticulation of the sternoclavicular joint may be required for optimum exposure. Meticulous surgical technique, knowledge of the possible complications, and close monitoring in the postprocedural period are of utmost importance. Chest X-ray showed to be routinely done to detect any complication early.

Right internal jugular venous cannulation complicated by tension hydrothorax

Central Venous Catheter (CVC) is a common procedure performed in patients' management, especially the critically ill ones. CVC has been used as main access in patients requiring large amount of fluid resuscitation, total parenteral nutrition or measuring the central venous pressure. Although most complications associated with central venous cannulation are minimal, local and easy to control, others may be critical and rapidly fatal if not recognized and treated immediately. One of the most serious incidents that can occur post CVC placement is delayed hydrothorax. It usually results from migration and perforation of the catheter through the SVC wall. In this report, we describe a case of tension hydrothorax that occurred a few hours after placement of CVC in the right internal jugular vein. In acutely ill patients that are already unstable, making the diagnosis of tension hydrothorax secondary to CVC placement requires high level of suspicion. Prompt pleural effusion drainage like in our case is crucial for favorable outcome.

Impact of phase of respiration on central venous catheter tip position

PURPOSE

To determine the impact of the phase of respiration on CVC tip position using cross-sectional imaging.

METHODS

We retrospectively analyzed the CT scans of 24 consecutive patients (eight men and 16 women, mean age 56.3 years, range 18-79) who underwent a CT scan protocol that includes both imaging of the thorax in inspiration and expiration. Only patients with a central venous catheter and absence of any substantial pulmonary pathology that might affect lung volumes were included. Measurements of the catheter tip location and central venous structures were obtained from inspiratory and expiratory phase images in each patient and compared using the paired <i>t</i> test.

RESULTS

The length of the SVC and superior mediastinum were significantly longer during inspiration compared to expiration (9 mm and 7 mm respectively, P<0.001 for both). The distance between the superior and inferior cavo-atrial junction did not change significantly with respiration. The catheter tip location moved on average 9 mm (range 0-25 mm) cephalad during inspiration compared to expiration (P=0.001) in relation to the superior cavoatrial junction. The amount of catheter tip movement correlated significantly with the degree of diaphragmatic excursion with respiration (R=0.58). During inspiration, the cavo-atrial junction was on average 11 mm inferior to the right cardiomediastinal angle observed on radiography, but was nearly identical during expiration (R=0.78, P<0.001).

CONCLUSIONS

The central catheter tip position varied significantly with respiratory motion, with a mean excursion of 9 mm. The right cardiomediastinal border demonstrated a strong correlation with the actual location of the superior cavo-atrial junction in expiration, but not in inspiration.

Massive hemothorax immediately after removal of central venous catheter -A case report-

Hemothorax is a possible immediate complication of central venous catheterization. We experienced a patient who suffered from massive hemothorax 72 hours after right subclavian venous catheterization. A 29-year-old female patient with Marfan's syndrome underwent the Bentall's operation and aortic arch replacement with an artificial graft, which was performed uneventfully. She recovered favorably in the intensive care unit and was transferred to the general ward on postoperative day 3. Immediately after the removal of the catheter in the general ward, massive hemothorax developed and emergent thoracotomy should have been performed to control bleeding. We report this case to re-emphasize the careful monitoring even after removal of central venous catheter and the need for ultrasound guidance during insertion of central venous catheters.

Bilateral total parenteral nutrition pleural effusions in a 5-week-old male infant

A 5-week-old male infant was admitted to the paediatric intensive care unit with small bowel obstruction secondary to an inguinal hernia. His postoperative course was complicated by suspected migration of his left internal jugular central venous catheter into branches of the inferior thyroid artery and mediastinum. This resulted in bilateral pleural effusions which were biochemically and visually similar to the total parenteral nutrition he was receiving. After drainage of the pleural effusions he made an uneventful recovery.

Hidrotórax secundário à nutrição parenteral: relato de caso

Hidrotórax secundário à infusão de nutrição parenteral é uma condição rara, embora se apresente cada vez mais comum. Neste relato de caso, uma paciente com síndrome do intestino curto desenvolveu instabilidade hemodinâmica e insuficiência respiratória algumas horas após o início da infusão de nutrição parenteral. Ressaltamos também as manobras para evitar e tratar tal complicação.

Evaluation of length of central venous catheter inserted via cubital route in Indian patients

Aim:

Peripherally inserted central venous catheters (PICCs) are popular due to the ease of insertion, low cost and low risk of complications. Anteroposterior (AP) chest radiograph (CXR) is then obtained to assess the location of the catheter tip. But poor-quality X-rays remain a significant problem. We planned a study using radiopaque marker at sternal angle, as a radiological landmark, to relate height of the patient and optimal length of PICC fixation, at the antecubital fossa, and to know the incidence of malpositioning.

Materials and Methods:

A total of 200 patients aged above 20 years, scheduled for elective major cancer surgeries were studied. Vygoflex PUR, 16-G catheter, length 70 cm was used. The right or the left arm was chosen depending on the availability of veins. Catheter tip was observed in the post procedure CXR.

Results:

200 patients [100 patients in group 1 (length of catheter fixation at antecubital fossa 45 cm) and 100 patients in group 2 (length of catheter fixation 50 cm)] were enrolled. The groups were further subdivided into 1a, 1b, 2a, 2b and results tabulated.

Conclusions:

Appropriate length of catheter fixation for group 1a was <45 cm, group 1b = 45 cm, group 2a = 50 cm, and for group 2b it was ≥50 cm. Gender and arm (right or left) did not have any bearing on the length of fixation. Incidence of malpositioning (15.5%) was more in right-sided catheters, more so, in short heighted people. PICC insertion via cubital route stands better compared with other routes, viz., Internal jugular vein IJV, subclavian and femoral.

Management of non-infectious central venous access device complications

OBJECTIVES

To review the central venous access device (VAD) complications of inadvertent device damage, device malfunction, and various causes of mechanical occlusion and to describe the limitations of VAD complication data.

DATA SOURCES

Journal articles, legal cases, case reports, manufacturers' product information, personal experience.

CONCLUSION

The available data on VAD complications are difficult to interpret and apply in practice because of the many limitations of the studies that have been conducted (eg, single-institution, mixed patient populations, inconsistent measurement of complications). However, considerable information is known about the signs and symptoms of non-thrombotic, non-infectious VAD complications and their management.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses routinely use central VADs and are on the frontline for detecting VAD complications. Well-informed nurses can serve as patient advocates and help ensure that patients' VADs are functional and safe to use.

Hydrothorax due to extravasation of intravenous contrast through left subclavian catheter -A case report-

Central venous catheterization is associated with a large number of complications, such as pneumothorax, hydrothorax, hemothorax, phlebothrombosis, pericardial tamponade, air embolism, aberrant placement and line sepsis. There are many case reports of the extravasation of various central venous catheter fluids, including the intravenous fluids, total parenteral nutrition and chemotherapeutic agents into the pleural cavity and mediastinum. These have led to hydrothorax, hydromediastinum and pericardial effusions. We report a case of the extravasation of intravenous contrast into the pleural cavity after dynamic CT through a left subclavian catheter.

Iatrogenic chylothorax due to pleural cavity extravasation of total parenteral nutrition in two adults receiving nutrition through a peripherally inserted central catheter

Extravasation of total parenteral nutrition (TPN) delivered via central lines is a known potential complication, but significant extravasations of infusate into the pleural space when using peripherally inserted central catheters (PICCs) have not been reported in adults. We report 2 cases ofpleural cavity extravasation ofTPN delivered via a PICC. Measurement of the glucose level of the effusate is a quick way to determine the presence of TPN and should be considered in any patient receiving TPN via any type of central line with a rapidly developing effusion.

Placement of Central Venous Catheters in Patients Undergoing Major Maxillofacial Surgery - A Retrospective Clinical Audit

Purpose

The subclavian vein is thought to be the most appropriate route for central venous access in major maxillofacial surgery. Evidence suggests that left-sided central venous catheters should lie below the carina and be angulated at less than 40° to superior vena cava wall. This reduces perforation risk. With this in mind we audited our current practice for placement of central venous catheters for major maxillofacial surgery. The criteria against which we compared our practice were: 1) all catheter tips should lie below the carina and 2) the angle of the distal 1 cm of the catheter should be no more than 40° to the superior vena cava wall.

Methods

Left subclavian central venous catheters placed on a weekly operating list between September 2005 and August 2008 were identified retrospectively: 83 patients were identified; 22 were excluded. The angle of the central venous catheter tip and distance from the carina were measured on the first post-procedure chest-X ray. All central venous catheters used were 16 cm long.

Results

82% of the catheter tips were located above the carina while 61% were angulated at greater than 40°; 11% of central venous catheters met both standards; 14% of central venous catheters placed by a consultant and 12% of catheters placed by a trainee met both standards.

Conclusions

89% of the central venous catheters were not correctly placed. The majority of central venous catheter tips above the carina were at an adverse angle to the superior vena cava wall. We suggest that for left subclavian central lines, 20 cm catheters be used.

[Bilateral hydrothorax and hydromediastinum after puncture of the right subclavian vein]

Complications after the percutaneous insertion of central venous catheters are pneumothoraces, catheter-associated infections and thrombosis. In rare cases, late problems occur as a disruption of the main thoracic duct or vascular erosion. The developing pleural effusion must be analysed for other causes such as congestive heart disease, inflammatory or tumorous disease, pancreatitis, low blood protein, or subdiaphragmatic abscess. The following case report describes a rare catheter complication in a 16-year-old polytraumatised patient. The differentiation to a chylothorax and suitable therapy are described.