Complications of central venous catheter insertion in a teaching hospital

Complications of central venous catheterization at a vascular surgery service in a teaching hospital: a prospective cohort study

Background

Central venous catheters are essential for management of hospitalized patients, but their insertion is subject to complications that can make them unusable and/or cause patient morbidity. There are few data on the incidence of these complications and the variables associated with these outcomes in Brazil.

Objectives

To determine the incidence of mechanical complications and failures of short stay central venous catheters fitted by the vascular surgery service at a teaching hospital and identify variables associated with their occurrence.

Methods

This was a prospective cohort of 73 attempts to fit patients with a central venous catheter performed by the vascular surgery service at a teaching hospital from July to October of 2022.

Results

Mechanical complications occurred in 12 cannulation attempts (16.44%) and there were 10 failures (13.70%). The factors associated with mechanical complications were less experienced operators (p < 0.001), less specialized operators (p = 0.014), a failed attempt prior to requesting help from the vascular surgery service (p = 0.008), and presence of at least two criteria for difficulty (p = 0.007).

Conclusions

The local incidence of mechanical complications and central venous cannulation failures was similar to rates described in the international literature, but higher than rates in other Brazilian studies. The results suggest that the degree of experience of the person fitting the catheter, history of a failed prior attempt, and presence of at least two criteria for difficulty identified before the procedure were associated with worse outcomes.

Spontaneous Knot Formation in a Central Venous Catheter

Patient: Male, 63-year-old

Final Diagnosis: Spontaneous knot formation in central venous catheter

Symptoms: Central venous catheter whit any flow • associated with pain at the insertion site of the access

Medication: —

Clinical Procedure: Central venous catheterization

Specialty: General and Internal Medicine • Surgery

[Complications and success rates of subclavian vein catheterization depending on experience]

BACKGROUND

The infraclavicular puncture of the subclavian vein is a standard procedure for anesthetists. Meanwhile the literature and recommendations are clear and the use of real-time ultrasound guidance is the standard procedure; however, anesthetists will always get into special circumstances were they have to use the landmark technique, so this competence must be preserved. Feared complications of infraclavicular subclavian vein puncture are pneumothorax and arterial puncture. Up to now there is no clear learning curve for the infraclavicular subclavian vein puncture in the landmark technique performed by anesthetists.

OBJECTIVE

The aim of this study was to examine the influence of the puncture experience on the success rate and mechanical complications, such as pneumothorax and arterial puncture in patients who received an infraclavicular subclavian vein puncture with the landmark technique. Three levels of experience were defined for comparison: inexperienced 0-20 punctures, moderately experienced 21-50 and experienced over 50 punctures.

MATERIAL AND METHODS

Post hoc analysis of a previously published noninferiority study to examine the influence of ventilation on the pneumothorax rate in the subclavian vein puncture using the landmark technique. This analysis included 1021 anesthetized patients who were included in the original study between August 2014 and October 2017. Demographic data as well as the number of puncture attempts, puncture success, the overall rate of mechanical complications, pneumothorax rate and arterial puncture rates were calculated.

RESULTS

The overall rate of mechanical complications (pneumothorax + arterial puncture) was significantly higher in the inexperienced group (0-21) compared to the experienced group (>50, 15% vs. 8.5%, respectively, p = 0.023). This resulted in an odds ratio of 0.52 (confidence interval, CI: 0.32-0.85, p = 0.027). Likewise, the rate of puncture attempts in the group of inexperienced (0-20) with 1.85 ± 1.12 was significantly higher than in the group of experienced (>50, 1.58 ± 0.99, p = 0.004) and resulted in an odds ratio of 0.59 (CI: 0.31-0.96, p = 0.028). Although the puncture attempts of the moderately experienced (21-50) compared to the inexperienced (0-20) was not significant lower, we found an odds ratio of 0.69 (CI: 0.48-0.99, p = 0.042). The rate of successful puncture was 95.1% in the experienced group versus 89.3% in the inexperienced group (p = 0.001), which resulted in an odds ratio of 2.35 (CI: 1.28-4.31, p = 0.018). When viewed individually, no significant differences were found for pneumothorax and arterial puncture.

CONCLUSION

In this post hoc analysis of the puncture of the subclavian vein using the landmark technique, we found a significant reduction of puncture attempts and overall mechanical complications. At least 50 punctures seem to be necessary to achieve the end of the learning curve; however, the landmark technique should only be used under special circumstances, when real-time ultrasound is not available. Anesthetists who want to complete their repertoire and learn the landmark technique should always perform a static ultrasound examination before starting the puncture in order to reduce complications due to anatomical variations or thrombosis.

Reducing central vein catheterization complications with a focused educational program: a retrospective cohort study

Central venous catheters (CVCs) are frequently used, but the rate of complications is high. This study evaluates the effects of a short training program for CVC insertion in a university-based teaching hospital. A sample of adults with CVCs inserted outside the intensive care unit was selected from two academic years: 2015, year without structured training, and 2016, year with structured training. Clinical and laboratory information, as well as the procedure’s characteristics and complications (mechanical and infectious) were collected. The incidence of complications before and after the training was compared. A total of 1502 punctures were evaluated. Comparing the pre- and post-training period, there was an increase in the choice for jugular veins and the use of ultrasound. A numerical reduction in the rate of complications was identified (RR 0.732; 95% CI 0.48–1.12; P = 0.166). This difference was driven by a statistically significant lower rate of catheter-related infections (RR 0.78; 95% CI 0.64–0.95; P = 0.047). In the multivariate analysis, aspects regarding technique (ultrasound use, multiple punctures) and year of training were associated with outcomes. Structured training reduces the rate of complications related to CVC insertion, especially regarding infections.

[Catheterization of the subclavian vein and the risk of pneumothorax : Mechanical ventilation increases the risk of pneumothorax during infraclavicular landmark-guided subclavian vein puncture: a prospective randomized study]

BACKGROUND

Infraclavicular subclavian vein (SCV) catheterization is a standard procedure in anesthesia and intensive care. There is a lack of evidence on how mechanical ventilation during venipuncture of the SCV influences pneumothorax rates.

OBJECTIVE

Primary hypothesis: non-inferiority of continuing vs. discontinuing mechanical ventilation during infraclavicular puncture of the SCV with respect to the pneumothorax rate.

MATERIAL AND METHODS

This prospective, randomized and single-blinded study was approved by the local ethics committee. A total of 1021 eligible patients who underwent cranial neurosurgery in 2 different university hospitals were assessed between August 2014 and October 2017. Patients were randomly assigned to two groups directly before induction of anesthesia. Intervention groups for venipuncture of the SCV were mechanical ventilation: tidal volume 7 ml/kg ideal body weight, positive end expiratory pressure (PEEP) ideal body weight/10, n = 535, or apnea: manual/spontaneous, APL valve 0 mbar, n = 486. Patients and the physicians who assessed pneumothorax rates were blinded to the intervention group. Venipuncture was carried out by both inexperienced and experienced physicians.

RESULTS

The pneumothorax rate was significantly higher in the mechanical ventilation group (2.2% vs. 0.4%; p = 0.012) with an odds ratio (OR) of 5.63 (95% confidence interval, CI: 1.17-27.2; p = 0.031). A lower body mass index (BMI) was associated with a higher pneumothorax rate, OR 0.89 (95% CI: 0.70-0.96; p = 0.013).

CONCLUSION

In this study landmark-guided infraclavicular SCV catheterization was associated with a significantly higher rate of pneumothorax when venipuncture was performed during mechanical ventilation and not in apnea. If a short phase of apnea is justifiable in the patient, mechanical ventilation should be discontinued during the venipuncture procedure.

Comparison of Ultrasound-Guided Right Brachiocephalic and Right Subclavian Vein Cannulation in Adult Patients

OBJECTIVES

To compare ultrasound-guided right brachiocephalic vein (BCV) central venous catheter (CVC) placement to right subclavian vein (SCV) CVC insertion in terms of the puncture success rate and complications.

METHODS

A retrospective review was performed for all adult patients who received an ultrasound-guided CVC via the right BCV or right SCV access route between January 2016 and March 2018. The puncture success rates and procedure-related complications were analyzed.

RESULTS

Data were analyzed from 755 adult patients who underwent 915 CVC insertions. The overall success rate was higher in the BCV group compared to that in the SCV group (98.99% versus 96.87%; P = .019). The first-attempt success rate was higher in the BCV group compared to that in the SCV group (96.64% versus 89.34%; P < .001). Intraoperative complications were observed in 16 cases in the BCV group (2.68%) and in 12 cases in the SCV group (3.76%). The incidence rates of postprocedure complications were 5.20% in the BCV group and 6.58% in the SCV group and included catheter-related infections and thrombosis.

CONCLUSIONS

Ultrasound-guided cannulation of the right BCV is an effective and safe method for CVC placement in adult patients and provides an additional option for catheter access.

Efficacy and safety of ultrasound-guided cannulation via the right brachiocephalic vein in adult patients

Central venous catheter (CVC) insertion is difficult to perform and is a high-risk operation; ultrasound (US)-guided cannulation helps increase the odds of success while reducing the associated complications. The internal jugular vein (IJV) and subclavian vein (SCV) are the most commonly sites in US-guided CVC insertion. In the present study, we evaluated the safety and efficacy of US-guided supraclavicular right brachiocephalic vein (BCV) cannulations in adult patients.Between January 2016 and December 2017, 428 adult patients requiring 536 CVC insertions underwent ultrasound-guided right BCV cannulation. The success rate and complications related to indwelling catheters were analyzed.The technical success rate was 98.32% (527/536). The procedure was successful at the first try in 511 cases (95.34%). The mean operation time was 13.26 ± 3.34 minutes. The mean length of catheter introduction was 13.57 ± 3.53 cm. Incidence of intraoperative complications was 2.61%. For 3 patients, the procedure was terminated due to pneumothorax (PNX), and in 11 arterial punctures there were self-limiting hematomas. The incidence of postprocedure complications was 5.97% (32/536). These complications included catheter-related infections (n = 18) and thromboses (n = 14). Insertion lasted an average of 10.68 ± 8.77 days.Supraclavicular, in-plane, US-guided cannulation of the right BCV is an effective and safe method for inserting central venous catheters in adult patients. It provides another option for catheter access to boost clinical performance in central venous catheterization.

O papel da ecografia vascular no manejo das complicações associadas ao acesso venoso central para hemodiálise em pacientes oncológicos: relato de dois casos e revisão da literatura

Central venous catheter implantation for hemodialysis is commonly performed in large centers and its complications are sometimes associated with insufficient training of those who perform it, but may also be related to the patient’s clinical condition. The present study reports two cases of complications related to use of a short-stay catheter for hemodialysis. In the first case, the cannula was inadvertently inserted into the left subclavian artery, causing arterial thrombosis, which was conservatively managed and good collateral perfusion was documented with vascular echography. The second case illustrates an incidental finding of Central Venous Septic Thrombosis in a patient who had used a catheter for a week, which was treated with antibiotic therapy, anticoagulation, and ultrasound control. In both cases, surgical intervention would have been high risk because of the patients' poor prognosis. Vascular ultrasonography enabled monitoring of these clinical situations and use of less aggressive treatments.

Handgrip exercise reduces peripherally-inserted central catheter-related venous thrombosis in patients with solid cancers: A randomized controlled trial

BACKGROUND

Peripherally-inserted central catheter-related venous thrombosis has serious complications including the loss of vascular access, recurrent venous thrombosis, and post-thrombotic syndrome. Current guidelines recommend non-pharmacological strategies to prevent peripherally-inserted central catheter-related venous thrombosis. There is little evidence for the effectiveness of handgrip exercise on the prevention of peripherally-inserted central catheter-related venous thrombosis.

OBJECTIVES

To examine the effectiveness of handgrip exercise using an elastic ball to prevent peripherally-inserted central catheter-related venous thrombosis in patients with solid cancers.

DESIGN

A randomized controlled trial.

SETTINGS

One teaching hospital in Nanjing, China.

PARTICIPANTS

In total, 120 subjects with solid cancers were eligible; each had a new peripherally-inserted central catheter. They were recruited and randomly assigned into two exercise groups and one control group.

METHODS

Subjects from exercise groups 1 and 2 performed a 3-week, 25-repetition handgrip exercise, 3 and 6 times daily, respectively. The control group subjects performed a gentle limb exercise with no frequency and intensity requirements. Ultrasound was used to detect venous thrombosis development and examine axillary vein blood flow over the three points.

RESULTS

There were 32 cases of peripherally-inserted central catheter-related venous thrombosis detected. Two venous thrombosis cases in the control group were symptomatic, but all venous thrombosis cases in the exercise groups were asymptomatic. All venous thromboses were partial. There were significant differences in the incidence of venous thrombosis among the three groups (χ² = 12.813, p = 0.002; χ² = 9.340, p = 0.009; χ² = 11.480, p = 0.003; and χ² = 10.534, p = 0.005, respectively) at days 2, 3 and 21. The incidence of venous thrombosis in the two exercise groups was lower than that in the control group over the 3 time points (all, p < 0.05). The between-group effects and interaction effect in vein maximum velocity and time-mean flow velocity showed significant differences (F = 4.180, p = 0.025; F = 4.010, p = 0.045; and F = 2.928, p = 0.025) at days 2, 3, and 21, respectively. The axillary vein blood flow parameters in the control group were lower than those in the two exercise groups at day 21 (all, p < 0.05). However, no significant differences occurred in the incidence of venous thrombosis and axillary vein blood flow parameters between the two exercise groups.

CONCLUSION

Handgrip exercise using an elastic ball daily for three weeks could decrease the incidence of peripherally-inserted central catheter-related venous thrombosis. The method is simple, with no negative consequence reported. Further studies are required to confirm this conclusion and to explore the optimal frequency of handgrip exercise.