Indications

Intravenous Infusion of Total Parenteral Nutrition (TPN) (see Total Parenteral Nutrition, [[Total Parenteral Nutrition]])

• Common Indication

Intravenous Infusion of Vasoactive Medications

Agents Where Administration Via Central Venous Catheter is Recommended

• Dopamine (see Dopamine, [[Dopamine]])
• Epinephrine (see Epinephrine, [[Epinephrine]])
• Isoproterenol (Isuprel) (see Isoproterenol, [[Isoproterenol]])
• Norepinephrine (Levophed) (see Norepinephrine, [[Norepinephrine]])
• Phenylephrine (Neosynephrine) (see Phenylephrine, [[Phenylephrine]])
• Vasopressin (see Vasopressin, [[Vasopressin]])

Clinical Efficacy – Central Venous Catheter vs Peripheral IV in Intensive Care Unit (ICU) Patients

• French Randomized Trial Comparing Risks and Benefits of CVC vs Peripheral IV Access in ICU Patients (Crit Care Med, 2013) [MEDLINE]
  • Study: randomized cross-over trial studying assignment of initial venous access in 3 French ICU’s (n = 135 CVC’s + 128 non-midline peripheral IV’s)
    • Primary Endpoint: 28-day incidence of major catheter-related complications
      • Mechanical Complications: pneumothorax, arterial puncture, hematoma, CVC insertion site changes, peripheral venous catheter insertion difficulty, infiltration
      • Infectious Complications: erythema, phlebitis, bacteremia, catheter-related infection
      • Thrombotic Complications: thrombosis of vessel
    • Seconary Endpoints
      • Minor Complications
      • Mortality
      • Amount of Medical/Paramedical Time Used
  • Main Findings
    • Significantly Increased Major Catheter-Related Complications in Peripheral IV Group (133), as Compared to the CVC Group (87) (p=0.02)
    • Trend Toward Increased Minor Catheter-Related Complications in Peripheral IV Group (248), as Compared to the CVC Group (251) (p=0.06)
    • No Difference in Kaplan-Meier Probabilities of Survival Between the Groups

Inadequate Peripheral Venous Access

• Common Indication

Intravenous Administration of Other Medications

• Chemotherapy
• Hypertonic Saline (see Hypertonic Saline, [[Hypertonic Saline]])
• Nicardipine (Cardene) (see Nicardipine, [[Nicardipine]])
• Potassium Chloride (KCl) (see Potassium Chloride, [[Potassium Chloride]]): when more rapid replacement is required

Intravenous Fluid Resuscitation in Hypotension/Shock States (see Hypotension, [[Hypotension]])

• Cardiogenic Shock (see Cardiogenic Shock, [[Cardiogenic Shock]])
• Distributive Shock
  • Anaphylactic Shock/Anaphylaxis (see Anaphylaxis, [[Anaphylaxis]])
  • Septic Shock/Sepsis (see Sepsis, [[Sepsis]])
  • Systemic Inflammatory Response Syndrome (SIRS) (see Sepsis, [[Sepsis]])
  • Endocrine/Nutritional Deficiency-Associated Hypotension
  • Hematologic Disease-Associated Hypotension
  • Neurogenic Shock (see Neurogenic Shock, [[Neurogenic Shock]])
  • Drug/Toxin-Associated Hypotension
• Hemorrhagic Shock (see Hemorrhagic Shock, [[Hemorrhagic Shock]])
• Hypovolemic Shock (see Hypovolemic Shock, [[Hypovolemic Shock]])
• Obstructive Shock

Monitoring of Central Venous Pressure (CVP) (see Hemodynamics, [[Hemodynamics]])

• Common Indication

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Central Venous Catheter (CVC) Placement

Ultrasound-Guided Central Venous Catheter Placement

Agency for Healthcare Quality Research (AHRQ) Recommendation

• Use of ultrasound for CVC placement is recommended by AHRQ as patient safety practice

Advantages of Vascular Ultrasound

• Identifies Vein by Compressibility: although it is harder to compress subclavian vein
• Identifies Vein and Artery by Doppler Flow
  • Red = flow toward probe
  • Blue = flow away from probe
• Identifies Increase in Vein Size with Valsalva

Use of Ultrasound in Internal Jugular Location

• Can Identify Artery-Vein Transposition, Absent Vein, <5 mm Vein, or Thrombosis: one of these is present in 4.3% of cases
• Decreases Procedure Time
• Decreases Number of Attempts
• Decreases Failed Catheter Placements and Complication Rates: mainly due to avoidance of inadvertent carotid puncture at IJ site

Use of Ultrasound in Subclavian Location

• Decreases Failed Catheter Placements and Complication Rates

Use of Ultrasound in Femoral Location

• Decreases Number of Attempts

Impact of Ultrasound on CVC Infection Rates

• No Impact on Infection Rate

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Complications of Central Venous Catheter

Air Embolism (see Air Embolism, [[Air Embolism]])

• Increased risk in internal jugular and subclavian, as compared to femoral location
• Air embolism most often occurs with catheter hub fractures or disconnections rather than during the insertion of the catheter

Central Venous Catheter Infection

Epidemiology of Central Venous Catheter Infection

• Incidence of Central Venous Catheter Infection
  • Infection is the most common CVC complication
  • 3-7% of CVC’s become infected
• Risk of Infection Relative to Peripheral IV: CVC’s have a much higher risk of infection than peripheral IV
• Impact of Central Venous Catheter Infection: nosocomial bloodstream infections increase morbidity, duration of hospitalization, and cost per patient

Risk Factors for Central Venous Catheter Infection

• Administration of Total Parenteral Nutrition (TPN)
• Catheter Insertion into Femoral or Internal Jugular Sites
  • French Multi-Center, Randomized Trial Examining Complication Rates of Three Different Central Venous Catheter Insertion Sites (2015) [MEDLINE]
    • Study: multi-center, randomized trial (n = 3471)
    • Main Findings
      • Subclavian Site: 1.5 central venous catheter-related infections per 1000 catheter-days
      • Internal Jugular Site: 3.6 central venous catheter-related infections per 1000 catheter-days
      • Femoral Site: 4.6 central venous catheter-related infections per 1000 catheter-days
• Heavy Colonization at Cathterization Site
• Increasing Severity of Illness
• Need for Mechanical Ventilation
• Prolonged Duration of Cathterization
• Prolonged Hospitalization Before Catheterization

Microbiology of Central Venous Catheter Infection

• Staphylococcus Epidermidis (see Staphylococcus Epidermidis, [[Staphylococcus Epidermidis]])
• Staphylococcus Aureus (see Staphylococcus Aureus, [[Staphylococcus Aureus]])

Factors Which Decrease Bacterial Colonization of Central Venous Catheter

(note: plastic shields over Swan do not decrease catheter bacterial colonization)

• Tunneling of Central Venous Catheter
  • Tunneling increases the distance between skin site (which is the main site of entry of the bacteria) and the bloodstream
  • Several trials have shown that tunneling decreases rates of catheter-related sepsis
• Heparin-Bonding of Central Venous Catheter
  • Heparin (whether bonded to CVC, infused, or given SQ) decreases thrombus formation
  • Heparin also decreases the incidence of catheter-related bacteremia
• Silver-Impregnation of Central Venous Catheter Cuff
• Antimicrobial-Impregnation of Central Venous Catheter
  • Using minocycline + rifampin or chlorhexidine + silver sulfadiazine
  • Antimicrobial CVC impregnation decreases the incidence of catheter-related bacteremia
  • Antimicrobial effectiveness decreases with duration of CVC catheterization

Prevention of Central Venous Catheter Infection

• Remove Central Venous Catheter as Soon as Possible
• Minimize Manipulation of Central Venous Catheter: hand washing before contact
• Use Safer Geographic Sites of Insertion
• Use Good Sterile Technique During Central Venous Catheter insertion
  • Routine replacement of Central Venous Catheters prophylactically does not decrease risk of infection
• Antibiotic or Antiseptic-Impregnated Central Venous Catheter: although may decrease rates of CVC infection, they are not recommended at this time (except possibly in high-risk immunocompromised patients)
  • However, adverse reactions to chlorhexidine CVC’s has been reported in Japan and effect on antibiotic resistance has not been evaluated
  • Systematic Review of Impregnation, Coating, or Binding of Central Venous Catheters in Preventing Catheter-Related Bloodstream Infection (Cochrane Database Syst Rev, 2016) [MEDLINE]
    • Catheter Impregnation Decreased Catheter-Related Bloodstream Infection (High-Quality Evidence)
    • Catheter Impregnation Decreased Catheter Colonization (Moderate-Quality Evidence, Downgraded Due to Substantial Heterogeneity)
    • Catheter Impregnation Did Not Decreased Rate of Clinically-Diagnosed Sepsis, All-Cause Mortality, and Catheter-Related Local Infections
    • In Subgroup Analysis for Catheter Colonization, Catheter Impregnation Conferred Benefit in ICU Patients, But Not in Hematologic-Oncologic Patients or Patients Who Required CVC for Chronic TPN: no variation between groups was observed for the outcome of of catheter-related bloodstream infection
    • No Difference Between Risks of Thrombosis/Thrombophlebitis, Bleeding, Erythema, or Insertion Site Tenderness Between Impregnated and Non-Impregnated Catheters
• Use of Central Venous Catheter Dressing/Securement Device
  • Systematic Review of Central Venous Catheter Dressing/Securement Devices (Cochrane Database Syst Rev, 2015) [MEDLINE]: most studies were conducted in the ICU setting
    • Medication-Impregnated Dressings Decrease the Incidence of Catheter-Related Bloodstream Infection, as Compared to All Other Dressing Types
    • Some Evidence that Chlorhexidine Gluconate-Impregnated Dressings, as Compared to Polyurethane Dressings, Decrease the Frequency of Infection Per 1000 Patient Days, Risk of Catheter Tip Colonization, and Possibly the Risk of Catheter-Related Bloodstream Infection
    • Sutureless Securement Devices are Likely the Most Effective at Decreasing Catheter-Related Bloodstream Infection, Although Data Quality is Low

Prognosis of Central Venous Catheter Infection

• Patients that develop nosocomial bloodstream infections are 15-20x more likely to die than those that do not

Factors influencing Management of Suspected Central Venous Catheter Infection

• Whether There is Frank Evidence of Infection at Insertion Site
• Whether or Not Septic Shock is Present
• Blood Culture Results and the Specific Organism Recovered
• Risk of Placing a New CVC

Techniques to Manage Suspected Central Venous Catheter Infection

• Central Venous Catheter Removal/Replacement at New Site
  • Indications for CVC Removal
    • Presence of Septic Shock
    • Presence of Infection with Staphylococcus Aureus, Candida species, and most GNR’s
      • These have increased risk of persistent infection, metastatic infection, and/or higher mortality if treated with antimicrobial agents through the existing CVC
      • In a multicenter, prospective, observational study of patients with Candidemia, mortality rate for patients in whom the CVC was retained was 2x that of patients in whom the CVC was removed
• Guidewire CVC Exchange
  • Culture CVC Tip (distal 5 cm): if positive with >15 cfu, replacement CVC should be removed and reinserted at new site
• Retention of Current CVC
  • Staphylococcus Epidermidis CVC-related infection can usually be managed with CVC left in place

Inadvertent Central Venous Catheter Placement Into Pleural Space

• Clinical
  • Pleural Effusion (see Pleural Effusion-Transudate, [[Pleural Effusion-Transudate]] and Pleural Effusion-Exudate, [[Pleural Effusion-Exudate]]): pleural fluid will have characteristics of the infused fluid, so may be transudative or exudative

Pneumothorax (see Pneumothorax, [[Pneumothorax]])

• Epidemiology
  • French Multi-Center, Randomized Trial Examining Complication Rates of Three Different Central Venous Catheter Insertion Sites (2015) [MEDLINE]
    • Study: multi-center, randomized trial (n = 3471)
    • Main Findings: subclavian central venous catheters had a 3x higher risk of pneumothorax requiring chest tube insertion (1.5% of cases), as compared to internal jugular sites (0.5% of cases)

Septic Embolism to Lungs (see Septic Embolism, [[Septic Embolism]])

• Epidemiology: associated with chronic CVC use

Venous Thrombosis

• Deep Venous Thrombosis (DVT) (see Deep Venous Thrombosis, [[Deep Venous Thrombosis]])
  • Lower Extremity Deep Venous Thrombosis
  • Subclavian Deep Venous Thrombosis
• Internal Jugular Vein Thrombosis (see Internal Jugular Vein Thrombosis, [[Internal Jugular Vein Thrombosis]])
  • Epidemiology: when CVC placed is in the internal jugular vein
    • 63.5% of patients have detectable internal jugular thrombus (by Doppler U/S) after CVC removal [MEDLINE]
      • No correlations was found between thrombus formation and the basic disease, duration of cannulation, the type of catheters used, and the mode of heparinization
      • Local inflammation signs and local hematoma were more frequently observed in patients with internal jugular thrombus

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References

• Duplex Sonographic Detection of Internal Jugular Venous Thrombosis after Removal of Central Venous Catheters. Clin Cardiol 1993; 16(1): 26–29 [MEDLINE]
• Subclavian hemodialysis catheter infections: a prospective, randomized trial of an attachable silver-impregnated cuff for prevention of catheter-related infections. Infect Control Hosp Epidemiol 1995; 16:506-511 [MEDLINE]
• Therapeutic approaches in patients with candidemia. Evaluation in a multicenter, prospective, observational study. Arch Intern Med 1995; 155:2429-2435 [MEDLINE]
• Tunneling short-term central venous catheters to prevent catheter-related infection: a meta-analysis of randomized, controlled trials. Crit Care Med 1998; 26:1452-1457 [MEDLINE]
• Benefit of heparin in central venous and pulmonary artery catheters: a meta-analysis of randomized controlled trials. Chest 1998; 113:165-171 [MEDLINE]
• A comparison of two antimicrobial-impregnated central venous catheters. N Engl J Med 1999; 340:1-8 [MEDLINE]
• Prevention of intravascular catheter-related infections. Ann Intern Med 2000; 132:391-402 [MEDLINE]
• Guidelines for the management of intravascular catheter-related infections. Clin Infect Dis 2001; 32:1249-1272 [MEDLINE]
• Guidelines for the prevention of catheter-related infections. MMWR 2002; 51:1-29 [MEDLINE]
• Preventing complications of central venous catheterization. N Engl J Med 2003; 348:1123-1133 [MEDLINE]
• Central venous catheterization. Crit Care Med. 2007 May;35(5):1390-6 [MEDLINE]
• Central or peripheral catheters for initial venous access of ICU patients: a randomized controlled trial. Crit Care Med. 2013 Sep;41(9):2108-15. doi: 10.1097/CCM.0b013e31828a42c5 [MEDLINE]
• Intravascular Complications of Central Venous Catheterization by Insertion Site. N Engl J Med. 2015 Sep 24;373(13):1220-9. doi: 10.1056/NEJMoa1500964 [MEDLINE]
• Dressings and securement devices for central venous catheters (CVC). Cochrane Database Syst Rev. 2015 Sep 10;(9):CD010367. doi: 10.1002/14651858.CD010367.pub2 [MEDLINE]
• Catheter impregnation, coating or bonding for reducing central venous catheter-related infections in adults. Cochrane Database Syst Rev. 2016 Mar 16;3:CD007878. doi: 10.1002/14651858.CD007878.pub3 [MEDLINE]