French Randomized Trial Comparing Risks and Benefits of Central Venous Catheter (CVC) vs Peripheral Intravenous Catheter Access in Intensive Care Unit (ICU) Patients (Crit Care Med, 2013) [MEDLINE]: 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)
Study Endpoints
Primary: 28-day incidence of major catheter-related complications
Significantly Increased Major Catheter-Related Complications were Observed in the Peripheral Intravenous Catheter Group (133), as Compared to the Central Venous Catheter (CVC) Group (87) (p = 0.02)
Trend Toward Increased Minor Catheter-Related Complications was Observed in Peripheral Intravenous Catheter Group (248), as Compared to the Central Venous Catheter (CVC) Group (251) (p = 0.06)
No Difference in Kaplan-Meier Probabilities of Survival Between the Groups
CENSER Trial of Early Norepinephrine Use in Septic Shock (Am J Respir Crit Care Med, 2019) [MEDLINE]
Only 6 Adverse Events (Related to Peripheral Vasopressor Use) Occurred in the Early Vasopressor Group (3.8%)
1 Patient with Skin Necrosis
5 Patient with Acute Limb or Intestinal Ischemia
Retrospective Cohort Study of the Safety of Peripheral Vasopressor Administration (J Intensive Care Med, 2019) [MEDLINE]: n = 202
Incidence of Extravasation was 4%
All of the Events were Managed Conservatively (None Required an Antidote or Surgical Management)
Vasopressors were Restarted at Another Peripheral Site in 88% of the Events
Systematic Review and Meta-Analysis of Peripheral Vasopressor Administration (Am J Emerg Med, 2020) [MEDLINE]: n = 1,835
Approximately 7% of Patients Had Complications
Approximately 96% of the Complications were Minor
Meta-Analysis with Random Effects Demonstrated the Pooled Prevalence of Complications as 0.086 (95% CI: 0.031-0.21)
Studies Reporting Infusion Safety Guidelines Had Significantly Lower Prevalence of Complications (0.029; 95% CI: 0.018-0.045), as Compared to Those Not Reporting a Safety Guideline (0.12; 95% CI: 0.038-0.30, p = 0.024)
Single Center retrospective Observational Study of Peripheral vs Central Administration of Vasopressors (Aust Crit Care, 2022) [MEDLINE]: n = 212
Importantly, There were Baseline Differences Between the Groups Group 1 (Peripheral Only) Had the Lowest Median Acute Physiology and Chronic Health Evaluation III Score (64, Interquartile Range: 44-77) and Group 3 (Central Only) Had the Highest (86; Interquartile Range: 57-101)
There were No Major Complications
However, Minor Complications (Leakage, Extravasation, and Erythema) Occurred in 41% of Group 1 (Peripheral Only) and 28% of Group 2 (Peripheral Followed by Central) Patients
Duration of Peripheral Vasopressor Infusion was Not Associated with an Increased Risk of Complications
Rwandan Prospective Cohort Study of Peripheral Vasopressor Administration in Critically Ill Patients (Afr J Emerg Med, 2022) [MEDLINE]: n = 64
Median Treatment Duration was 19 hrs (IQR: 8.5-37 hrs)
Treatment Discontinuation was Predominantly Due to Mortality (41%) or Resolution of Instability (36%)
There were Two Extravasation Events (2.9%), Both Limited to Soft Tissue Swelling
Extravasation Incidence was 0.8 Events Per 1,000 Patient-Hours (95% CI: 0.2-2.2)
Prospective Observational Cohort Study of the Peripheral Administration of Norepinephrine (Chest, 2023) [MEDLINE]: n = 635
Protocol for Peripheral Norepinephrine Administration was Developed and Implemented in the Medical Intensive Care Unit
Median Number of Central Venous Catheter Days Avoided Per Patient was 1 Day (Interquartile Range: 0-2 Days Per Patient)
Of the 603 Patients Who Received Norepinephrine Peripherally as the First Norepinephrine Exposure, 51.6% of Patients Never Required Central Venous Catheter Insertion
CLOVERS Trial of Fluid Resuscitation Strategies in Sepsis (NEJM, 2023) [MEDLINE]: n = 1,563
There were 3 Events (Related to Peripheral Vasopressor Use) in Peripheral IV Catheter Vasopressor Group (Out of n = 500), All 3 were Site Extravasations
Review of Studies of Adverse Events with Peripheral Vasopressor Administration (Cleve Clin J Med, 2024) [MEDLINE]
Authors Suggested a Protocol-Based Approach to Decrease Risk of Adverse Events with Peripheral Vasopressor Administration
Monitoring of Central Venous Pressure (CVP) (see Hemodynamics)
Common Indication
Technique
Background-Internal Jugular Venous Anatomy
Trendelenburg Position Increases the Size of Internal Jugular Veins (see Trendelenburg Position)
Valsalva Maneuver Increases the Size of Internal Jugular Veins
This is Particularly Useful in the Setting of Hypovolemia
Anatomic Variations in Internal Jugular Vein and Carotid Artery Positions (Crit Care Med, 1991) [MEDLINE]
92% of Cases: internal jugular vein is located anterolateral to the carotid artery
5.5% of Cases: internal jugular vein is located outside of the path predicted by landmarks
2% of Cases: internal jugular vein is located medial to the carotid
1% of Cases: internal jugular vein is located >1 cm lateral to the carotid
Use of Ultrasound-Guidance During Central Venous Catheter (CVC) Placement
General Comments
Agency for Healthcare Research and (AHRQ) and National Institute for Health and Clinical Excellence Recommend Use of Ultrasound for Central Venous Catheter (CVC) Placement
General Advantages of Ultrasound Use for Central Venous Catheter (CVC) Placement
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
Note: arterial pulsatility will be absent during cardiopulmonary bypass, with use of a non-pulsatile ventricular assist device (VAD), and during cardiopulmonary arrest
Ultrasound Identifies the Normal Physiologic Increase in Vein Size with Valsalva
Ultrasound is Useful for Identification of Guidewire During the Procedure
Confirmation of Guidewire Position May Decrease the Morbidity/Mortality Associated with Arterial Dilation During Central Venous Catheter (CVC) Placement (Scand J Trauma Resusc Emerg Med, 2010)* [MEDLINE]
Echocardiography May Be Used for Identification of Guidewire Location and to Optimize CVC Placement During Insertion (Intensive Care Med, 2013) [MEDLINE]
Comparison of ultrasound-guided internal jugular vein and supraclavicular subclavian vein catheterization in critically ill patients: a prospective, randomized clinical trial. Ann Intensive Care. 2022 Oct 1;12(1):91. doi: 10.1186/s13613-022-01065-x [MEDLINE]
Methods: A total of 250 consecutive patients requiring central venous catheterization, were randomly assigned to undergo either ultrasound-guided out-of-plane internal jugular vein (OOP-IJV) or -plane supraclavicular subclavian vein (IP-SSCV) cannulation
All catheterizations were carried out by three physicians
The primary outcome was the first attempt success rate. Ultrasound scanning time, venous puncture time, insertion time, overall access time, number of puncture attempts, number of needle redirections, success rate, guidewire advancing difficulties, venous collapse and adverse events were also documented.
Results: The first attempt success rate was significantly higher in IP-SSCV group (83.2%) compared to OOP-IJV group (63.2%) (p = 0.001)
The IP-SSCV group was associated with a longer ultrasound scanning time (16.54 ± 13.51 vs. 5.26 ± 4.05 s; p < 0.001) and a shorter insertion time (43.98 ± 26.77 vs. 53.12 ± 40.21 s; p = 0.038)
In the IP-SCCV group, we recorded a fewer number of puncture attempts (1.16 ± 0.39 vs. 1.47 ± 0.71; p < 0.001), needle redirections (0.69 ± 0.58 vs. 1.17 ± 0.95; p < 0.001), difficulties in guidewire advancement (2.4% vs. 27.4%; p < 0.001), venous collapse (2.4%, vs. 18.4%; p < 0.001) and adverse events (8.8% vs. 13.6%; p = 0.22).
Conclusions: The IP-SSCV approach is an effective and a safe alternative to the classic OOP-IJV catheterization in critical adult patients
Use of Ultrasound in the Internal Jugular Vein Location
Ultrasound Can Identify Artery-Vein Transposition, Absent Vein, <5 mm Vein, or Thrombosis
One of These is Present in 4.3% of Cases
Ultrasound Decreases Procedure Time
Ultrasound Decreases the Number of Attempts
Ultrasound Decreases Failed Catheter Placements and Complication Rates: mainly due to avoidance of inadvertent carotid puncture at IJ site
Ultrasound Increases the Success Rate of Internal Jugular Central Venous Catheter (CVC) Placement from 96% to 100% (Anesth Analg, 1991) [MEDLINE]
Use of Ultrasound in Subclavian Location
Ultrasound Decreases Failed Catheter Placements and Complication Rates
Use of Ultrasound in Femoral Location
Ultrasound Decreases Number of Attempts
Use of Ultrasound in the Setting of Coagulopathy (see Coagulopathy)
Ultrasound is Recommended for Central Catheter Placement in the Setting of Coagulopathy (Eur J Radiol, 2008) [MEDLINE]
Success Rates are High and Complications Rates are Low Using Ultrasound in this Setting
Use of Ultrasound in the Subclavian Vein Location
Clinical Efficacy
Prospective Randomized Trial of Ultrasound-Guided Internal Jugular vs Supraclavicular Subclavian Vein Central Venous Catheter Placement (Ann Intensive Care, 2022) [MEDLINE]
First Attempt Success Rate was Significantly Higher in In-Plane Supraclavicular Subclavian Vein Group (83.2%), as Compared to Ultrasound-Guided Out-of-Plane Internal Jugular Vein Group (63.2%) (p = 0.001)
The In-Plane Supraclavicular Subclavian Vein Group was Associated with a Longer Ultrasound Scanning Time (16.54 ± 13.51 vs. 5.26 ± 4.05 s; p < 0.001) and a Shorter Insertion Time (43.98 ± 26.77 vs. 53.12 ± 40.21 s; p = 0.038)
In the In-Plane Supraclavicular Subclavian Vein Group, There were Fewer Number of Puncture Attempts (1.16 ± 0.39 vs. 1.47 ± 0.71; p < 0.001), Needle Redirections (0.69 ± 0.58 vs. 1.17 ± 0.95; p < 0.001), Difficulties in Guidewire Advancement (2.4% vs. 27.4%; p < 0.001), Venous Collapse (2.4%, vs. 18.4%; p < 0.001) and Adverse Events (8.8% vs. 13.6%; p = 0.22)
Considerations for Central Venous Catheter (CVC) Placement in the Setting of Coagulopathy (see Coagulopathy)
Types of Coagulopathy
Thrombocytopenia Represents a Higher Risk for Central Venous Catheter Placement than Clotting Factor Issues (Chest, 1996) [MEDLINE]
Site Selection in the Setting of Coagulopathy
Subclavian Site is Generally Avoided in the Setting of Coagulopathy/Thrombocytopenia, Since the Subclavian Site is Not Compressible and is Difficult to Monitor for Postprocedural Hemorrhage
Retrospective Single-Center Study of the Risk of Complications with CVC Placement in Patients with Thrombocytopenia Due to Leukemia/Stem Cell Transplant (Transfusion, 2011) [MEDLINE]
As Compared to Patients with Platelets ≥100k, Multivariate Analysis Demonstrated that Only Patients with Platelets <20k were at Increased Risk of Hemorrhage with CVC Placement
CVC Placements Can Be Safely Performed in Patients with Platelet Count ≥20k without Preprocedural Platelet Transfusion
Thrombocytopenia appears to pose a greater risk compared with prolonged clotting times (Chest, 1996) [MEDLINE] (Intensive Care Med, 2002) [MEDLINE]
Retrospective studies suggest that no preprocedure reversal is warranted for platelet Count >20k and INR <3 (Transfusion, 2017) [MEDLINE]
Use of Ultrasound in the Setting of Coagulopathy
Ultrasound is Recommended for Central Venous Catheter (CVC) Placement in the Setting of Coagulopathy (Eur J Radiol, 2008) [MEDLINE]
Success Rates are High (100% Success Rate) and Complication Rates are Low (6% Minor Complication Rate) Using Ultrasound for CVC Placement in this Setting
Recommendations for Central Venous Catheters (CVC’s) (CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011) [LINK]
Choice of Central Venous Catheter (CVC)
Use a Central Venous Catheter (CVC) with the Minimum Number of Ports/Lumens Essential for the Management of the Patient (Category IB Recommendation)
Site Selection for Nontunneled Central Venous Catheters
Weigh the Risks/Benefits of Placing a Central Venous Catheter (CVC) at a Recommended Site with the Goal of Reducing Infectious Complications Against the Risk for Mechanical Complications (Category IA Recommendation)
Subclavian Venous Site (Rather than Internal Jugular or Femoral Site) is Recommended for Nontunneled Central Venous Catheters (CVC’s) in Adult Patients to Minimize the Infection Risk (Category IB Recommendation)
Femoral Venous Site Should Be Avoided for Central Venous Access in Adult Patients, Due to the Infectious Risk (Category IA Recommendation)
Site Selection for Tunneled Central Venous Catheters
No Recommendation Can Be Made for a Preferred Site of Insertion to Minimize the Infection Risk for a Tunneled CVC (Unresolved Issue)
Site Selection for Central Venous Catheter in Patients with Chronic Kidney Disease (CKD)/End-Stage Renal Disease (ESRD)
Use a Fistula or Graft in Patients with End-Stage Renal Disease (ESRD) Instead of a Tunneled Permanent Central Venous Catheter (CVC) for Hemodialysis (Category IA Recommendation)
Avoid the Subclavian Site for CVC in Patients with Advanced Kidney Disease and Hemodialysis Patients to Avoid Subclavian Vein Stenosis (Category IA Recommendation)
Insertion Technique for Central Venous Catheter
Use Ultrasound Guidance to Place Central Venous Catheter (CVC) (If Available) to Reduce the Number of Cannulation Attempts and Mechanical Complications (Category IB Recommendation)
Ultrasound Guidance Should Only Be Used by Those Fully Trained in its Technique
When Adherence to Aseptic Technique Cannot Be Ensured (Such as a Central Venous Catheter (CVC) Inserted During a Medical Emergency), Replace the Central Venous Catheter (CVC) as Soon as Possible, Typically Within 48 hrs (Category IB Recommendation)
Routine Use of Central Venous Catheter
No Recommendation Can Be Made Regarding the Use of a Designated Lumen for Total Parenteral Nutrition (Unresolved Issue)
Promptly Remove Central Venous Catheter (CVC) When it is No Longer Required (Category IA Recommendation)
Recommendations (American Society of Diagnostic and Interventional Nephrology, Clinical Practice Committee and the Association for Vascular Access, 2008) (Semin Dial, 2008) [MEDLINE]
Identify CKD Patients Who May Require Hemodialysis in the Future
Patients with CKD-Stages 3-5
Patients with CKD-Stage 5 Currently Receiving Hemodialysis or Peritoneal Dialysis
Patients with a Functional Renal Transplant
Venous Access for stage 3–5 CKD patients
Dorsal Veins of the Hand are the Preferred Location for Phlebotomy and Peripheral Venous Access
Internal Jugular Veins are the Preferred Location for Central Venous Access
External Jugular Veins are an Acceptable Alternative for Venous Access
Subclavian Veins Should Not Be Used for Central Venous Access
Placement of a PICC Should Be Avoided
Implementation of Policy and Procedure for Venous Access in CKD Patients
Adverse Effects/Complications
Mechanical Complications Associated with Central Venous Catheter (CVC) Insertion
General Comments
Incidence of Mechanical Complications Increased 6-Fold When >3 Placement Attempts are Made by the Same Operator (NEJM, 2003) [MEDLINE]
Complication Rates of Central Venous Catheters: A Systematic Review and Meta-Analysis. JAMA Intern Med. 2024 Mar 4. doi: 10.1001/jamainternmed.2023.8232 [MEDLINE]: n = 130
Importance
Central Venous Catheters (CVC’s) are commonly used but are associated with complications. Quantifying complication rates is essential for guiding Central Venous Catheter (CVC) utilization decisions
Data sources
MEDLINE, Embase, CINAHL, and CENTRAL databases were searched for observational studies and randomized clinical trials published between 2015 to 2023
Study selection
This study included English-language observational studies and randomized clinical trials of adult patients that reported complication rates of short-term centrally inserted CVCs and data for 1 or more outcomes of interest
Studies that evaluated long-term intravascular devices, focused on dialysis catheters not typically used for medication administration, or studied catheters placed by radiologists were excluded
Data synthesis
Two reviewers independently extracted data and assessed risk of bias
Bayesian random-effects meta-analysis was applied to summarize event rates. Rates of placement complications (events/1000 catheters with 95% credible interval [CrI]) and use complications (events/1000 catheter-days with 95% CrI) were estimated
Main Outcomes
Ten Prespecified Complications Associated with Central Venous Catheter (CVC) Placement
Arrhythmia
Arterial Puncture
Arterial Cannulation
Arteriovenous Fistula
Bleeding Events Requiring Action
Cardiac Tamponade
Delay of ≥1 hr in Vasopressor Administration
Nerve Injury
Placement Failure
Pneumothorax
5 Prespecified Complications Associated with Central Venous Catheter (CVC) Use
Malfunction
Infection
Deep Venous Thrombosis
Thrombophlebitis
Venous Stenosis
Composite of 4 Serious Complications (Arterial Cannulation, Pneumothorax, Infection, or Deep Venous Thrombosis) After CVC Exposure for 3 Days was Also Assessed
Seven of 15 Prespecified Complications were Meta-Analyzed
Placement Failure occurred at 20.4 Events Per 1000 Catheters Placed (95% CrI: 10.9-34.4)
Other Rates of Central Venous Catheter (CVC) Placement Complications (per 1000 catheters) were arterial canulation (2.8; 95% CrI, 0.1-10), arterial puncture (16.2; 95% CrI, 11.5-22), and pneumothorax (4.4; 95% CrI, 2.7-6.5)
Rates of Central Venous Catheter (CVC) Use Complications were Malfunction (5.5 Per 1000 Catheter-Days; 95% CrI: 0.6-38), Infection (4.8 Per 1000 Catheter-Days; 95% CrI: 3.4-6.6), and DVT (2.7 Per 1000 Catheter-Days; 95% CrI: 1.0-6.2)
It was Estimated that 30.2 (95% CrI: 21.8-43.0) in 1000 Patients with a Central Venous Catheter (CVC) for 3 Days Would Develop ≥1 Serious Complication (Arterial Cannulation, Pneumothorax, Infection, or Deep Venous Thrombosis)
Use of Ultrasonography was Associated with Lower Rates of Arterial Puncture (Risk Ratio 0.20; 95 CrI: 0.09-0.44; 13.5 Events vs 68.8 Events/1000 Catheters) and Pneumothorax (RR 0.25; 95% CrI: 0.08-0.80; 2.4 Events vs 9.9 Events/1000 Catheters)
Conclusions
Approximately 3% of Central Venous Catheter (CVC) Placements were Associated with Major Complications
Use of Ultrasonography Guidance May Reduce Specific Risks (Including Arterial Puncture and Pneumothorax)
Subclavian Site is Associated with Increased Risk of Pneumothorax, as Compared to Femoral/Internal Jugular Sites (NEJM, 2015) [MEDLINE]
3SITES French Multi-Center, Randomized Trial Examining Complication Rates of Three Different Central Venous Catheter Insertion Sites (NEJM, 2015) [MEDLINE]: multi-center, randomized trial (n = 3471)
Subclavian Site Had a Decreased Risk of Bloodstream Infection and Symptomatic Thrombosis, as Compared to Internal Jugular and Femoral Sites
Subclavian Site: 1.5 CVC-related infections per 1000 catheter-days
Internal Jugular Site: 3.6 CVC-related infections per 1000 catheter-days
Femoral Site: 4.6 CVC-related infections per 1000 catheter-days
Subclavian SIte Had an Increased Risk of Pneumothorax, as Compared to Internal Jugular and Femoral Sites
Retained Guidewire
Epidemiology
Risk May Be Increased by Inserter Inexperience, Emergent Nature of a Procedure, or Distraction During the Procedure
Risk of Guidewire Loss Appears to Be Highest when Performing a Femoral CVC Insertion
Retained Guidewires May Be Discovered Days-Years After a Procedure (Often on Imaging Tests Performed for Unrelated Reasons): only 33% are discovered the same day as the procedure
Prognosis: 40% of guidewire retention events result in significant temporary harm due to the need for intervention to remove the wire and/or increased length of stay
Central Venous Catheter Insertion Using Femoral or Internal Jugular Venous Sites
French Meta-Analysis of the Impact of Site Selection on the Risk of Central Venous Catheter-Related Infection (Crit Care Med, 2012) [MEDLINE]
Subclavian Site was Associated with Decreased Risk of Central Venous Catheter Infection, as Compared to Femoral/Internal Jugular Sites: however, due to limitations of studies, further study is required
Systematic Review and Meta-Analysis of Catheter-Related Bloodstream Infection by Insertion Site (Crit Care Med, 2012) [MEDLINE]
Earlier Studies Demonstrated a Lower Risk of Central Line-Associated Bloodstream Infection with the Internal Jugular Site, as Compared to the Femoral Site
However, Later Studies Demonstrated No Difference in Central Line-Associated Bloodstream Infections Between the Three Sites
No Difference in the Risk of Thrombosis Between the Three Sites
Study of CVC-Related Intravascular Complications by Insertion Site (N Engl J Med, 2015) [MEDLINE]
Subclavian Site was Associated with Decreased Risk of Catheter-Related Infection and Symptomatic Thrombosis, as Compared to Other Two Sites
Subclavian Site was Associated with a Higher Risk of Pneumothorax, as Compared to Other Two Sites
French 3SITES Multi-Center, Randomized Trial Examining Complication Rates of Three Different Central Venous Catheter Insertion Sites (NEJM, 2015) [MEDLINE]: multi-center, randomized trial (n = 3471)
Subclavian Site Had a Decreased Risk of Bloodstream Infection and Symptomatic Thrombosis, as Compared to Internal Jugular and Femoral Sites
Subclavian Site: 1.5 CVC-related infections per 1000 catheter-days
Internal Jugular Site: 3.6 CVC-related infections per 1000 catheter-days
Femoral Site: 4.6 CVC-related infections per 1000 catheter-days
Subclavian SIte Had an Increased Risk of Pneumothorax, as Compared to Internal Jugular and Femoral Sites
Network Meta-Analysis Examining the Impact of Site of Insertion on Central Venous Catheter Infection Risk in ICU Patients (Crit Care Med, 2017) [MEDLINE]
Subclavian/Internal Jugular Sites Comparably Decrease the Risk of Central Venous Catheter-Related Bloodstream Infection, as Compared to the Femoral Site
Heavy Colonization at Central Venous Cathterization Site
Randomized Trial of Daily Chlorhexidine Gluconate Bath to Prevent the Acquisition of Multidrug-Resistant Organisms and Bloodstream Infections (N Engl J Med, 2013) [MEDLINE]
Daily Chlorhexidine Gluconate Bath Prevented the Acquisition of Multidrug-Resistant Organisms and Decreased the Risk of Bloodstream Infections (Including Candidemia)
French Randomized CLEAN Trial Comparing Chlorhexidine Gluconate with Povidone Iodine-Alcohol for Skin Preparation Prior to Intravascular Catheter (CVC, Hemodialysis Catheter, A-Line) Insertion (Lancet, 2015) [MEDLINE]
Chlorhexidine Gluconate Provided Better Protection Against Short-Term Catheter-Related Infections than Povidone Iodine-Alcohol
Scrubbing with Soap and Water Had No Effect on Catheter Colonization
Randomized Trial of Daily Chlorhexidine Bathing to Prevent Healthcare-Associated Infections ( JAMA, 2015) [MEDLINE]
Daily Chlorhexidine Gluconate Bathing Did Not Decrease the Incidence of Healthcare-Associated Infections (Central Line-Associated Bloodstream Infections, Catheter-Related Urinary Tract Infection, Ventilator-Associated Pneumonia, or Clostridium Difficile)
Use Lowest (Infectious) Risk Site for Central Venous Catheter Insertion: subclavian > internal jugular > femoral
Additionally, Use the Safest Insertion Site from the Perspective of Procedural Risk
Use Good Sterile Technique During Central Venous Catheter insertion
Routine Replacement of CVC’s Prophylactically Does Not Decrease the Risk of Infection
Minimize Manipulation of Central Venous Catheter and Wash Hands Before Any Contact with the Catheter
Remove Central Venous Catheter as Soon as Possible
Antibiotic or Antiseptic-Impregnated Central Venous Catheter
Although Antibiotic or Antiseptic-Impregnated Central Venous Catheters May Decrease Rates of CVC Infection, They are Not Recommended at this Time (Except Possibly in High-Risk Immunocompromised Patients)
Adverse Reactions to Chlorhexidine CVC’s Have Been Reported in Japan and the 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 Colonization (Moderate-Quality Evidence, Downgraded Due to Substantial Heterogeneity)
Catheter Impregnation Did Not Decrease the 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
Impact/Prognosis of Central Venous Catheter (CVC) Infection
Nosocomial bloodstream infections increase morbidity, duration of hospitalization, and cost per patient
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 (CVC) 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 Central Venous Catheter (CVC)
Techniques to Manage Suspected Central Venous Catheter (CVC) Infection
Central Venous Catheter (CVC) Removal/Replacement at New Site
Indications for Central Venous Catheter (CVC) Removal
Presence of Septic Shock
Presence of Infection with Staphylococcus Aureus, Candida species, and most Gram-negative rods (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 Central Venous Catheter (CVC) Exchange
Culture Central Venous Catheter (CVC) Tip (Distal 5 cm): if positive with >15 cfu, replacement CVC should be removed and reinserted at new site
Retention of Current Central Venous Catheter (CVC)
Staphylococcus Epidermidis Central Venous Catheter (CVC)-related infection can usually be managed with CVC left in place
Associated Internal Jugular Vein Site of Central Venous Catheter Placement
63.5% of patients Have Detectable Internal Jugular Thrombus (by Doppler Ultrasound) After Central Venous Catheter (CVC) Removal (Clin Cardiol, 1993) [MEDLINE]
No Correlations was Found Between Thrombus Formation and the Basic Disease, Duration of Cannulation, Type of Catheter Used, and the Mode of Heparinization
Local Inflammation Signs and Local Hematoma were More Frequently Observed in Patients with Internal Jugular Thrombus
Lower Extremity Deep Venous Thrombosis
Subclavian Deep Venous Thrombosis
Upper Extremity Deep Venous Thrombosis
Clinical Data
Study of Venous Thrombosis Rates with Subclavian vs Internal Jugular Tunneled Central Venous Catheters (CVC’s) (Radiology, 2000) [MEDLINE]
Venous Thrombosis Occurred in 13% of Patients with an Subclavian Vein Catheter, as Compared to 3% with an Internal Jugular Vein Catheter
Systematic Review and Meta-Analysis of Catheter-Related Bloodstream Infection by Insertion Site (Crit Care Med, 2012) [MEDLINE]
Earlier Studies Demonstrated a Lower Risk of Central Line-Associated Bloodstream Infection with the Internal Jugular Site, as Compared to the Femoral Site
However, Later Studies Demonstrated No Difference in Central Line-Associated Bloodstream Infections Between the Three Sites
No Difference in the Risk of Thrombosis Between the Three Sites
Meta-Analysis Comparing PICC Line with Central Venous Catheter (CVC) (Lancet, 2013) [MEDLINE]
PICC Lines Had a Higher Risk of DVT than CVC’s, Especially in Patients Who are Critically Ill or in Those with Cancer
PICC Lines Had No Increased Risk of Acute PE
Medical Inpatients and Thrombosis (MITH) Study of Central Venous Catheter (CVC) and Upper Extremity Deep Venous Thromboses (DVT’s) in Medical Inpatients (J Thromb Haemost, 2015) [MEDLINE]
Use of CVC was Associated with a 14x Increased Risk of Upper Extremity DVT (But Not Acute PE) in Medical Inpatients (95% CI, 5.9-33.2)
PICC’s were Associated with a Higher Risk of Upper Extremity DVT (Odds Ratio 13.0; 95% CI, 6.1-27.6) than CVC (Odds Ratio 3.4; 95% CI, 1.7-6.8)
French 3SITES Multi-Center, Randomized Trial Examining Complication Rates of Three Different Central Venous Catheter (CVC) Insertion Sites (NEJM, 2015) [MEDLINE]: multi-center, randomized trial (n = 3471)
Subclavian Site Had a Decreased Risk of Bloodstream Infection and Symptomatic Thrombosis, as Compared to Internal Jugular and Femoral Sites
Subclavian Site: 1.5 CVC-related infections per 1000 catheter-days
Internal Jugular Site: 3.6 CVC-related infections per 1000 catheter-days
Femoral Site: 4.6 CVC-related infections per 1000 catheter-days
Subclavian SIte Had an Increased Risk of Pneumothorax, as Compared to Internal Jugular and Femoral Sites
Incidence of asymptomatic catheter-related thrombosis in intensive care unit patients: a prospective cohort study. Ann Intensive Care. 2023 Oct 19;13(1):106. doi: 10.1186/s13613-023-01206-w [MEDLINE]
Background: Catheter-related thrombosis (CRT) incidence, rate, and risk factors vary in literature due to differences in populations, catheters, diagnostic methods, and statistical approaches. The aim of this single-center, prospective, observational study was to assess incidence, incidence rate (IR), cumulative incidence, and risk factors by means of IR ratio (IRR) of asymptomatic CRT in a non-oncologic Intensive Care Unit (ICU) population. CRT development was assessed daily by means of ultrasound screening. The proportions of patients and catheters developing CRT and CRT incidence rates, expressed as the number of events per catheter-days (cd), were calculated. Kalbfleisch and Prentice’s method was used to estimate the cumulative incidence of CRTs. Univariate and multivariable Poisson regression models were fitted to calculate IRR in risk factors analysis
Results: Fifty (25%, 95% CI 19-31) out of 203 included patients, and 52 (14%, 95% CI 11-18) out of 375 catheters inserted developed CRT [IR 17.7 (13.5-23.2) CRTs/1000cd], after 5 [3-10] days from insertion. Forty-six CRTs (88%) were partial thrombosis. All CRTs remained asymptomatic. Obesity and ECMO support were patient-related protective factors [IRR 0.24 (0.10-0.60), p = 0.002 and 0.05 (0.01-0.50), p = 0.011, respectively]. The internal jugular vein had higher CRT IR than other sites [20.1 vs. 5.9 CRTs/1000cd, IRR 4.22 (1.22-14.63), p = 0.023]. Pulmonary artery catheter and left-side cannulation were catheter-related risk factors [IRR 4.24 (2.00-9.00), p < 0.001 vs. central venous catheters; IRR 2.69 (1.45-4.98), p = 0.002 vs. right cannulation, respectively]. No statistically significant effect of the number of simultaneously inserted catheters [IRR 1.11 (0.64-1.94), p = 0.708] and of the catheterization length [IRR 1.09 (0.97-1.22), p = 0.155] was detected. The ICU length of stay was longer in CRT patients (20 [15-31] vs. 6 [4-14] days, p < 0.001), while no difference in mortality was observed
Conclusions: CRTs are frequent but rarely symptomatic. This study suggests that obesity and ECMO are protective factors, while pulmonary artery catheter, internal jugular vein and left-side positioning are risk factors for CRT.
Study of Post-Central Venous Catheter (CVC) Venous Stenosis (at Subclavian Vein vs Internal Jugular Vein Sites) in Patients Undergoing Hemodialysis (Nephrol Dial Transplant, 1991) [MEDLINE]
Post-Central Venous Catheter (CVC) Venous Stenosis Occurred in 42% of Subclavian Veins vs 10% of Internal Jugular Veins
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