Spotlight Case March 2004

1. Spotlight Case March 2004 Complication after Insertion of a Central Venous Catheter

2. Source and Credits • This presentation is based on the March 2004 AHRQ WebM&M Spotlight Case in Medicine • See the full article at http://webmm.ahrq.gov • CME credit is available through the Web site • Commentary by: Jeremy P. Feldman, MD, and Michael K. Gould, MD, MS; Stanford University School of Medicine • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Tracy Minichiello, MD • Managing Editor: Erin Hartman, MS

3. Learning Objectives At the conclusion of this educational activity, participants should be able to: • Review complications of central venous catheterization • Discuss patient and operator factors that affect complication rates • Describe interventions for preventing complications • Describe methods for promptly identifying complications when they occur

4. Case: Complication after CVC Placement A 46-year-old man was admitted with pneumonia and confusion. Extensive work-up included bronchoscopy, which revealed a pyogenic lung abscess, and an MRI of the brain, which showed multiple ring-enhancing lesions. IV antibiotic therapy was initiated. The attending physician inserted a central venous catheter (CVC) due to poor peripheral IV access. The procedure was performed at the right internal jugular site.

5. Case: Complication after CVC (cont.) At the end of the procedure, the operating physician reported excessive bleeding from the catheter site; this was eventually controlled with manual pressure. A chest radiograph was obtained after the procedure, and a radiologist interpreted the film as showing the catheter lying in the distal right jugular vein.

6. Complications of Venous Catheters • Mechanical • Infectious • Thrombotic McGee DC, Gould MK. N Engl J Med. 2003;348:1123-33.

7. Frequency of Complications, According to Route of Catheterization McGee DC, Gould MK. N Engl J Med. 2003;348:1123-33.

8. Choosing a site for CVC insertion • Subclavian vein is preferred • Lowest rates of infection, thrombosis, and arterial puncture • Patient comfort • Avoid femoral approach except in emergencies • Higher risk of infectious and thrombotic complications Merrer J, et al. JAMA. 2001;286:700-7; Ruesch S, et al. Crit Care Med. 2002;30:454-60.

9. The Internal Jugular Approach

10. The Subclavian Approach

11. Risk Factors for Mechanical Complications of CVC Insertion • Patient factors • Extremes in weight • Prior surgery or catheter at catheter site • Skeletal deformities • Severe scoliosis, upper extremity or neck contractures • Inability to cooperate Mansfield PF, et al. N Engl J Med. 1994;331:1735-8.

12. Risk Factors for Mechanical Complications of CVC Insertion • Operator factors: Experience • Physicians who have performed more than 50 catheterizations have half as many complications • Three or more unsuccessful passes with the needle is a marker for increased complications Sznajder JI, et al. Arch Intern Med. 1986;146:259-61; Mansfield PF, et al. N Engl J Med. 1994;331:1735-8.

13. Case: Complication after CVC (cont.) Twelve hours after the procedure, the patient developed new dysarthria, dysphagia, and left hemiplegia. A repeat brain MRI showed new cerebral infarctions in the right frontal, parietal, and temporal lobes. A carotid ultrasound was obtained to rule out carotid stenosis.

14. Case: Complication after CVC (cont.) There was no evidence of carotid artery stenosis; however, the ultrasound showed that the CVC was within the lumen of the right carotid artery. The catheter was immediately removed. The patient suffered permanent neurologic deficits, including left hemiplegia. He was eventually discharged to a long-term skilled nursing facility.

15. Chest X-ray and CVC placement • Radiographic confirmation of catheter position is generally reliable • Can also identify other complications such as pneumothorax or hemothorax • When correctly positioned, tip of catheter lies in the cavo-atrial junction, at the level of the right main stem bronchus • If catheter not inserted far enough, then the course of the arterial and venous system can be difficult to distinguish

16. Chest X-ray and CVC placement Chest x-ray showing catheter in correct position with tip at cavo-atrial junction. Chest x-ray with catheter tip in the carotid artery; note this was a subclavian approach.

17. Neurologic Deficits after CVC Placement • Neurologic deficits following catheter placement suggest arterial injury or paradoxical embolization • Immediate deficits favor air embolism • Delayed symptoms favor arterial puncture with subsequent thrombus formation and embolization

18. Arterial Puncture with CVC Insertion • Arterial puncture occurs in 5%-10% of internal jugular catheterization attempts • Pulsatile bright red blood may be an indicator but is not reliable • Volume overloaded patients on 100% oxygen may have pulsatile venous blood • Hypotensive/hypoxemic patients may have minimally pulsatile, dark arterial blood Sznajder JI, et al. Arch Intern Med. 1986;146:259-61; Martin C, et al. Crit Care Med. 1990;18:400-2.

19. Identifying Arterial Puncture During CVC Insertion • Pressure transducer • Connect needle to pressure transducer and inspect wave form • Construct manometer • After vessel cannulation, attach 20-30cm piece of sterile tubing to needle and hold upright • In arterial puncture, saline column will not drop and blood will pulsate through to top of tubing

20. Identifying Arterial Puncture During CVC Insertion • Send venous blood sample • Simultaneous analysis of radial artery blood improves accuracy • If artery is inadvertently dilated, consider vascular surgery consult

21. Ultrasound Guidance for CVC Placement • Increased successful cannulation in internal jugular approach by 10% • Reduced incidence of arterial puncture from 8.3% to 1.7% • Average access time reduced by a factor of 4 • Ultrasound visualization of subclavian vein more difficult and has not been shown to reduce complications Denys BG, et al. Circulation. 1993;87:1557-62.

22. RIJ C Ultrasound Guidance for CVC Placement Ultrasound image of the right side of the neck. C: carotid artery; RIJ: right internal jugular vein. Portable ultrasound machine for vascular access procedures.

23. Reducing CVC-related Complications • Consider PICC placement when feasible • Limit catheter insertion to experienced operators • Preferentially use the subclavian site • Use ultrasound guidance to identify target vessel when internal jugular approach necessary • Optimize patient positioning prior to insertion

24. Reducing CVC-related Complications • Use maximal sterile barrier precautions • Use chlorhexidine solution to prepare the catheter site • Consider antibiotic impregnated catheters • Assess ongoing need for CVC daily and promptly remove when no longer necessary

25. Systems-Level Approach to Reducing CVC Complications • Make institutional commitment to reduce complications rate • Identify respected physician to advocate the change • Offer training courses in central line placement • Ensure adequate supplies are available • Empower nurses to intervene if sterile precautions not followed • Follow individual complication rates and provide feedback