Cases & Commentaries

Crossing the Line

Spotlight Case
Commentary By Jeremy P. Feldman, MD; Michael K. Gould, MD, MS

Case Objectives

  • Review complications of central venous
    catheterization
  • Discuss patient and operator factors
    that affect complication rates
  • Describe methods for preventing
    complications and for promptly identifying complications when they
    occur

Case & Commentary: Part 1

A 46-year-old man was admitted with pneumonia
and confusion. The patient underwent an extensive work-up including
bronchoscopy, which revealed a pyogenic lung abscess, and an MRI of
the brain, which showed multiple ring-enhancing lesions.
Intravenous (IV) antibiotic therapy was initiated. Due to poor
peripheral IV access, a central venous catheter (CVC) was inserted
by the attending physician. The procedure was performed at the
right internal jugular site. At the end of the procedure, the
operating physician reported excessive bleeding from the catheter
site, but this was eventually controlled by manual pressure over
the site. 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.

Central venous catheterization can result in
mechanical, infectious, and thrombotic complications.(1) Mechanical
complications, such as bleeding, hematoma formation, pneumothorax,
and arterial puncture and cannulation, typically occur at the time
of insertion (Table 1).
Bleeding complications occur more commonly in patients with
coagulation abnormalities or elevated central venous pressure.

Central venous catheterization can be performed
at the internal jugular, subclavian, or femoral venous sites.
Femoral venous catheterization should be avoided except in
emergencies because it is associated with an increased risk of
infectious and thrombotic complications.(2-4) The
subclavian vein is the preferred site, especially in patients with
indistinct landmarks for internal jugular catheterization. The
subclavian site has the lowest rates of infection, thrombosis, and
arterial puncture.(2-6) There is
no difference in the rates of pneumothorax for internal jugular
versus subclavian vein placement.(6) However, it
is more difficult to control excessive bleeding when it occurs at
the subclavian site. Importantly, patients generally find
subclavian catheters more comfortable than the internal jugular
catheters.

The internal jugular vein usually runs just
lateral to the carotid artery as it traverses the anterior triangle
formed by the sternocleidomastoid muscles (Figure 1).
However, this relationship is not present in 20% of individuals, in
whom the internal jugular vein may lie medial, deep, or just
superficial to the carotid artery.(7) In contrast
to the variable anatomy of the internal jugular vein, the anatomy
at the subclavian site is more constant. The subclavian vein begins
at the lateral border of the first rib and joins the internal
jugular vein medial to the anterior scalene muscle to form the
brachiocephalic vein (Figure 2).
Throughout its course, it runs anterior and inferior to the artery.
The junction of the middle and lateral thirds of the clavicle
provides a useful surface landmark.

Several factors increase the risk of mechanical
complications during CVC insertion. These can be divided into
patient factors and operator factors. Patient factors include
extremes of weight, prior surgery in the area of the site, prior
catheterization at the same location, skeletal deformities (severe
scoliosis, upper extremity or neck contractures), and inability to
cooperate.(8) Perhaps the
most important operator-related factor is experience. Physicians
who have performed more than 50 catheterizations have half as many
complications as less experienced operators.(3)
Having three or more unsuccessful passes with the needle is also
associated with increased complications.(8)
Whenever possible, subsequent attempts should be made by a more
experienced operator, or at a different site.

Post-procedure chest x-rays are used to confirm
correct positioning of the catheter and to identify complications,
such as hemothorax and pneumothorax. In general, radiographic
confirmation of catheter location is reliable. When correctly
positioned, the tip of the catheter lies at the cavo-atrial
junction, at the level of the right mainstem bronchus (Figure 3).
However, if a catheter is not inserted far enough, then the course
of the venous and arterial system can be difficult to distinguish,
which was probably the situation in this case (Figure 4). The
suspected tip location suggests that at least 10 cm of the catheter
was outside the patient's body, since most central venous catheters
are 15-20 cm long. Conversely, if the catheter is inserted too far
and enters the right atrium or right ventricle, arrhythmias or,
less commonly, perforation of the myocardium can occur.

Case & Commentary: Part 2

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. 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.

Neurologic deficits following catheterization at
the internal jugular site, similar to the ones seen in this case,
suggest arterial injury or paradoxical embolization of thrombus or
air through a right to left shunt. The timing of this patient's
neurologic deterioration favors an arterial injury. An air embolism
would be expected to result in immediate symptoms during insertion
(or withdrawal), and catheter-related thrombosis often develops
after a period of time.

Arterial puncture occurs in approximately 5% to
10% of internal jugular catheterization attempts.(3,9) Although
pulsatile bright red blood is typically encountered when arterial
puncture occurs (hitting "Big Red"), this finding can be
unreliable. For example, volume overloaded patients breathing 100%
oxygen can have pulsatile venous blood that appears quite red, and
patients who are hypotensive and/or hypoxemic may have minimally
pulsatile arterial blood that is surprisingly dark.

The key to preventing serious injury to the
artery is identifying the arterial puncture prior to dilating the
vessel. The ideal technique should be quick, easy to perform, and
inexpensive. The most definitive technique is to attach a pressure
transducer to the needle and inspect the waveform. Alternatively,
one can insert a single lumen catheter without dilating the vessel
and attach the transducer to the catheter. Venous waves are easily
distinguished from arterial waves. Another option is to construct a
manometer with a 20-cm to 30-cm piece of sterile IV tubing flushed
with saline. After vessel cannulation, the tubing is attached to
the needle and held upright. Arterial puncture is easily
identified, as the saline column will not drop and blood will
pulsate through the top of the tubing. In contrast, venous
cannulation results in an immediate drop in the column of saline.
Sending a venous blood sample for gas analysis is another option.
Although this method often works, the result may be difficult to
interpret if the patient is particularly well oxygenated or if
hypercarbia is present. Simultaneous analysis of radial artery
blood improves the accuracy of this technique. The major drawback
to blood gas analysis is time delay, which can be minimized when
point-of-care testing is available. In the event that the carotid
or subclavian artery is dilated, vascular surgical consultation may
be indicated. This is particularly important if a large catheter,
such as an introducer sheath or a dialysis catheter, has been
placed in an artery.

Using real-time ultrasound to guide internal
jugular vein cannulation reduces complications and increases
success rates.(10,11) In one
study, the success rate with ultrasound guidance was 100%, compared
with 88% when ultrasound was not used. The same study showed that
the incidence of carotid puncture was reduced from 8.3% to 1.7%,
and the average access time was reduced by a factor of
four.(12) By using
this aid, the internal jugular vein is easily identified (Figure 5) even
in patients with thick necks and poorly visible landmarks. In
contrast, visualizing the subclavian vein with ultrasound is more
difficult; it is probably for this reason that the use of
ultrasound for subclavian placement does not clearly reduce the
incidence of complications.(8) The lack of
clear benefit at the subclavian site may also be due to the more
consistent anatomic relationship between the subclavian vein and
surface landmarks.

Several inexpensive portable ultrasound machines
are available for use (Figure 6). As
with all new technologies, training is required to ensure optimal
results. To avoid contamination of the site, specially designed
sterile sleeves should be used to cover the transducer. Sterile
gloves are not an appropriate alternative, because they do not
cover the entire apparatus.

Mechanical, infectious and thrombotic
complications of central venous catheterization are common but
preventable. Reduction in mechanical complications can be achieved
by ensuring adequate training and experience of the operator,
preferential use of the subclavian site for vascular access,
regular use of an ultrasound device to identify the target vessel
when the internal jugular approach is necessary, and optimization
of patient positioning prior to procedure. Table
2
lists several additional system-level interventions that may
reduce the incidence of CVC-related complications.

To implement these changes with the greatest
chances of success, health care systems should: (i) make it an
institutional priority to reduce complications of central venous
catheterization, (ii) identify a respected clinician to be an
advocate for change, (iii) offer training courses in central line
placement, (iv) ensure that necessary supplies (sterile drapes,
portable ultrasound devices, chlorhexidine antiseptic solution,
antibiotic-impregnated catheters) are readily available, (v)
empower nurses to intervene when sterile precautions are not
followed, and (vi) provide specific feedback to providers with high
complication rates. Because brief, one-time interventions are not
likely to result in lasting improvements, ongoing efforts to change
both the attitudes and behaviors of providers are necessary.

Jeremy P. Feldman,
MD
E-Bay Fellow in Pulmonary Vascular Disease
Stanford University School of Medicine

Michael K. Gould, MD,
MS
Research Associate and Staff Physician, VA Palo Alto Health Care
System
Assistant Professor of Medicine and of Health Research and
Policy
Fellow, Center for Primary Care and Outcomes Research
Stanford University School of Medicine

Dr. Gould is supported by an Advanced Research
Career Development Award from the Department of Veterans Affairs
Health Services Research and Development Service. The views
expressed in this commentary are those of the authors and do not
necessarily represent the views of the Department of Veterans
Affairs.

Faculty Disclosure: Drs. Feldman and Gould
have declared that neither they, nor any immediate member of their
family, have a financial arrangement or other relationship with the
manufacturers of any commercial products discussed in this
continuing medical education activity. In addition, their
commentary does not include information regarding investigational
or off-label use of pharmaceutical products or medical devices.

References

1. McGee DC, Gould MK. Preventing complications
of central venous catheterization. N Engl J Med.
2003;348:1123-33.[ go to PubMed ]

2. Merrer J, De Jonghe B, Golliot F, et al.
Complications of femoral and subclavian venous catheterization in
critically ill patients: a randomized controlled trial. JAMA.
2001;286:700-7.[ go to PubMed ]

3. Sznajder JI, Zveibil FR, Bitterman H, Weiner
P, Bursztein S. Central vein catheterization: failure and
complication rates by three percutaneous approaches. Arch Intern
Med. 1986;146:259-61.[ go to PubMed ]

4. Durbec O, Viviand X, Potie F, Vialet R,
Albanese J, Martin C. A prospective evaluation of the use of
femoral venous catheters in critically ill adults. Crit Care Med.
1997;25:1986-9.[ go to PubMed ]

5. McKinley S, Mackenzie A, Finfer S, Ward R,
Penfold J. Incidence and predictors of central venous catheter
related infection in intensive care patients. Anaesth Intensive
Care. 1999;27:164-9.[ go to PubMed ]

6. Ruesch S, Walder B, Tramer M. Complications of
Central Venous Catheters: Internal Jugular versus Subclavian
access-A Systematic Review. Crit Care Med. 2002;30:454-60.[ go to PubMed ]

7. Dickinson CS, Roth SM, Russell JM, et al.
Placement of internal jugular vein central venous catheters:
anatomic ultrasound assessment and literature review. Surg Rounds.
1996;19:102-16

8. Mansfield PF, Hohn DC, Fornage BD, Gregurich
MA, Ota DM. Complications and failures of subclavian-vein
catheterization. N Engl J Med. 1994;331:1735-8.[ go to PubMed ]

9. Martin C, Eon B, Auffray JP, Saux P, Gouin F.
Axillary or internal jugular central venous catheterization. Crit
Care Med. 1990;18:400-2.[ go to PubMed ]

10. Teichgraber UK, Benter T, Gebel M, Manns MP.
A sonographically guided technique for central venous access. AJR
Am J Roentgenol. 1997;169:731-3.[ go to PubMed ]

11. Randolph AG, Cook DJ, Gonzales CA, Pribble
CG. Ultrasound guidance for placement of central venous catheters:
a meta-analysis of the literature. Crit Care Med.
1996;24:2053-8.[ go to PubMed ]

12. Denys BG, Uretsky BF, Reddy PS.
Ultrasound-assisted cannulation of the internal jugular vein. A
prospective comparison to the external landmark-guided technique.
Circulation. 1993 May;87:1557-62.[ go to PubMed ]

13. Raad II, Hohn DC, Gilbreath BJ, et al.
Prevention of central venous catheter-related infections by using
maximal sterile barrier precautions during insertion. Infect
Control Hosp Epidemiol. 1994;15:231-8.[ go to PubMed ]

14. Maki DG, Stolz SM, Wheeler S, Mermel LA.
Prevention of central venous catheter-related bloodstream infection
by use of an antiseptic-impregnated catheter: a randomized,
controlled trial. Ann Intern Med. 1997;127:257-66.[ go to PubMed ]

15. Veenstra DL, Saint S, Sullivan SD.
Cost-effectiveness of antiseptic-impregnated central venous
catheters for the prevention of catheter-related bloodstream
infection. JAMA. 1999;282:554-60.[ go to PubMed ]

Tables

Table 1. Frequency of Mechanical
Complications, According to the Route of Catheterization

Complication

Frequency

 

Internal Jugular (%)

Subclavian (%)

Femoral (%)

Arterial puncture

6.3 to 9.4

3.1 to 4.9

9.0 to 15.0

Hematoma

1.2 to 2.1

3.8 to 4.4

Hemothorax

NA

0.4 to 0.6

NA

Pneumothorax

1.5 to 3.1

NA

Total

6.3 to 11.8

6.2 to 10.7

12.8 to 19.4

Adapted from reference 1. NA= not applicable.

Table 2. Interventions that May Reduce the
Risk of Complications

1. Limit catheter insertion to
experienced operators (3)

2. Consider peripherally inserted central
venous catheters (PICC) when possible

3. Have available ultrasound machines
with a supply of sterile sleeves (10,11)

4. Tape sterile IV tubing to the catheter
kit

5. Preferentially use the subclavian site
(2-5)

6. Optimize patient positioning prior to
beginning the procedure (Trendelenburg for internal jugular
insertions; towel roll under the back for insertion at the
subclavian site)

7. Use maximal sterile barrier
precautions (large sterile drape, cap, gown, gloves, mask)
(13)

8. Use chlorhexidine solution to prepare
the catheterization site

9. Consider using an antibiotic
impregnated catheter, especially if the institutional risk of
infectious complications is above average (14,15)

10. Assess ongoing need for central
catheter at least once daily and promptly remove when no longer
necessary

Figures

Figure 1. Landmarks for Internal Jugular
Approach


Figure 2. Landmarks for Subclavian
Approach


Figure 3. Chest X-Ray Showing Catheter in
Correct Position with Tip at Cavo-Atrial Junction


Figure 4. Chest X-Ray with Catheter in Wrong
Position*


*Not the actual radiograph from this case.
Catheter tip in the carotid artery; note this was a subclavian
approach.

Figure 5. Ultrasound Image of the Right Side
of the Neck


C=Carotid artery, RIJ=Right internal jugular
vein

Figure 6. Portable Ultrasound Machine for
Vascular Access Procedures