Central line complications

Craig Kornbau, Kathryn C Lee, Gwendolyn D Hughes, Michael S Firstenberg, Craig Kornbau, Kathryn C Lee, Gwendolyn D Hughes, Michael S Firstenberg

Abstract

Central venous access is a common procedure performed in many clinical settings for a variety of indications. Central lines are not without risk, and there are a multitude of complications that are associated with their placement. Complications can present in an immediate or delayed fashion and vary based on type of central venous access. Significant morbidity and mortality can result from complications related to central venous access. These complications can cause a significant healthcare burden in cost, hospital days, and patient quality of life. Advances in imaging, access technique, and medical devices have reduced and altered the types of complications encountered in clinical practice; but most complications still center around vascular injury, infection, and misplacement. Recognition and management of central line complications is important when caring for patients with vascular access, but prevention is the ultimate goal. This article discusses common and rare complications associated with central venous access, as well as techniques to recognize, manage, and prevent complications.

Keywords: Bleeding; central line; complications; infection; pneumothorax.

Figures

Figure 1
Figure 1
Chest X-ray demonstrating a pulmonary artery catheter inadvertently placed via the right carotid artery into the thoracic aorta. Despite pressure waveform monitoring, erroneous placement was not noticed until a post-procedure chest was obtained. The catheter was removed immediately. Follow-up carotid ultrasound was unremarkable for arteriovenous (AV) fistula or pseudoaneurysm. This patient had no residual complications as this complication was immediately recognized and managed
Figure 2
Figure 2
(a) Vascular injury following dialysis catheter placement. Initial chest X-ray after reported uneventful place of a tunneled right internal jugular dialysis line in a 67-year-old female with end-stage renal disease. (b) After initial attempts to access catheter demonstrated that fluid was easily flushed, but not aspirated out of the catheter, attempts to change the “malfunctioning” catheter over a wire suggested that the wire was in the pleural space, and hence the catheter tip was extravascular. (c) Due to concerns of a vascular injury, removal under direct visualization was recommended. Following median sternotomy, the intraoperative findings demonstrated the catheter had punctured the confluence of the right subclavian vein as it entered into the superior vena cava. The catheter was in the right pleural space. The pericardial space had not been violated. Under direct visualization the catheter was removed and the residual hole was repaired with a purse-string and pledgeted suture. Blood loss was minimal and the postoperative recovery was uneventful. Repeat line placement several days later, under fluoroscopic guidance, was uneventful
Figure 3
Figure 3
Contralateral pneumothorax. Pneumothorax following failed chronic port placement on contralateral side
Figure 4
Figure 4
Ipsilateral pneumothorax. Pneumothorax following left-sided subclavian line placement
Figure 5
Figure 5
Fractured catheters following chronic port removal. An elderly lady who underwent combined chemo and radiation therapy for breast cancer presented for elective removal of her chronic intravascular port (top image). Upon attempted removal of the port in the operating room, the distal half fractured (bottom image). As it appeared to be immobile and potentially adherent to the vascular wall, the initial recommendation was to follow it closely for signs of migration with serial chest X-rays. Patient concern for embolization prompted attempted extraction by interventional catheter-directed techniques by interventional radiology. Such attempts were unsuccessful as the catheter appeared, as suspected, to be adherent to the innominate vein. Due to patient frailty and concerns for causing a major injury, further attempts at removal were abandoned. The patient remains asymptomatic
Figure 6
Figure 6
Chronic catheter fracture. Catheter fragment incidentally found on chest X-ray 4 years following chronic port removal. The patient was asymptomatic and opted for no intervention

References

    1. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. 2003;348:1123–33.
    1. O’Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, et al. Healthcare Infection Control Practices Advisory Committee (HICPAC) (Appendix 1). Summary of recommendations: Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis. 2011;52:1087–99.
    1. Kusminsky RE. Complications of central venous catheterization. J Am Coll Surg. 2007;204:681–96.
    1. 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.
    1. Bhutta ST, Culp WC. Evaluation and management of central venous access complications. Tech Vasc Interv Radiol. 2011;14:217–24.
    1. Powell JT, Mink JT, Nomura JT, Levine BJ, Jasani N, Nichols WL, et al. Ultrasound-guidance can reduce adverse events during femoral central venous cannulation. J Emerg Med. 2014;46:519–24.
    1. Leung J, Duffy M, Finckh A. Real-time ultrasonographically-guided internal jugular vein catheterization in the emergency department increases success rates and reduces complications: A randomized, prospective study. Ann Emerg Med. 2006;48:540–7.
    1. Fragou M, Gravvanis A, Dimitriou V, Papalois A, Kouraklis G, Karabinis A, et al. Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: A prospective randomized study. Crit Care Med. 2011;39:1607–12.
    1. Bowdle A. Vascular complications of central venous catheter placement: Evidence-based methods for prevention and treatment. J Cardiothorac Vasc Anesth. 2014;28:358–68.
    1. Vats HS. Complications of catheters: Tunneled and nontunneled. Adv Chronic Kidney Dis. 2012;19:188–94.
    1. Troianos CA, Jobes DR, Ellison N. Ultrasound-guided cannulation of the internal jugular vein. A prospective, randomized study. Anesth Analg. 1991;72:823–6.
    1. 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.
    1. Hind D, Calvert N, McWilliams R, Davidson A, Paisley S, Beverley C, et al. Ultrasonic locating devices for central venous cannulation: Meta analysis. BMJ. 2003;327:361.
    1. Pillai L, Zimmerman P, d’Audiffret A. Inadvertent great vessel arterial catheterization during ultrasound-guided central venous line placement: A potentially fatal event. J Vasc Surg. 2009;53:74.
    1. Parsons AJ, Alfa J. Carotid dissection: A complication of internal jugular vein cannulation with the use of ultrasound. Anesth Analg. 2009;109:135–6.
    1. Thompson C, Barrows T. Carotid arterial cannulation: Removing the risk with ultrasound? Can J Anaesth. 2009;56:471–2.
    1. Guilbert MC, Elkouri S, Bracco D, Corriveau MM, Beaudoin N, Dubois MJ, et al. Arterial trauma during central venous catheter insertion: Case series, review and proposed algorithm. J Vasc Surg. 2008;48:918–25.
    1. Shah PM, Babu SC, Goyal A, Mateo RB, Madden RE. Arterial misplacement of large-caliber cannulas during jugular vein catheterization: Case for surgical management. J Am Coll Surg. 2004;198:939–44.
    1. Khouzam RN, Soufi MK, Weatherly M. Heparin Infusion through through a central line misplaced in the carotid artery leading to hemorrhagic stroke. J Emerg Med. 2013;45:e87–9.
    1. Wang RC, Katz SE, Lubow M. Visual loss and central venous catheterization: Cortical blindness and hemianopsia after inadvertent subclavian artery entry. J Neuroophthalmol. 2000;20:32–4.
    1. Shah PM, Leong B, Babu SC, Goyal AM, Mateo RB. Cerebrovascular events associated with infusion through arterially malpositioned triple-lumen catheter: Report of three cases and review of literature. Cardiol Rev. 2005;13:304–8.
    1. Nayeemuddin M, Pherwani AD, Asquith JR. Imaging and management of complications of central venous catheters. Clin Radiol. 2013;68:529–44.
    1. Ratliff HL, Yousufuddin M, Lieving WR, Watson BE, Malas A, Rosencrance G, et al. Persistent left superior vena cava: Case reports and clinical implications. Int J Cardiol. 2006;113:242–6.
    1. Higgs AG, Paris S, Potter F. Discovery of left-sided superior vena cava during central venous catheterization. Br J Anaesth. 1998;81:260–1.
    1. Leibowitz AB, Halpern NA, Lee MH, Iberti TJ. Left-sided superior vena cava: A not-so-unusual vascular anomaly discovered during central venous and pulmonary artery catheterization. Crit Care Med. 1992;20:1119–22.
    1. Sweitzer BJ, Hoffman WJ, Allyn JW, Daggett WJ., Jr Diagnosis of a left-sided superior vena cava during placement of a pulmonary artery catheter. J Clin Anesth. 1993;5:500–4.
    1. Schelling G, Briegel J, Eichinger K, Raum W, Forst H. Pulmonary artery catheter placement and temporary cardiac pacing in a patient with a persistent left superior vena cava. Intensive Care Med. 1991;17:507–8.
    1. Duong MH, Jensen WA, Kirsch CM, Wehner JH, Kagawa FT. An unusual complication during central venous catheter placement. J Clin Anesth. 2001;13:131–2.
    1. Andrews RT, Geschwind JF, Savader SJ, Venbrux AC. Entrapment of J-tip guidewires by Venatech and stainless-steel Greenfield vena cava filters during central venous catheter placement: Percutaneous management in four patients. Cardiovasc Intervent Radiol. 1998;21:424–8.
    1. Graff J, Gong R, Byron R, Hassett JM. Knotting and entanglement of multiple central venous catheters. JPEN J Parenter Enteral Nutr. 1986;10:319–21.
    1. Bossert T, Gummert JF, Bittner HB, Barten M, Walther T, Falk V, et al. Swan-Ganz catheter-induced severe complications in cardiac surgery: Right ventricular perforation, knotting, and rupture of a pulmonary artery. J Card Surg. 2006;21:292–5.
    1. Hida S, Ohashi S, Kinoshita H, Honda T, Yamamoto S, Kazama J, et al. Knotting of two central venous catheters: A rare complication of pulmonary artery catheterization. J Anesth. 2010;24:486–7.
    1. Yoho DJ, Firstenberg MS. The sequelae of silence: Catheter entrapment as a preventable morbidity resulting from communication failure. Heart Res Open J. 2015;2:82–4.
    1. Wang HE, Sweeney TA. Subclavian central venous catheterization complicated by guidewire looping and entrapment. J Emerg Med. 1999;17:721–4.
    1. Song Y, Messerlian AK, Matevosian R. A potentially hazardous complication during central venous catheterization: Lost guidewire retained in the patient. J Clin Anesth. 2012;24:221–6.
    1. Jalwal GK, Rajagopalan V, Bindra A, Goyal K, Rath GP, Kumar A, et al. Percutaneous retrieval of malpositioned, kinked and unraveled guide wire under fluoroscopic guidance during central venous cannulation. J Anaesthesiol Clin Pharmacol. 2014;30:582.
    1. Vannucci A, Jeffcoat A, Ifune C, Salinas C, Duncan JR, Wall M. Special article: Retained guidewires after intraoperative placement of central venous catheters. Anesth Analg. 2013;117:102–8.
    1. Teichgraber UK, Nibbe L, Gebauer B, Wagner HJ. Inadvertent puncture of the thoracic duct during attempted central venous catheter placement. Cardiovasc Intervent Radiol. 2003;26:569–71.
    1. Konichezky S, Saguib S, Soroker D. Tracheal puncture. A complication of percutaneous internal jugular vein cannulation. Anaesthesia. 1983;38:572–4.
    1. Malik IA, Adams RG. Tracheal cuff puncture: A complication of percutaneous internal jugular vein cannulation. Am J Med. 2003;115:590–1.
    1. Lampl L. Tracheobronchial injuries. Conservative treatment. Interact Cardiovasc Thorac Surg. 2004;3:401–5.
    1. Hsu M, Trerotola SO. Air embolism during insertion and replacement of tunneled dialysis catheters: A retrospective investigation of the effect of aerostatic sheaths and over-the-wire exchange. J Vasc Interv Radiol. 2015;26:366–71.
    1. Huang YC, Huang JC, Chen SC, Chang JM, Chen HC. Lethal cardiac arrhythmia during central venous catheterization in a uremic patient: A case report and review of the literature. Hemodial Int. 2013;17:644–8.
    1. Centers for Disease Control and Prevention (CDC). Vital signs: Central line-associated blood stream infections--United States, 2001, 2008, and 2009. MMWR Morb Mortal Wkly Rep. 2011;60:243–8.
    1. To KB, Napolitano LM. Common complications in the critically ill patient. Surg Clin North Am. 2012;92:1519–57.
    1. Early TF, Gregory RT, Wheeler JR, Snyder SO, Jr, Gayle RG. Increased infection rate in double-lumen versus single-lumen Hickman catheters in cancer patients. South Med J. 1990;83:34–6.
    1. Hilton E, Haslett TM, Borenstein MT, Tucci V, Isenberg HD, Singer C. Central catheter infections: Single- versus triple-lumen catheters. Influence of guide wires on infection rates when used for replacement of catheters. Am J Med. 1988;84:667–72.
    1. Yeung C, May J, Hughes R. Infection rate for single lumen v triple lumen subclavian catheters. Infect Control Hosp Epidemiol. 1988;9:154–8.
    1. Watson CM, Al-Hasan MN. Bloodstream infections and central line-associated bloodstream infections. Surg Clin North Am. 2014;94:1233–44.
    1. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725–32.
    1. Marsteller JA, Sexton JB, Hsu YJ, Hsiao CJ, Holzmueller CG, Pronovost PJ, et al. A multicenter, phased, cluster-randomized controlled trial to reduce central line-associated bloodstream infections in intensive care units*. Crit Care Med. 2012;40:2933–9.
    1. Hoshal VL., Jr Total intravenous nutrition with peripherally inserted silicone elastomer central venous catheters. Arch Surg. 1975;110:644–6.
    1. Safdar N, Maki DG. Risk of catheter-related bloodstream infection with peripherally inserted central venous catheters used in hospitalized patients. Chest. 2005;128:489–95.
    1. Shuman EK, Washer LL, Arndt JL, Zalewski CA, Hyzy RC, Napolitano LM, et al. Analysis of central line-associated bloodstream infections in the intensive care unit after implementation of central line bundles. Infect Control Hosp Epidemiol. 2010;31:551–3.
    1. Al Raiy B, Fakih MG, Bryan-Nomides N, Hopfner D, Riegel E, Nenninger T, et al. Peripherally inserted central venous catheters in the acute care setting: A safe alternative to high-risk short-term central venous catheters. Am J Infect Control. 2010;38:149–53.
    1. Pikwer A, Akeson J, Lindgren S. Complications associated with peripheral or central routes for central venous cannulation. Anaesthesia. 2012;67:65–71.
    1. Chopra V, Anand S, Krein SL, Chenoweth C, Saint S. Bloodstream infection, venous thrombosis, and peripherally inserted central catheters: Reappraising the evidence. Am J Med. 2012;125:733–41.
    1. Chow LM, Friedman JN, MacArthur C, Restrepo R, Temple M, Chait PG, et al. Peripherally inserted central catheter (PICC) fracture and embolozation in the pediatric population. J Pediatr. 2003;142:141–4.
    1. Ioachimescu OC, Stoller JK. An ectopic peripherally inserted central catheter (’ectoPICC’) Cleve Clin J Med. 2006;73:617–8.
    1. Orme RM, McSwiney MM, Chamberlain-Webber RF. Fatal cardiac tamponade as a result of a peripherally inserted central venous catheter: A case report and review of the literature. Br J Anaesth. 2007;99:384–8.
    1. Burns KE, McLaren A. Catheter-related right atrial thrombus and pulmonary embolism: A case report and systematic review of the literature. Can Respir J. 2009;16:163–5.
    1. Elsharkawy H, Lewis BS, Steiger E, Farag E. Post placement positional atrial fibrillation and peripherally inserted central catheters. Minerva Anestesiol. 2009;75:471–4.
    1. Links DJ, Crowe PJ. Horner's syndrome after placement of a peripherally inserted central catheter. JPEN Parenter Enteral Nutr. 2006;30:451–2.
    1. Puhaindran ME, Wong HP. A case of anterior interosseous nerve syndrome after peripherally inserted central catheter (PICC) line insertion. Singapore Med J. 2003;44:653–5.
    1. Maruyama K, Koizumi T. Hydromediastinum associated with a peripherally inserted central venous catheter in a newborn infant. J Clin Ultrasound. 2006;34:195–8.
    1. David G, Gunnarsson CL, Waters HC, Horblyuk R, Kaplan HS. Economic measurement of medical errors using a hospital claims database. Value Health. 2013;16:305–10.
    1. Rosenthal MB. Nonpayment for performance? Medicare's new reimbursement rule. N Engl J Med. 2007;357:1573–5.
    1. Waters TM, Daniels MJ, Bazzoli GJ, Perencevich E, Dunton N, Staggs VS, et al. Effect of Medicare's nonpayment for Hospital-Acquired Conditions: Lessons for future policy. JAMA Intern Med. 2015;175:347–54.
    1. Martin-Hirsch DP, Newbegin CJ. Right vocal fold paralysis as a result of central venous catheterization. J Laryngol Otol. 1995;109:1107–8.
    1. Silva FS. Neck haematoma and airway obstruction in a patient with goitre: Complication of internal jugular vein cannulation. Acta Anaesthesiol Scand. 2003;47:626–9.
    1. Drachler DH, Koepke GH, Weg JG. Phrenic nerve injury from subclavian vein catheterization. Diagnosis by electromyography. JAMA. 1976;236:2880–1.
    1. Lal SM, Twardowski ZJ, Van Stone J, Keniston D, Scott WJ, Berg GG, et al. Benign intracranial hypertension: A complication of subclavian vein catheterization and arteriovenous fistula. Am J Kidney Dis. 1986;8:262–4.
    1. Sloan MA, Mueller JD, Adelman LS, Caplan LR. Fatal brainstem stroke following internal jugular vein catheterization. Neurology. 1991;41:1092–2.
    1. Tek le WG, Adkinson CD, Chaudhry SA, Jadhav V, Hassan AE, Rodriguez GJ, et al. Factors associated with favorable response to hyperbaric oxygen therapy among patients presenting with iatrogenic cerebral arterial gas embolism. Neurocrit Care. 2013;18:228–33.

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