Central venous catheterization

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In medicine, central venous catheterization (CVC or central venous line) is "placement of an intravenous catheter in the subclavian, jugular, or other central vein for central venous pressure determination, chemotherapy, hemodialysis, or hyperalimentation."[1]. A catheter is placed into a large vein in the neck, chest or groin. This is inserted by a physician when the patient needs more intensive cardiovascular monitoring, for assessment of fluid status, and for improved of intravenous infusions of medications or fluid therapy. The most commonly used veins are the internal jugular vein, the subclavian vein and the femoral vein. This is in contrast to a peripheral catheterization which is usually placed in the arms or hands.

Peripherally inserted central catheters (PICC lines) are an option.[2][3]

It is unclear if measurement of the central venous pressure is the best guide to intravenous infusions.[4]

Pulmonary arterial catheterization does not offer advantages.[5][6]

How to insert

A before and after study, although without an interrupted time series analysis to exclude the possibility of a secular trend, found that a five-item protocol can reduce cross infections:[7]

  1. hand washing
  2. full-barrier precautions during the insertion
  3. cleaning the skin with chlorhexidine
  4. avoiding the femoral site if possible
  5. removing unnecessary catheters

If after the insertion the chest radiography shows that the vertical distance from the CVC tip to the carina is more than 55 mm, the line may have been inserted too far.[8]


Ultrasonographic guidance

Ultrasonographic guidance may reduce complications.[9]

How to remove

The line should be removed while the patient is laying down in the Trendelenburg position and having the patient perform the Valsalva maneuver and exhaling in order to prevent air embolism..[10]

If an air embolism occurs, positioning the patient in the left lateral decubitus or Trendelenburg positions may help. Administering intravenous fluids and supplmenental oxygen may help. The air can be aspirated with a new central venous or pulmonary arterial catheter. More details are available.[10][11]

Complications

Thrombosis

27% to 67% of patients may have catheter-associated deep vein thrombosis.[12] A meta-analysis found that "anticoagulant prophylaxis is effective for preventing all catheter-associated deep vein thrombosis in patients with central venous catheters. The effectiveness for preventing symptomatic venous thromboembolism, including pulmonary embolism, remains uncertain."[12]

Thrombosis may also occur with peripherally inserted central catheters, especially if the catheter tip is not in the superior vena cava.[13]

Treatment

If the central line needs to remain for drug administration, then thrombolysis may be used.[14] If the line is no longer needed, the catheter is removed after 3-5 days of anticoagulation.[14] Clinical practice guidelines by the American College of Chest Physicians agree for neonotes (ACCP states the recommendation is a "Weak recommendation, low or very low-quality evidence, Grade 2C")[15] , but anticoaguation is not specified for adults[16]. Anticoagulation should be continued for at least 3 months.[16]

Air embolism

Air embolism may occur when a catheter is removed - see section above on removal.

Embolism of catheter fragment

A catheter fragment may embolize.[17] This may be due to pinch-off syndrome (catheter constricted between clavicle and first rib), catheter removal, catheter disconnection, and catheter rupture .[17] This may manifest at catheter malfunction, arrhythmia, pulmonary symptoms, or septic syndromes.[17]

Infection

All catheters can introduce bacteria into the bloodstream, but CVCs are known for occasionally causing Staphylococcus aureus and Staphylococcus epidermidis sepsis. The incidence of staphylococcal infections is decreasing.[18]

Clinical practice guidelines address the diagnosis and treatment of infections.[19]

Diagnosis

A patient with a central line, fever, and no obvious cause of the fever may have catheter-related sepsis. A meta-analysis found "Paired quantitative blood culture is the most accurate test for diagnosis of IVD-related bloodstream infection. The cultures are compared for number of colonies with line infection indicated by 5:1 ratio (CVC versus peripheral). However, most other methods studied showed acceptable sensitivity and specificity (both >0.75) and negative predictive value (>99%)".[20]

Quantitative cultures are not commonly available. Alternatively, paired qualitative cultures in which time to positivity is assessed with line infection indicated by cultures that are positive 2 hours before peripheral cultures.[20]

This analysis did not include Gram stain and acridine-orange leucocyte cytospin test (AOLC) of 100 microliters of catheter blood (treated with edetic acid) which one group of investigators proposes. [21]

The American Centers for Disease Control and Prevention recommends again routine culturing of central venous lines upon their removal.[22] However, the three cited studies do not directly address the validity of this practice.[23][24][25]

Treatment

Generally, antibiotics are used, and occasionally the catheter will have to be removed. In the case of bacteremia from staphylococcus aureus, removing the catheter without administering antibiotics is not adequate as 38% of such patients may still develop bacterial endocarditis.[26]

Prevention of complications

A "chlorhexidine gluconate–impregnated sponge (CHGIS) in intravascular catheter dressings may reduce catheter-related infections" whereas changing unsoiled dressings every 3 versus every 7 days may not matter according to a factorial randomized controlled trial. [27]

To prevent infection, some central lines are now coated or impregnated with antibiotics, silver (specifically silver sulfadiazine) and or chlorahexadine.

Using chlorhexidine-based solutions to wash the insertion site[28], or the whole patient[29], may prevent bacteremia according to randomized controlled trials.

Routine replacement of a new central line catheter did not help in a randomized controlled trial.[30]

Clinical practice guidelines from the American Centers for Disease Control and Prevention make a number of recommendations.[22]

References

  1. ↑ Anonymous (2024), Central venous catheterization (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. ↑ Lam S, Scannell R, Roessler D, Smith MA (1994). "Peripherally inserted central catheters in an acute-care hospital.". Arch Intern Med 154 (16): 1833-7. PMID 8053751.
  3. ↑ Graham DR, Keldermans MM, Klemm LW, Semenza NJ, Shafer ML (1991). "Infectious complications among patients receiving home intravenous therapy with peripheral, central, or peripherally placed central venous catheters.". Am J Med 91 (3B): 95S-100S. PMID 1928199.
  4. ↑ Marik PE, Baram M, Vahid B (2008). "Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares.". Chest 134 (1): 172-8. DOI:10.1378/chest.07-2331. PMID 18628220. Research Blogging.
  5. ↑ National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. Wheeler AP, Bernard GR, Thompson BT, Schoenfeld D, Wiedemann HP et al. (2006). "Pulmonary-artery versus central venous catheter to guide treatment of acute lung injury.". N Engl J Med 354 (21): 2213-24. DOI:10.1056/NEJMoa061895. PMID 16714768. Research Blogging. Review in: ACP J Club. 2006 Nov-Dec;145(3):70
  6. ↑ Richard C, Warszawski J, Anguel N, Deye N, Combes A, Barnoud D et al. (2003). "Early use of the pulmonary artery catheter and outcomes in patients with shock and acute respiratory distress syndrome: a randomized controlled trial.". JAMA 290 (20): 2713-20. DOI:10.1001/jama.290.20.2713. PMID 14645314. Research Blogging. Review in: ACP J Club. 2004 Jul-Aug;141(1):6
  7. ↑ Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S et al. (2006). "An intervention to decrease catheter-related bloodstream infections in the ICU.". N Engl J Med 355 (26): 2725-32. DOI:10.1056/NEJMoa061115. PMID 17192537. Research Blogging.
  8. ↑ Wirsing M, Schummer C, Neumann R, Steenbeck J, Schmidt P, Schummer W (September 2008). "Is traditional reading of the bedside chest radiograph appropriate to detect intraatrial central venous catheter position?". Chest 134 (3): 527–33. DOI:10.1378/chest.07-2687. PMID 18641117. Research Blogging.
  9. ↑ 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 Nov;48(5):540-7. Epub 2006 Feb 21. PMID 17052555
  10. ↑ 10.0 10.1 Pronovost PJ, Wu AW, Sexton JB (2004). "Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit.". Ann Intern Med 140 (12): 1025-33. PMID 15197020.
  11. ↑ Muth CM, Shank ES (2000). "Gas embolism.". N Engl J Med 342 (7): 476-82. PMID 10675429.
  12. ↑ 12.0 12.1 Kirkpatrick A, Rathbun S, Whitsett T, Raskob G (2007). "Prevention of central venous catheter-associated thrombosis: a meta-analysis". Am. J. Med. 120 (10): 901.e1–13. DOI:10.1016/j.amjmed.2007.05.010. PMID 17904462. Research Blogging.
  13. ↑ Lobo BL, Vaidean G, Broyles J, Reaves AB, Shorr RI (2009). "Risk of venous thromboembolism in hospitalized patients with peripherally inserted central catheters.". J Hosp Med 4 (7): 417-22. DOI:10.1002/jhm.442. PMID 19753569. Research Blogging.
  14. ↑ 14.0 14.1 Baskin JL, Pui CH, Reiss U, Wilimas JA, Metzger ML, Ribeiro RC et al. (2009). "Management of occlusion and thrombosis associated with long-term indwelling central venous catheters.". Lancet 374 (9684): 159-69. DOI:10.1016/S0140-6736(09)60220-8. PMID 19595350. PMC PMC2814365. Research Blogging.
  15. ↑ Monagle P, Chalmers E, Chan A, DeVeber G, Kirkham F, Massicotte P et al. (2008). "Antithrombotic therapy in neonates and children: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).". Chest 133 (6 Suppl): 887S-968S. DOI:10.1378/chest.08-0762. PMID 18574281. Research Blogging.
  16. ↑ 16.0 16.1 Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota AJ et al. (2008). "Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).". Chest 133 (6 Suppl): 454S-545S. DOI:10.1378/chest.08-0658. PMID 18574272. Research Blogging.
  17. ↑ 17.0 17.1 17.2 Surov A, Wienke A, Carter JM, Stoevesandt D, Behrmann C, Spielmann RP et al. (2009 Nov-Dec). "Intravascular embolization of venous catheter--causes, clinical signs, and management: a systematic review.". JPEN J Parenter Enteral Nutr 33 (6): 677-85. DOI:10.1177/0148607109335121. PMID 19675301. Research Blogging.
  18. ↑ Burton DC, Edwards JR, Horan TC, Jernigan JA, Fridkin SK (2009). "Methicillin-resistant Staphylococcus aureus central line-associated bloodstream infections in US intensive care units, 1997-2007.". JAMA 301 (7): 727-36. DOI:10.1001/jama.2009.153. PMID 19224749. Research Blogging.
  19. ↑ Mermel LA, Allon M, Bouza E, Craven DE, Flynn P, O'Grady NP et al. (2009). "Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America.". Clin Infect Dis 49 (1): 1-45. DOI:10.1086/599376. PMID 19489710. Research Blogging.
  20. ↑ 20.0 20.1 Safdar N, Fine JP, Maki DG (2005). "Meta-analysis: methods for diagnosing intravascular device-related bloodstream infection". Ann. Intern. Med. 142 (6): 451-66. PMID 15767623. [e]
  21. ↑ Kite P, Dobbins BM, Wilcox MH, McMahon MJ (1999). "Rapid diagnosis of central-venous-catheter-related bloodstream infection without catheter removal". Lancet 354 (9189): 1504-7. PMID 10551496. [e]
  22. ↑ 22.0 22.1 O'Grady NP, Alexander M, Dellinger EP, et al (2002). "Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention". MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control 51 (RR-10): 1-29. PMID 12233868. [e]
  23. ↑ Widmer AF, Nettleman M, Flint K, Wenzel RP (1992). "The clinical impact of culturing central venous catheters. A prospective study". Arch. Intern. Med. 152 (6): 1299-302. PMID 1599360. [e]
  24. ↑ Pittet D, Tarara D, Wenzel RP (1994). "Nosocomial bloodstream infection in critically ill patients. Excess length of stay, extra costs, and attributable mortality". JAMA 271 (20): 1598-601. PMID 8182812. [e]
  25. ↑ Raad II, Baba M, Bodey GP (1995). "Diagnosis of catheter-related infections: the role of surveillance and targeted quantitative skin cultures". Clin. Infect. Dis. 20 (3): 593-7. PMID 7756481. [e]
  26. ↑ Watanakunakorn C, Baird IM (1977). "Staphylococcus aureus bacteremia and endocarditis associated with a removable infected intravenous device". Am. J. Med. 63 (2): 253-6. PMID 888847. [e]
  27. ↑ Timsit, Jean-Francois; Carole Schwebel, Lila Bouadma, Arnaud Geffroy, Maite Garrouste-Orgeas, Sebastian Pease, Marie-Christine Herault, Hakim Haouache, Silvia Calvino-Gunther, Brieuc Gestin, Laurence Armand-Lefevre, Veronique Leflon, Chantal Chaplain, Adel Benali, Adrien Francais, Christophe Adrie, Jean-Ralph Zahar, Marie Thuong, Xavier Arrault, Jacques Croize, Jean-Christophe Lucet, for the Dressing Study Group (2009-03-25). "Chlorhexidine-Impregnated Sponges and Less Frequent Dressing Changes for Prevention of Catheter-Related Infections in Critically Ill Adults: A Randomized Controlled Trial". JAMA 301 (12): 1231-1241. DOI:10.1001/jama.2009.376. Retrieved on 2009-03-25. Research Blogging.
  28. ↑ Mimoz O, Villeminey S, Ragot S, et al (2007). "Chlorhexidine-based antiseptic solution vs alcohol-based povidone-iodine for central venous catheter care". Arch. Intern. Med. 167 (19): 2066–72. DOI:10.1001/archinte.167.19.2066. PMID 17954800. Research Blogging.
  29. ↑ Bleasdale SC, Trick WE, Gonzalez IM, Lyles RD, Hayden MK, Weinstein RA (2007). "Effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients". Arch. Intern. Med. 167 (19): 2073–9. DOI:10.1001/archinte.167.19.2073. PMID 17954801. Research Blogging.
  30. ↑ Cobb DK, High KP, Sawyer RG, et al (1992). "A controlled trial of scheduled replacement of central venous and pulmonary-artery catheters". N. Engl. J. Med. 327 (15): 1062-8. PMID 1522842. [e]

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