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Preventing
Complications of Central Venous Catheterization
David C. McGee, M.D., and Michael K. Gould, M.D.
In the United States, physicians insert more than 5 million
central venous catheters every year.1 Central
venous catheters allow measurement of hemodynamic variables that
cannot be measured accurately by noninvasive means and allow delivery
of medications and nutritional support that cannot be given safely
through peripheral venous catheters. Unfortunately, the use of
central venous catheters is associated with adverse events that are
both hazardous to patients and expensive to treat.2,3,4
More than 15 percent of patients who receive these catheters have
complications.5,6,7
Mechanical complications are reported to occur in 5 to 19 percent of
patients,5,6,8
infectious complications in 5 to 26 percent,5,7,9
and thrombotic complications in 2 to 26 percent.5
In this review, we explain methods for reducing the frequency of
complications in adult patients.
Types of Catheters
Antimicrobial-Impregnated Catheters
Catheters impregnated with chlorhexidine and silver sulfadiazine
and catheters impregnated with minocycline and rifampin are the
most frequently used types of antimicrobial-impregnated catheters. In
randomized clinical trials, the use of these catheters has been shown
to lower the rate of catheter-related bloodstream infections9,10
(Table 1). The use of catheters impregnated with
chlorhexidine and silver sulfadiazine lowered the rate of catheter-related
bloodstream infections from 7.6 infections per 1000 catheter-days
(4.6 percent of catheters) to 1.6 infections per 1000 catheter-days
(1.0 percent) (relative risk, 0.21; 95 percent confidence interval,
0.03 to 0.95; P=0.03).10 A
cost-effectiveness analysis concluded that using these catheters
would decrease direct medical costs by $196 per catheter inserted.11
The use of antimicrobial-impregnated catheters should be considered
in all circumstances, especially when the institutional rate of
catheter-related bloodstream infections is higher than 2 percent,
which is the threshold at which
chlorhexidine-and-silver-sulfadiazine–impregnated catheters may
reduce overall costs.10 Current evidence suggests
that minocycline-and-rifampin–impregnated catheters are even
more effective for minimizing the risk of infection than those that
are impregnated with chlorhexidine and silver sulfadiazine.29
However, this evidence comes from a single randomized trial,
and the cost effectiveness of these catheters relative to those that
are impregnated with chlorhexidine and silver sulfadiazine has not
been formally evaluated. Thus, either
chlorhexidine-and-silver-sulfadiazine–impregnated catheters or
minocycline-and-rifampin–impregnated catheters may be used.
The emergence of resistant organisms resulting from the use of
antimicrobial-impregnated catheters remains a potentially important
concern. Continued surveillance will be needed as the use of
antimicrobial-impregnated catheters increases.
Single-Lumen and Multilumen Catheters
The number of lumina does not directly affect the rate of catheter-related
complications.30,31,32
Therefore, the choice of either a single-lumen or a multilumen
catheter should be made according to the type required to deliver the
needed medications or nutritional support.
Insertion Sites
Characteristics of Patients
There are multiple approaches for internal jugular, subclavian,
and femoral venous catheterization.33 Successful
catheterization by either the internal jugular or the subclavian
route relies on a thorough understanding of the anatomy of the neck (Figure
1). The internal jugular vein is located at the apex of the
triangle formed by the heads of the sternocleidomastoid muscle
and the clavicle. The subclavian vein crosses under the clavicle just
medial to the midclavicular point. When it is difficult to identify
the landmarks for one type of catheterization, another route should
be considered. All patients should be assessed for factors that might
increase the difficulty of catheter insertion, such as a history of
failed catheterization attempts or the need for catheterization at a
site of previous surgery, skeletal deformity, or scarring.8
When a difficult catheterization is anticipated, the importance of
patient safety dictates that the procedure be performed or supervised
by an experienced physician.
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Figure 1. Technique for
Catheterization at the Internal Jugular and Subclavian Sites.
In the central approach for internal jugular venous catheterization
(Panel A), the apex of the triangle formed by the two heads of the
sternocleidomastoid muscle and the clavicle serves as a landmark. The
internal jugular vein runs deep to the sternocleidomastoid muscle and
then through this triangle before it joins the subclavian vein to become
the brachiocephalic vein. After the landmarks have been identified,
sterile barriers have been prepared, and local anesthesia has been
administered, the patient is placed in Trendelenburg's position with the
head rotated 45 degrees away from the site of cannulation. The physician
places the index and middle finger of his or her nondominant hand on the
carotid artery and inserts a 22-gauge "finder" needle through the skin,
immediately lateral to the carotid pulse and slightly superior to the
apex of the triangle. The needle is advanced past the apex of the
triangle, in the direction of the ipsilateral nipple, at an angle of 20
degrees above the plane of the skin. The vein is usually located near
the surface of the skin and is often encountered after less than 0.5 in.
(1.3 cm) of the needle has been inserted. If the first pass is
unsuccessful, the needle should be directed slightly more medially on
the next insertion attempt. With the finder needle in place, an 18-gauge
introducer needle is then inserted alongside it and into the vein.
In the infraclavicular approach for subclavian venous catheterization
(Panel B), the subclavian vein arises from the axillary vein at the
point where it crosses the lateral border of the first rib. It is
usually 1 to 2 cm in diameter and is fixed in position directly beneath
the clavicle. It is separated from the subclavian artery by the anterior
scalene muscle. For catherization, the patient is placed in
Trendelenburg's position, and a small rolled towel is placed between the
shoulder blades. After identification of the landmarks, sterile
preparation, and administration of local anesthesia, the skin is
punctured 2 to 3 cm caudal to the midpoint of the clavicle with an
18-gauge, 2.5-in. (6.3-cm) introducer needle. The needle is advanced in
the direction of the sternal notch until the tip of the needle abuts the
clavicle at the junction of its medial and middle thirds. The needle is
then passed beneath the clavicle, with the needle hugging the inferior
surface of the clavicle. If no blood returns with passage of the needle,
the needle is withdrawn past the clavicle while gentle suction is
applied. Blood return may be achieved during withdrawal of the needle.
If the first pass is unsuccessful, the needle should be angled in a
slightly more cephalad direction on the next insertion attempt.
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Internal jugular catheterization can be difficult in morbidly obese
patients, in whom the landmarks of the neck are often obscured.
Subclavian venous catheterization should be avoided in patients with
severe hypoxemia, because the complication of pneumothorax is more
likely to occur at this site and is less likely to be tolerated by
such patients. Femoral catheterization should be avoided in patients
who have grossly contaminated inguinal regions because femoral
insertion places these patients at high risk for the development of
catheter-related infections. If central venous access is needed for
resuscitation from shock, femoral venous access should be considered
because of the speed with which it can be performed, especially if it
is believed that internal jugular or subclavian venous
catheterization will be difficult. After resuscitation, the catheter
can be replaced at the most appropriate site for the patient.
Mechanical Complications
Arterial puncture, hematoma, and pneumothorax are the most common
mechanical complications during the insertion of central venous
catheters (Table 2). Overall, internal jugular catheterization
and subclavian venous catheterization carry similar risks of
mechanical complications. Subclavian catheterization is more likely
than internal jugular catheterization to be complicated by
pneumothorax and hemothorax, whereas internal jugular catheterization
is more likely to be associated with arterial puncture. Hematoma and
arterial puncture are common during femoral venous catheterization.
Because mechanical complications are most likely during
catheterization at the femoral site, the internal jugular or
subclavian venous route should be chosen unless contraindicated.
However, the rate of serious mechanical complications (e.g.,
pneumothorax requiring insertion of a chest tube or hemorrhage
requiring blood transfusion or surgery) associated with subclavian
insertion is similar to that associated with femoral insertion.5
Infectious Complications
Catheter-related infections are thought to arise by several
different mechanisms: infection of the exit site, followed by
migration of the pathogen along the external catheter surface;
contamination of the catheter hub, leading to intraluminal catheter
colonization; and hematogenous seeding of the catheter. A randomized
trial found that subclavian venous catheterization was associated
with a significantly lower rate of total infectious complications
than femoral venous catheterization and a trend toward a lower rate
of suspected or confirmed catheter-related bloodstream infections
(1.2 infections per 1000 catheter-days, vs. 4.5 infections per 1000
with femoral catheterization; P=0.07).5 Available
evidence suggests that subclavian catheterization is less likely to
result in catheter-related infection than internal jugular
catheterization, although the two approaches have not been compared
in randomized trials.9,12,13
Thus, selection of the subclavian site appears to minimize the risk
of infectious complications.
Thrombotic Complications
Patients who require central venous catheterization are at high
risk for catheter-related thrombosis. Used routinely, ultrasonography
with color Doppler imaging detects venous thrombosis in 33 percent of
patients in medical intensive care units34 and in
approximately 15 percent of these patients the thrombosis is
catheter-related. The risk of catheter-related thrombosis varies
according to the site of insertion. In one trial, catheter-related
thrombosis occurred in 21.5 percent of the patients with femoral
venous catheters and in 1.9 percent of those with subclavian venous
catheters (P<0.001).5 In an observational
study, the risk of thrombosis associated with internal jugular
insertion was approximately four times the risk associated with
subclavian insertion.28
Subclavian venous catheterization carries the lowest risk of catheter-related
thrombosis. The clinical importance of
catheter-related thrombosis remains undefined, although all
thromboses have the potential to embolize.
Insertion Technique
Preparation
When inserting a catheter, one should use maximal sterile-barrier
precautions, including a mask, a cap, a sterile gown, sterile
gloves, and a large sterile drape. This approach has been shown to
reduce the rate of catheter-related bloodstream infections and to
save an estimated $167 per catheter inserted.14
The use of chlorhexidine-based solutions for skin preparation may be
preferable to the use of povidone–iodine solutions, because
chlorhexidine reduces the risk of catheter colonization.35,36
A video that shows the insertion of catheters at the internal
jugular and subclavian sites is available as
Supplementary
Appendix 1 with the full text of the article at
http://www.nejm.org.
Experience with Catheterization
As with most medical procedures, the level of experience of the
physician reduces the risk of complications.6,37
Insertion of a catheter by a physician who has performed
50 or more catheterizations is half as likely to result in a
mechanical complication as insertion by a physician who has performed
fewer than 50 catheterizations.6
If a physician is unable to insert a catheter after three attempts,
he or she should seek help rather than continue to attempt the
procedure. The incidence of mechanical complications after three or
more insertion attempts is six times the rate after one attempt.8
Ultrasound Guidance
The use of ultrasound guidance has been promoted as a method for
reducing the risk of complications during central venous
catheterization. In this technique, an ultrasound probe is used to
localize the vein and to measure its depth beneath the skin. Under
ultrasound visualization, the introducer needle is then guided
through the skin and into the vessel. During internal jugular venous
catheterization, ultrasound guidance reduces the number of mechanical
complications, the number of catheter-placement failures, and the
time required for insertion.25,26
However, its use during subclavian venous catheterization has had
mixed results in clinical trials,26,38,39
probably for anatomical reasons. The fixed anatomical relation
between the subclavian vein and the clavicle makes ultrasound-guided
catheter insertion more difficult and less reliable than
landmark-based insertion. As with all new techniques,
ultrasound-guided catheterization requires training. In hospitals
where ultrasound equipment is available and physicians have adequate
training, the use of ultrasound guidance should be routinely
considered for cases in which internal jugular venous catheterization
will be attempted.
Recognition of Arterial Puncture and Prevention of Air Embolism
In a patient with normal blood pressure and normal arterial oxygen
tension, arterial puncture is usually easy to identify by the
pulsatile flow into the syringe and the bright-red color of the
blood. However, in patients with profound hypotension or marked
arterial desaturation, these findings may not be present. If there is
any doubt as to whether the introducer needle is in the artery or the
vein, an 18-gauge, single-lumen catheter (included in most kits)
should be inserted over the wire and into the vessel. This step does
not require the use of a dilator. This catheter can then be connected
to a pressure transducer to confirm the presence of venous waveforms
and venous pressure. Simultaneous samples for measurement of blood
gases can then be drawn, one from the catheter and another from an
artery. There should be a substantial difference in the oxygen
tension if the catheter is located in a vein.
A spontaneously breathing patient generates negative intrathoracic
pressure during inspiration. If a catheter is open to room air, this
negative intrathoracic pressure can draw air into the vein, resulting
in air embolism. Even small amounts of air can be fatal, especially
if transmitted to the systemic circulation through an atrial or
ventricular septal defect. To prevent this complication, catheter
hubs should be occluded at all times, and the patient should be
placed in Trendelenburg's position during insertion. If air embolism
occurs, the patient should be placed in Trendelenburg's position with
a left lateral decubitus tilt to prevent the movement of air into the
right ventricular outflow tract. One hundred percent oxygen should be
administered to speed the resorption of the air. If a catheter is
located in the heart, aspiration of the air should be attempted.
Prophylactic Antibiotics
Most studies of the use of prophylactic antibiotics have demonstrated
that this strategy is associated with reductions in the rate of
catheter-related bloodstream infections.40,41,42
However, this use of antibiotics is discouraged because of concern
that it will encourage the emergence of antibiotic-resistant
organisms.43
Maintenance of the Insertion
Site
Ointments, Subcutaneous Cuffs, and Dressings
Application of antibiotic ointments (e.g., bacitracin, mupirocin,
neomycin, and polymyxin) to catheter-insertion sites increases
the rate of catheter colonization by fungi,15
promotes the emergence of antibiotic-resistant bacteria,16
and has not been shown to lower the rate of catheter-related
bloodstream infections.17 These
ointments should not be used.44 Likewise, the use
of silver-impregnated subcutaneous cuffs has not been shown to reduce
the incidence of catheter-related bloodstream infections and
therefore is not recommended.15,45,46
Because there are conflicting data on the optimal type of dressing
(gauze vs. transparent material)47,48
and the optimal frequency of dressing changes,49,50
evidence-based recommendations cannot be made.
Hubs and Needleless Access Devices
Catheter hubs are a common source of contamination,18
especially during prolonged catheterization.51
The use of two types of antiseptic-containing hub has been shown to
decrease the risk of catheter-related bloodstream infections.52,53
In some hospitals, the introduction of needleless access devices has
been linked to an increase in the rate of these infections.54,55
In one instance, this increase was due to a high rate of
noncompliance with the manufacturer's recommendations to change the
end cap with each use and to change the device every three days.54
In another, more frequent hub changes were required before the
rate of catheter-related bloodstream infection returned to base
line.55
Catheter Maintenance
Every catheter should be removed as soon as it is no longer
needed, since the probability of catheter-related infections
increases over time. The risks of catheter colonization and
catheter-related bloodstream infection are low until the fifth to
seventh days of catheterization, at which time the risks increase.9,10,21
Multiple trials have tested strategies for reducing the risk of
catheter-related infections, including scheduled, routine replacement
of catheters by exchange over a guide wire and scheduled, routine
replacement at a new site. However, none of these strategies have
been shown to decrease the rate of catheter-related bloodstream
infections.19,20,56
In fact, scheduled, routine exchanges of catheters over a guide
wire are associated with a trend toward an increased rate of
catheter-related infections.19 Furthermore, the
more frequently a catheter is replaced with a new catheter at a new
site, the more likely it is that the patient will have a mechanical
complication during insertion.19,27
A meta-analysis of 12 randomized trials of
catheter-replacement strategies concluded that the data do not
support either scheduled, routine exchange of catheters over a guide
wire or scheduled, routine replacement at a new site.19
Accordingly, central venous catheters should not be replaced on a
scheduled basis.44
Suspected Catheter-Related
Bloodstream Infection
Even with optimal efforts to prevent infectious complications of
central venous catheterization, catheter-associated infections will
develop in some patients (Table 3). In any patient who
has a central venous catheter, symptoms and signs of infection
without another confirmed source should raise the concern that the
catheter may be the source of the infection (Figure 2).
Once a catheter-associated infection is suspected, two samples
of blood should be drawn for culture to evaluate the possibility of
bacteremia. Two cultures of blood from peripheral sites should be
evaluated because it is difficult to determine whether a positive
culture of blood from a central venous catheter indicates
contamination of the hub, catheter colonization, or a catheter-related
bloodstream infection.65,66
However, a negative culture from a catheter indicates that the
presence of a catheter-related bloodstream infection is unlikely.67
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Figure 2. Management of Suspected
Catheter-Related Bloodstream Infection.
Sepsis is defined as a systemic response to infection, manifested by
two or more of the following conditions: temperature above 38.5°C or
below 36.0°C; heart rate above 90 beats per minute; respiratory rate
above 20 breaths per minute or partial pressure of arterial carbon
dioxide below 32 mm Hg; and white-cell count greater than 12,000 per
cubic millimeter or less than 4000 per cubic millimeter or with 10
percent immature (band) forms.61 Septic
shock is defined as sepsis-induced hypotension or a requirement for
vasopressors or inotropic agents to maintain blood pressure despite
adequate fluid resuscitation, along with the presence of perfusion
abnormalities that may include (but are not limited to) lactic acidosis,
oliguria, or acute alteration in mental status.61
When blood cultures are obtained, samples from peripheral sites are
preferred. Catheter-tip cultures should be performed by the
semiquantitative or quantitative technique.27,62,63
Empirical antibiotic therapy for suspected catheter-related bloodstream
infection should include vancomycin. Antibiotics that are effective
against gram-negative organisms should be added, especially if the
patient is immunocompromised or has neutropenia, is infected with
gram-negative organisms, or has other risk factors for infection with
gram-negative organisms. In patients with a catheter-related bloodstream
infection, treatment for more than 14 days is indicated in patients with
endocarditis (duration of treatment, 4 to 6 weeks) or Staphylococcus
aureus bacteremia (2 to 3 weeks).64
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The catheter site should be examined carefully. If there is any
purulence or erythema, an exit-site infection is likely, and the
catheter needs to be removed. If the patient has signs of either
sepsis or septic shock, empirical antibiotic therapy should be begun
to treat Staphylococcus epidermidis or S. aureus
infections. Antibiotic therapy for gram-negative organisms should be
added, especially if the patient is immunocompromised or has
neutropenia or has other risk factors for infection with
gram-negative organisms. The catheter should be changed over a guide
wire.56,62,63
This technique reduces the number of insertion-related complications
and is safe, even in patients with sepsis, as long as antibiotic
therapy has been initiated.56,63
In patients who have septic shock and no other source of infection,
the catheter should be removed and replaced with a new one at a
new site.
If a culture of the catheter tip is positive, the patient has
either catheter colonization or a catheter-related bloodstream
infection, and a catheter that was replaced over a guide wire should
be removed. If the catheter-tip culture is negative, then catheter
colonization and catheter-related bloodstream infection are unlikely,
and efforts should be made to identify another source of infection.
Supported in part by a Research Career Development Award from
the Department of Veterans Affairs Health Services Research and
Development Service (to Dr. Gould).
We are indebted to Drs. Deborah Cook and Stephen Ruoss for reviewing
a previous version of the manuscript.
Source Information
From the Division of Pulmonary and Critical Care Medicine
(D.C.M., M.K.G.), the Department of Health Research and Policy (M.K.G.), and the
Center for Primary Care and Outcomes Research (M.K.G.), Stanford University
School of Medicine, Stanford, Calif.; and the Health Services Research and
Development Service and Center for Health Care Evaluation, Veterans Affairs Palo
Alto Health Care System, Palo Alto, Calif. (M.K.G.).
Address reprint requests to Dr. Gould at the Pulmonary and
Critical Care Section (111P), Veterans Affairs Palo Alto Health Care System,
3801 Miranda Ave., Palo Alto, CA 94304.
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