Central Line Placement Complications 

Central Line Placement Complications – 11 Interesting Facts

1. Central venous line placement is accompanied by a significant rate of complications, many of which have potentially serious, even life-threatening consequences, including vascular injury, air embolus, arrhythmia, nerve injury, and others
2. Many, if not most, central line complications are preventable
3. Prevention of vascular injury includes the routine use of ultrasonography for central venous catheter placement, measurement of the intraluminal pressure before placement of a large-bore cannula, avoidance of overinsertion of the guidewire, ascertainment that the guidewire is intact before and after placement, and a close supervision of trainees
4. Prevention of air embolism depends on proper positioning of the patient based on the access site and avoiding communication of the atmosphere around or with the lumen of needles or catheters
5. ECG monitoring during central line placement is important to detect and assess arrhythmias and indicate adjustment of the depth of the guidewire and/or catheter. In patients with LBBB (left bundle branch block), the practitioner should be prepared with the means to immediately institute temporary cardiac pacing if complete heart block or asystole occurs
6. Aseptic technique and other specific measures to prevent CLABSI (central line–associated bloodstream infection) are now well described and should be followed for every central line insertion
7. Use of ultrasonography improves first-pass success rates and reduces other complications, such as pneumothorax and nerve injuries, which are associated with multiple needle passes
8. When complications occur, proper management is paramount in reducing and/or preventing devastating consequences
9. If an inadvertent arterial cannulation occurs, the cannula or catheter should be left in place until an interventional radiologist or vascular surgeon can be consulted
10. Obtain postprocedural imaging, preferably before the use of the catheter, to assess for complications requiring treatment or further monitoring, for example, pneumothorax, malpositioning of the catheter, and retained guidewire or catheter fragments
11. Resistance to withdrawal of a guidewire or catheter calls for imaging assistance to assess for knotting, kinking, or other entanglement and to prevent vascular injury or embolization of the guidewire or catheter

Alarm Signs and Symptoms

• Hypotension, tachycardia, and/or shortness of breath that develops during central line placement requires immediate cessation of placement efforts and assessment for possible vascular injury and hemorrhage, significant pneumothorax, air embolism, or other injury
• Return of bright red pulsatile blood through a catheter or cannula requires immediate cessation of placement efforts and assessment for possible inadvertent arterial cannulation
• Onset of complete heart block or asystole requires immediate intervention, such as withdrawal of the guidewire or catheter, institution of cardiac pacing, and pharmacologic support
• Patients describing sharp pain or paresthesia during placement should result in immediate cessation of needle manipulation, assessment for nerve contact, and movement of the needle to another location, as well as later assessment for significant nerve injury

Introduction

• SC (subclavian)
• IJ (internal jugular)
• Femoral
• CLABSI (central line–associated bloodstream infection)

Background Information

• Cannulation of a large central vein, such as the femoral, IJ, or SC vein, is an integral part of many medical procedures. These include, but are not limited to, the following:
  • Central venous line placement
  • Administration of vasoactive drugs
  • Rapid fluid resuscitation
  • Cardiac pacing
  • Hemodialysis
  • Introduction of pressure monitoring catheters
    • Central venous
    • Pulmonary artery pressure
  • Venous access when peripheral access is not possible
  • Introduction of invasive interventional catheters and wires, as in percutaneous cardiovascular interventional therapy
• Overall, complications of central line placement are not rare, but reports differ significantly in reported incidence, largely because there are few prospective studies

Epidemiology

• Complications of central venous access, excluding failure to access, occur in about 12% to 14% of cases.¹² Incidence of specific complications is detailed in Table 1
• Not all complications are obvious at the time of central line placement, but often have their origins during placement, such as infection due to improper aseptic technique
• Most common early complications in a recent study³ included:
  • Malposition of the catheter (2.1%)
  • Pneumothorax (1.1%)
  • Hematoma (0.8%)
  • Infection (0.27%)
  • Nerve injury (0.1%)
• A separate study indicates that accidental arterial puncture is the most frequent complication (4.2%-9.3%)⁴ and an important contributor to potentially devastating sequelae, such as inadvertent arterial cannulation and hematoma formation (which may be associated with nerve injuries)
• Complication rates
  • Complication rates are highest with SC access followed by IJ followed by femoral access²
  • Overall, the complication rate for SC line placement in a recent review was approximately 24%, and the most common complication was arterial puncture⁵
  • Compared with IJ line placement, SC line placement was associated with fewer arterial punctures and CLABSIs
  • IJ line placement was associated with fewer cases of catheter malpositioning, pneumo- or hemothorax, and vein thrombosis or occlusion compared with SC line placement⁶⁷

Table 1. Epidemiology of specific central line placement complications.

Complication	Description	Incidence	Morbidity and mortality
Vascular injury
Arterial injury	Carotid, SC, or femoral artery puncture	4.2%-9.3%248	Carotid puncture (even without cannulation) associated with acute and delayed stroke9
Inadvertent arterial cannulation	Placement of large-bore catheter in adjacent artery	0.1%-1%48	Requires immediate management or potential for devastating consequences10
Pulmonary artery injury	Most often occurs with the insertion of pulmonary artery catheters	0.1%-0.2%11	Mortality 42%11
Major venous injury	Injury to intrathoracic veins, including SVC, during IJ or SC line placement due to deep insertion of the dilator or guidewire perforationPossible mechanismsDirect injury to the vessels from the dilator when inserted deeply during IJ central line placement12A through-and-through injury to an intrathoracic vein, when either the guidewire itself perforates the vein, or the wire becomes trapped against the vein wall, and the advancing dilator or catheter causes a tear in the vein wall4	Overall incidence of major venous injuries is unclear; however, lacerations of the vena cava, mediastinal veins, SC vein, azygous vein, and right atrium have all been reported, as well as injury to the vein of access13Most SVC injuries occur at the innominate-caval confluence14	Mortality in small case series 85%15All injuries to major intrathoracic veins have the potential to be rapidly fatal if not rapidly recognized and appropriately managed14
Thrombosis or vein occlusion	Disruption of the vessel leads to inflammation that can result in thrombus formation	5%-10%16Incidence of thrombosis or vein occlusion is most common with femoral line placement (1.2%) followed by IJ (0.9%) and then SC line placement (0.5%)7	In a series of 76 cases of upper extremity thrombus, 58% of which were associated with an indwelling CVC, mean survival was limited (16.3 months)Actual mortality from the central line–related thrombosis itself was much lower (about 17.5% of the deaths were not related to malignancy, but specific causes were not detailed);17 there are no studies providing specific numbersMortality in the patient group was 52.6%, most of which were deaths due to underlying malignancy17
Bleeding	HematomaHemothoraxCardiac tamponade	1%20.3%20.14%18	Mortality from hematoma is not reported but is presumably smallMortality from hemothorax will depend largely on the cause: acute arterial bleeding into the pleural space can be rapidly fatal, whereas venous bleeding is less acuteMortality from cardiac tamponade complicating the central line specifically is not reported, but acute in-hospital mortality from pericardial tamponade is reported to be 10%19
Air embolism
	Occurs when air is entrained into the venous or arterial system20Open communication of the atmosphere into the vasculature via the needle, catheter, or catheter tractVascular pressure lower than atmospheric pressure. For example:Deep inspiration combined with open catheter, line, or needleHypovolemiaSemiupright or upright position	Incidence of venous air embolism associated with central lines is not reported, but is considered “rare”20	Mortality is reported as 23%-50%, with many survivors having significant neurologic deficits10Paradoxical embolism (movement of venous air into the arterial system) can occur with or without the presence of intracardiac shunts and result in strokes and systemic embolic phenomena
Arrhythmias
	Usually occur during advancement of catheters and wires (incidence is higher with SC line placement than with IJ line placement)21 but can occur with indwelling cathetersPreexisting cardiac disease and serum potassium level do not correlate with incidence of significant arrhythmias22Catheter length and movement of the guidewire during line placement may be important predisposing factors	Up to 50% of patients experienced asymptomatic, transient arrhythmia during guidewire advancement23Another study described the incidence of SVT to be 0.8%, RBBB 0.1%, and AVB 0.07%	Managed by a simple repositioning of the guidewireOne study found that patients experiencing acute kidney failure were more likely to experience ventricular arrhythmias than those with normal kidney function, but there was no correlation with pH abnormalities or known preexisting cardiac disease24
Chylothorax
	Lymphatic fluid leaks into space between the lungs and the chest wallAssociated with SC line placement16Thrombosis of SC vein16Puncture thoracic duct25	Very rare, only a few case reports in the literature	Because of rarity, overall outcomes are not well studied
Guidewire needle complications
Loss of guidewire	Known risk factors include:1InattentionOperator’s inexperience or exhaustionInadequate supervision of trainees	Rare	Because of rarity, overall outcomes are not well studied
Knotted catheters	Can be associated with vascular injury and arrhythmiaRisk factors include placement of a catheter into a vein with a preexisting catheter or wire, or an overinsertion of the guidewire2627	Rare	Because of rarity, overall outcomes are not well studied
Malpositioned CVCs	Associated or causally related to other complications such as vascular injury, arrhythmia, thrombosis, pneumothorax, pleural effusion, cardiac tamponade, and others27Unclear whether IJ or SC approach presents more risk of malpositioning	Occurs in about 10% of cases28	See associated complications (eg, arterial injury, venous injury, arrhythmia, pneumothorax) for morbidity and/or mortality
Infection
CLABSIs29	Associated with increased ICU length of stay, hospital length of stay, total hospital costs, and patient mortality (odds ratio, 2.75)29Patient risk factors include immunocompromised condition, prolonged hospital stay, severe burns,30 BMI higher than 40 kg/m2, and premature birth29Practitioner risk factors include placement of CVC under emergency conditions, incomplete adherence to sterile technique, multiple manipulations of the catheter, low nurse to patient ratios, and failure to remove unnecessary catheters29	A 2020 retrospective study found CLABSI rates of 5.1 (SC), 3.73 (IJ), and 6.93 (femoral) per 1000 catheter days31	Mortality rate associated with CLABSI in studies ranges from 30.3% to 41.9%. Site-specific mortality rates in one study were IJ 38%, SC 33%, and femoral 44%; however, the difference between femoral and other sites was not statistically significant32
Pneumothorax
	Incidence is higher with SC line placement than with IJ line placement (1.5% versus 0.4%, respectively)7	Reported up to 17%,33 but most reviews estimate 1%-1.5%10	Mortality of iatrogenic pneumothorax specific to central line placement is not well studied. In one institution, iatrogenic pneumothorax in general was associated with a relative risk of 28-day mortality of 3.2.34 These cases included pneumothorax related to thoracentesis and mechanical ventilation, as well as other causes
Nerve injury35
	Presumed mechanism is direct contact with the placement needle or pressure neuropraxia due to compression by hematomaTransient phrenic nerve dysfunction has been reported because of phrenic nerve block by the local anesthetic infiltration ahead of central venous cannulation in the IJ approach36	Rare, less than 1 per 1000 cases	Overall, long-term morbidity from rare nerve injuries specific to central line placement is not well studied
Stroke
	Usually results from vessel injury or embolization of wire or catheter, or air embolism937	Unknown	Overall, long-term morbidity from rare instance of stroke specific to central line placement is not well studied
Retroperitoneal hematoma or hemorrhage	Associated with perforation of the posterior wall of the femoral artery during cannulation	Significant retroperitoneal hemorrhage or hematoma associated with central venous placement is rare—most iatrogenic occurrences are associated with arterial cannulation during interventional cardiac catheterization procedures38	Cases are rare and incidence of morbidity and mortality is not well studied

Caption: AVB, atrioventricular block; CLABSI, central line–associated bloodstream infection; CVC, central venous catheter; IJ, internal jugular; RBBB, right bundle branch block; SC, subclavian; SVC, superior vena cava; SVT supraventricular tachycardia.

Etiology

• Central line placement complications depend in part on the site being accessed. Common sites include IJ, SC, or femoral vein (Table 2)
• Risks of thrombosis or vein occlusion with IJ or SC vein approach are small, with IJ line insertion associated with the lowest risk 0% versus 1.2% for SC approach as found in one systematic review⁶

Risk Factors

• Complications of line placement are increased by the following:³⁹
  • Large-size catheters or placement of multiple catheters in the same central vein
  • Use of catheter-over-needle technique, rather than wire-through-thin-wall-needle technique
  • Multiple insertion attempts
  • Operator’s inexperience
• Complications of line placement are reduced by the following:
  • Use of ultrasonography, or use of vascular pressure transducers or manometry to identify intra-arterial location to avoid intra-arterial placement of the catheter³⁹
  • Increased operator’s experience: in a recent study on pediatric patients, complication rates of line placement were lower when done by attending physicians compared with when done by resident physicians. The rates were also lower when this procedure was done by more experienced than less experienced residents⁴⁰
• Common risk factors for complications during central line placement are discussed in Table 3

Table 2. Central line complications by access site.

Complication(s)	IJ	SC	F
Arterial punctureArterial cannulation with large-bore catheterInfectionEmbolization of catheter tip or guidewireAir embolismDeep vein thrombosis*ArrhythmiaExtravascular line placement	✓	✓	✓
Pneumothorax†Hemothorax and bleedingThoracic duct injuryMyocardial perforation and tamponade	✓	✓
Retroperitoneal hemorrhage or hematoma			✓

Caption: IJ, internal jugular; SC, subclavian.

*Most frequent with femoral line placement.

†Most frequent with SC versus IJ line placement.

Data from Laterza RD et al. Central venous catheterization. In: Keech BM, et al, eds. Anesthesia Secrets. 6th ed. Elsevier; 2021:153-160.

Table 3. Risk factors for complications of central venous catheter placement, maintenance, and removal.

Risks for mechanical complications of placement139Large-size catheterPlacement of multiple catheters in the same veinUse of catheter-over-needle technique rather than wire-through-thin-wall-needle techniqueOverinsertion of the guidewireIncreased number of needle passes10 Operator’s inexperienceInattention or inadequate supervision of traineesLack of centra venous catheter placement “kits”Patient’s coagulopathyPatient’s hypovolemiaPatient’s BMI10 higher than 40 kg/m2

Risks for complications of maintenancePatients who are immunocompromisedProlonged hospital staySevere burnsBMI 40 kg/m2 or higherPremature birthLow nurse to patient ratio

Diagnosis

Approach to Diagnosis

• Diagnosis of central line placement complications is largely clinical
• History pertaining to onset and timing in relation to symptoms can point to a specific complication
• Physical examination findings can also aid in the identification of complications
• Laboratory studies such as CBC and blood cultures can provide evidence of infection
• Imaging with chest radiograph can confirm complications of IJ or SC line placement identified clinically
• Additional imaging with modalities such as CT, MRI, echocardiogram, or ultrasonography may be indicated to delineate vessel wall injury or if there is a concern for tamponade, thrombus, or embolus
• If hematoma or hemorrhage related to femoral line placement is suspected, radiographic imaging with multislice CT or angiography may be indicated; digital subtraction angiography can be useful in urgent evaluations⁴¹
• ECG can identify arrythmias
• Thoracentesis can be both diagnostic and therapeutic with pneumothorax, hemothorax, or chylothorax
• Management of specific complications is detailed in Table 4

Staging or Classification

Table 4. Diagnosis and treatment of central line placement complications.

Complication	Diagnosis	Management	Prognosis
Large-bore arterial injuries	Generally evident at time of cannulationRed pulsatile blood returnExpanding hematomaProgressive tachycardia or hypotensionBlood gas analysisUltrasonography or CT	Leave the catheter in placeVascular surgery for repairPercutaneous device closureEndovascular repair or stent placement	Generally favorable prognosis with emergency repairHigh rate of complications if “pull-and-pressure” technique used to treat large-bore arterial injuries42
Small-bore arterial injuries	Generally evident at time of cannulationBlood gas analysis	For minor femoral artery injuries, compressionMonitor for resolution	Generally, no long-term consequences
Venous injury	Generally diagnosed by physical examinationChest radiographFluoroscopy ortransesophageal echocardiography	Leave the catheter in place to slow hemorrhageInterventional radiology or thoracic surgeryEmbolization, spring coil or stent graft blockingThoracoscopy or open heart surgery	Anecdotal evidence onlyNo systematic reports on outcomes
Venous thrombosis	Symptoms and workup vary with the location of thrombusD dimerVenous duplex ultrasonographyContrast venography	Oral anticoagulation (approximately 70%)17May require surgical removal	3-year mortality among patients with upper extremity deep vein thrombosis in 1 series was 52.6%; however, most deaths were due to underlying malignancy, and overall life expectancy did not appear related to the presence of a central venous catheter17
Catheter thrombosis	D dimerVenous duplex ultrasonographyContrast venographyImaging of catheter	Fibrinolytic therapyReplacement of central line	In one study, 66% of patients had positive response to fibrinolytic therapy43
Air embolism	Bedside echocardiogramCT or MRI	Locate the source of air and stop further entrainmentFlood the field; pouring saline onto the field will displace any airDurant maneuver (place the patient in left later decubitus position with the head down)20Support and maintain oxygenation and circulationHyperbaric oxygen therapy1044	One study suggests that 1-year mortality from vascular air embolism in the medical setting is approximately 21%44Systematic studies are lacking
Arrhythmias PVC, PAC, sinus bradycardia, ventricular tachycardia, atrial tachycardia	Evident on cardiac rhythm monitoring	Withdrawal of guidewire or catheter repositioningArrhythmia-specific ACLS protocol	Almost always resolves with withdrawal of the wire or catheter repositioningNo systematic studies
Arrhythmia in preexisting LBBB Can lead to CHB, unstable ventricular rhythm, asystole	Evident on cardiac rhythm monitoringHemodynamic instability	Withdrawal of guidewire or catheter repositioningCardiac resuscitationIsoproterenolEmergency cardiac pacing	Rare eventNo systematic outcome studies
Chylothorax	Chest radiograph with a large pleural effusionThoracentesis yields milky fluid, positive for chyleDuplex scan showing ipsilateral SC vein thrombosis16	If SC vein thrombosis, heparinization45Chest tube placementRarely surgical ligation for thoracic duct	Extremely rare evenIn the setting of central line placement, and no systematic outcome studies for this context
Retained guidewire	Immediate: poor backflow, missing guidewireCan present with arrhythmia, thrombosis, stroke, perforations of vasculature, pericardium, pleuraChest radiograph	Endovascular extraction by interventional radiologySurgical removal if failed extraction	Anecdotal evidence onlyNo systematic outcome studies
CLABSI	Blood culture	Remove catheterBroad-spectrum antibiotics until sensitivities are available	Mortality 0%-35%10
Knotting catheters or guidewires	Radiograph or fluoroscopy	Removal by interventional radiologyReferred to a vascular surgeon if interventional removal not possible	Because of rarity, overall outcomes are not well studied
Brachial plexus injury	EMG	Consult a neurologist and neurosurgeon early if suspected injuryEarly intervention improves recovery46	Dependent on the location and extent of injury and timeliness of intervention
Horner syndrome4748	Ophthalmologic examination	Generally transientSurgical correction of ptosis if does not resolve spontaneously	Most episodes appear to be transientNo systematic outcome studies
Phrenic nerve injury	Respiratory distressIncidental hemidiaphragmatic paralysis on radiography	Respiratory supportive careDiaphragmatic plication if respiratory distress does not resolve48	Case reports onlyNo systematic outcome studies
Vagus nerve or recurrent49 laryngeal nerve injury	Persistent hoarseness after central line placementOtolaryngologist for vocal cord evaluation	Generally conservative as spontaneous recovery can take up to 12 monthsVocal cord surgery if persistent hoarseness	Rare complicationNo systematic outcome studies
Pneumothorax	Postprocedure chest radiographySymptom-directed chest imaging	If small and symptomatic, often resolves spontaneouslyProvide oxygenLarger or symptomatic pneumothorax may require tube thoracostomy	57% required intervention in one series50
Retroperitoneal hemorrhage	Hypotension, tachycardia, declining HCT, back pain	There are no case series involving management of femoral vein complications leading to retroperitoneal hemorrhageExperience with management of arterial injuries with retroperitoneal hemorrhage suggests management (endovascular or open surgical approach) as with other venous injuries	There are insufficient studies to provide specific prognostic information in the setting of central line placement

Caption: ACLS advanced cardiac life support; CHB, complete heart block; CLABSI, central line–associated bloodstream infection; HCT, hematocrit; LBBB, left bundle branch block; PAC, premature atrial contraction; PVC, premature ventricular contraction.

Workup

History

• History of patient’s preexisting medical conditions that increase the risk for complications with central line insertion includes:
  • Coagulopathy
  • Overweight
  • Immunocompromised
  • Premature birth
  • Burns
  • Acute kidney failure
• Historical factors pertaining to procedures that increase the risk of complications with central line insertion include:
  • Operator’s inexperience
  • Inattention or inadequate supervision of trainees
  • Overinsertion of guidewire
  • Catheter-over-needle technique
  • Placement of multiple catheters in the same vein
  • Lack of kits
  • Multiple needle passes
  • Improper aseptic technique
• Shortness of breath
  • Sudden breathing difficulty during the procedure can suggest air embolism, pneumothorax, hemothorax, chylothorax, or phrenic nerve injury
• Pain in the chest or abdomen can be seen with cardiac tamponade, pneumothorax, or hemothorax
• Limb swelling can suggest thrombus related to central line placement
• Neurologic changes, including asymmetric weakness, can suggest stroke or arterial air embolus
• Kidney failure can be consistent with air embolus
• Fever with pain or drainage at insertion site can suggest CLABSIs
• Palpitations can suggest arrhythmias related to central line placement
• Persistent hoarseness after central line placement suggests injury to the recurrent laryngeal nerve
• Paresthesias in the arm during central line placement can suggest brachial plexus injury

Physical Examination

• Physical signs can suggest specific central line placement complications
• Often, changes in vital signs can suggest potential complications
  • Hypotension and tachycardia can suggest vascular injury, air embolus, cardiac tamponade, or sustained arrhythmia
  • Decreased oxygen saturation with tachypnea is suggestive of pulmonary or air embolus, chylothorax, or pneumothorax
  • Precipitous drop in end-tidal CO₂ on capnography suggests air embolism
• Cardiovascular examination
  • Arrhythmia can be an isolated complication or suggest air embolization or malpositioning of the catheter. The guidewire in contact with the right ventricle or outflow tract can cause premature ventricular contraction, premature atrial contractions, bradycardia, and brief runs of ventricular or atrial tachycardia
  • Signs suggestive of arterial injury include:
    • Bright red pulsatile blood return suggests catheter placement in an artery
    • Expanding hematoma
    • Signs suggestive of venous injury
    • Difficulty advancing guide wire
    • Rarely cardiac arrest
• Extremity
  • Redness or oozing at insertion site, especially with concomitant fever, suggests central line infection
  • Asymmetric swelling of the limb can suggest thrombus
• Inability to aspirate or inject a catheter suggests thrombus formation, dislodged guidewire, or knotted guidewire

Laboratory Tests

• CBC
  • An elevated WBC count suggests infection
  • Declining hematocrit level may suggest occult hemorrhage from vascular injury
• Arterial blood gas
  • Arterial blood gas analysis can guide diagnosis and therapy if respiratory impairment due to intrathoracic complication is suspected
  • If there is doubt about needle or catheter location, comparison of blood gases sampled from the central line and a peripheral vein can help determine if the central line is arterial
• D dimer
  • Indicated when concern for embolism or thromboembolism
• Blood culture
  • Can identify organism and guide targeted antibiotic therapy for CLABSI

Imaging Studies

• Chest radiograph
  • Obtain postprocedure to ensure proper IJ or SC line placement.
  • Hemidiaphragmatic paralysis can be identified as seen with phrenic nerve injury
  • Identify air or fluid in the lungs as seen with hemothorax, pneumothorax, and chylothorax
  • Identify knotted or dislodged guidewire
    • Additional images with fluoroscopy may be required
• Echocardiogram
  • Can identify air embolism and cardiac tamponade
  • Transesophageal echocaridogram can identify large-vessel venous injury
• Ultrasonography
  • If physical examination signs are concerning for arterial injury, ultrasonography can aid in locating injury
  • Venous duplex ultrasonography can identify venous or catheter thrombosis
• CT or MRI
  • More detailed imaging may be required to inform location and extent of vessel wall injury or air embolus
• Angiographic imaging, including possible digital subtraction angiography, may be indicated when major vessel injury is suspected

Diagnostic Procedures

• Thoracentesis
  • Patients with pneumothorax or pleural effusion require chest tube placement
  • Fluid removed can be diagnostic as well as therapeutic
  • Milky fluid suggests chylothorax and be confirmed with laboratory testing
• Pericardiocentesis
  • Fluid removal in cases of cardiac tamponade
  • Can be diagnostic as well as therapeutic

Diagnostic Tools

• ECG
  • Monitor patients with continuous cardiac monitoring during central line placement
  • Transient arrhythmias such as premature atrial contractions, premature ventricular contraction, and short runs of atrial and ventricular tachycardia can often be identified
  • Patients with persistent arrhythmias require additional intervention

Differential Diagnosis

Table 5. Differential Diagnosis: Central venous line placement complications by signs and/or symptoms.

Signs and/or symptoms	Potential complication (incidence)	Evaluated or differentiated by	Mechanism
Hypotension and tachycardia	Vascular injury (arterial)Arterial punctureArterial laceration or tearInadvertent placement of a large-bore catheter or dilator into the arteryAssociated with neurologic sequelae10Can be life-threatening	Bright red pulsatile blood return suggests arterial injury or cannulation	Most large-bore perforations have been attributed to overinsertion of the guidewire and/or dilator5152
	Vascular injury (venous)Injury to the SVC or other intrathoracic veins during central venous catheter placement using the IJ or SC approachCan be a catastrophic, life-threatening complication1253	Can be evident by radiograph or ultrasonography of guidewire in unusual location	Direct injury to the vessels from the dilator when inserted deeply during IJ central line placement12Through-and-through injury to an intrathoracic vein, when either the guidewire itself perforates the vein, or the wire becomes trapped against the vein wall, and the advancing dilator or catheter causes a tear in the vein wall4
	Air embolus	Bedside echocardiogram may aid in visualization of airCT or MRI may be necessaryA characteristic, churning “mill wheel” murmur in the central precordiumLate finding, transient, and depends on a large amount of air present in the right ventricle and outflow tract54	Entrainment of air from catheter, lines, or dressings
	Sustained arrhythmia	ECG evidence	Overinsertion of guidewire that touches RV or RVOT
	Cardiac tamponade	Muffled heart sounds with pulsus paradoxusEvidence of pericardial effusion on transthoracic echocardiography	Direct trauma to myocardiumMechanical or chemical erosion
Difficulty advancing catheter or guidewire	Venous injury	Can be evident by radiograph or ultrasonography of guidewire in unusual location	Direct injury to the vessels from the dilator when inserted deeply during IJ central line placement12Through-and-through injury to an intrathoracic vein, when either the guidewire itself perforates the vein, or the wire becomes trapped against the vein wall, and the advancing dilator or catheter causes a tear in the vein wall4 (see Figure 2)
	Knotted guidewire	Fluoroscopy or radiograph	Can occur with single catheters as well as additional catheters inserted over preexisting one26
Inability to aspirate or inject a catheter	Venous thrombus	Elevated D dimer level, contrast venography43	May result from a retained guidewire55
	Catheter thrombosis (more often associated with peripheral lines)	May require imaging of catheterD dimer test	Thrombus forms over catheter
	Dislodged guidewire	Postprocedure chest radiograph or other imaging showing guidewire, guidewire fragment, or needle fragmentsMissing guidewire or part of the guidewire or needle after the procedure	Guidewire is inadvertently advanced with the dilator during vessel dilation and becomes entrapped against the vascular wall (see Figure 3)Guidewire is withdrawn through the needle (against the needle’s cutting bevel)
	Knotted guidewire	Fluoroscopy or radiograph	Can occur with single catheters as well as additional catheters inserted over preexisting one26
Tachypnea with decrease in oxygen saturations	Pneumothorax	Postprocedure imaging	Direct injury
	Pulmonary embolism	CT angiogram or V/Q scan	Thromboembolism17
	Air embolus	Bedside echocardiogram may aid in visualization of airCT or MRI may be necessary	Entrainment of air from catheter, lines, or dressings
	Hemothorax	Postprocedure imaging	Direct injury
Chylothorax	Chest radiograph or other imaging showing a large pleural effusionThoracentesis yielding milky fluid that tests positive for chyleDuplex scan may show ipsilateral SC vein thrombosis16	Direct injury to thoracic duct
	Phrenic nerve injury	Hemidiaphragmatic paralysis is ipsilateral to the side of line placement by chest radiograph	Direct injury or pressure from expanding hematoma
Precipitous drop in end-tidal CO2 capnography	Air embolus	Bedside echocardiogram may aid in visualization of airCT or MRI may be necessary	Entrainment of air from catheter, lines, or dressings
Redness or oozing at insertion site	CLABSI	Blood cultures with bacterial growth	Contamination of sterile field
Palpitations	Arrhythmia, rarely cardiac arrest	ECG findings	Can result from overinsertion of guidewire and contact with RV or RVOTAir embolus
Limb swelling	Thrombus	Ultrasonographic evidence of vessel occlusion	May result from retained guidewireEmbolization of guidewire can occur if the wire is withdrawn through a needle with a cutting bevel10
Asymmetric weakness Neurologic changes	Stroke	MRI of the brain	Seen with carotid puncture even without cannulation9Can be acute or delayed
Paresthesias during placement in peripheral nerve distribution	Brachial plexus injury	EMG can confirm peripheral nerve injury	Direct injury or expanding hematoma with IJ or SC line placement
Ipsilateral eyelid droop with constricted pupil	Horner syndrome	Confirm with an ophthalmologic examination	Direct injury to the sympathetic trunk (closely adjacent to the carotid sheath) from the needle or expanding hematoma56
Persistent hoarseness	Recurrent laryngeal nerve damageVagus nerve injury	Vocal cord evaluation by an otolaryngologist	Direct trauma to phrenic nerve or expanding hematoma

Caption: CLABSI, central line–associated bloodstream infection; IJ, internal jugular; RV, right ventricular; RVOT, right ventricular outflow tract; SC, subclavian; SVC, superior vena cava; V/Q, ventilation-perfusion.

Treatment

Approach to Treatment

• Treatment varies by each complication
• Often, preventative measures can be taken to decrease the risk of complications

Arterial Injury

• If a large-bore catheter has been placed in the artery: leave the device in place and seek immediate emergency endovascular repair or open surgical repair³⁹⁵⁷
  • Emergency consultation with a vascular surgeon
  • Percutaneous device closure has been associated with high success rate and low complication rates—many authors recommend this now as the first line of treatment⁵⁸⁵⁹
  • Endovascular repair or stent placement has also proven highly successful with low complication rates⁶⁰⁶¹
• “Pull-and-pressure” response: remove the needle, wire, or catheter and apply pressure
  • Acceptable for simple arterial puncture with a small-bore or thin-wall needle
    • May be appropriate in minor femoral artery injuries, where arterial compression is easier to accomplish, bleeding is easy to monitor, and prolonged arterial compression is unlikely to result in permanent patient injury
  • Because it is not possible to apply direct compression to the SC artery, do not attempt this approach if concern for SC artery injury
  • Associated with a high rate of complications if used to treat large-bore arterial injuries:⁴² in some series, virtually 100% of patients suffered severe complications, and between 10% and 20% of patients died⁶²⁶³
  • Not preferred as initial treatment of most significant injuries or inadvertent arterial placement of catheter, dilator, or cordis
• A number of studies suggest a surprisingly low rate of long-term serious complications if the device is left in place and emergency endovascular repair, percutaneous closure, or open surgical repair occurs; in almost all reported cases, survival and complete recovery have occurred
  • In one review of 11 patients, 2 were treated with the “pull-and-pressure” technique and 9 underwent open surgical repair
    • Both patients treated with the pull-and-pressure technique suffered major complications: one suffered a stroke, and the other developed an arterial pseudoaneurysm that required surgery later
    • None of the 9 patients treated with open surgical repair suffered major complications⁶²
  • A review of inadvertent arterial cannulations between 1979 and 1995 found that 19 of 20 inadvertent arterial cannulations were treated with the pull-and-pressure technique, resulting in 6 serious complications and 2 deaths. The authors recommended direct surgical repair over pull-and-pressure technique in these types of injuries⁶²
  • Another review of 13 cases from 1980 to 2006 found that the 5 patients who were treated with the pull-and-pressure technique all had severe complications, including major stroke and death in 1 patient and false aneurysm or massive bleeding in the other 4. The remaining 8 patients were treated with immediate open surgical repair (6) or via endovascular approach (2) and suffered no complications⁶³
  • Authors of the above review found just 30 patients in the literature with inadvertent arterial cannulation⁶³
    • 17 patients were treated with the pull-and-pressure technique, of which 8 had major complications and 2 died
    • Remaining 13 patients had immediate surgical exploration, with catheter removal at the time of exploration and arterial repair under direct vision, without complications

Venous Injuries

• Although no studies have examined treatment, it is generally recommended that the catheter be left in place because it may slow hemorrhage
  • Immediate emergency consultation with an interventional radiologist or a thoracic surgeon;⁶⁴ massive hemorrhage can result from intrathoracic venous injuries
  • Treatment usually involves emergency embolization, spring coil or stent graft blocking, thoracoscopy, or open heart surgery⁵³⁶⁵
    • In one report, in at least 2 cases, the catheter was left in place for 2 weeks, and once a false lumen outside the catheter was formed, the catheter could then be manipulated. In a third case, the catheter was immediately removed, resulting in massive hemorrhage and hemothorax, although the patient ultimately survived⁵³

Thrombosis—Vein

• Oral anticoagulation
  • In a series of patients with upper extremity or IJ thrombus related to central venous catheter or malignancy, treatment included oral anticoagulation (approximately 70%)¹⁷
• To date, there is no consensus about treatment of upper extremity deep venous thrombosis¹⁷
• May require surgical removal of the thrombus

Thrombosis—Catheter

• Not generally a complication of line placement per se and will only be summarized here⁴⁰
• More often associated with peripheral vein access
• Fibrinolytic therapy
• Replacement of central line

Air Embolism²⁰

• When suspicion is raised, immediately begin treatment or offer supportive measures such as cardiopulmonary resuscitation if needed, and respiratory and blood pressure support, because this can be a life-threatening complication
• Air bubbles can be quickly absorbed, and the absence of air on tests should not deter treatment if suspicion remains high
• Immediately try to locate the source of air and stop further entrainment
• Flood the field: if air entrainment is suspected to be occurring around the catheter insertion site, flooding the field with saline will slow or stop further entrainment
• Place the patient in the left lateral decubitus position with the head down (Durant maneuver)
  • If air has been entrained in the right side of the heart, this maneuver may stabilize the bubble in the right ventricular apex and prevent it from traveling into the lungs
    • Evidence regarding the effectiveness of the Durant maneuver is not clear²⁰
    • Note that if cerebral (paradoxical) embolism is suspected, the head down position should be weighed against the problem of increasing intracerebral pressure⁴⁴
• If intracardiac air is suspected, aspiration of air with a central catheter, particularly a multihole catheter could be attempted, although the effectiveness of this maneuver in human participants is not known⁴⁴
• Maintain oxygenation and circulation while simultaneously obtaining diagnostic tests
  • High-flow oxygen
  • May require chest compressions and defibrillation
  • Hemodynamic support in the form of inotropes such as dobutamine or norepinephrine⁶⁶
• Once stabilized, consider hyperbaric oxygen treatment, particularly if signs of cerebral impairment are present¹⁰⁴⁴

Arrhythmias

• Premature ventricular contractions, premature atrial contractions, sinus bradycardia, and brief ventricular or atrial tachycardia occur regularly during central line placement; usually brief and asymptomatic⁶⁷
• Sustained arrhythmias during central line placement that do not resolve with withdrawal of the wire or repositioning of the catheter are rarely reported
  • In a series of 1527 central venous catheter placements, approximately 50% of placements were associated with transient, hemodynamically insignificant arrhythmias (most were atrial in origin) that resolved with withdrawal of the guidewire
  • No hemodynamically significant arrhythmias were seen²³⁶⁸
• Arrhythmia in the presence of preexisting LBBB (left bundle-branch block)
  • Transient RBBB (right bundle branch block) develops during the passage of a guidewire or catheter into the heart in about 3% to 12% of cases but usually goes unnoticed, because it is seldom hemodynamically significant⁶⁹
  • In the presence of preexisting LBBB, however, even transient RBBB can lead to complete heart block, and result in unstable ventricular escape rhythms, or even asystole⁶⁸⁶⁹
• If sustained arrhythmia does not resolve with removal of wire and/or catheter, begin arrhythmia-specific protocols as outlined by 2020 ACLS protocols
  • Bradyarrhythmia⁷⁰
  • Adult tachyarrhythmia with a pulse⁷¹
  • Adult cardiac arrest⁷²
• Immediate initiation of drug therapy, such as isoproterenol, to support and restore cardiac conduction and rhythm
• Prompt institution of emergency cardiac pacing. Note that transesophageal pacing relies on atrial capture and intact His bundle conduction and would therefore not be useful

Guidewire or Needle Complications⁴⁵⁵

• Often asymptomatic, especially initially
• If there are no signs of vascular perforation, the treatment of choice is interventional radiology with endovascular extraction, and in most cases a guidewire can be removed⁷³
• Surgery is usually reserved for patients in whom endovascular extraction has failed, or is not available, or if wire location or perforation causes an injury requiring surgical approach. Fragmented wire or needle may require surgical exploration⁷³
• Supportive treatment of arrhythmias until removal
• Supportive treatment of bleeding until vascular control can be achieved and the injury repaired (rare cases)

Chylothorax¹⁶

• No studies discuss the treatment of chylothorax as a complication of central line placement
• When SC vein thrombosis is present, a resolution has been reported after heparinization⁴⁵
• No consensus on optimal treatment of chylothorax from other causes
  • Conservative management with chest tube placement
  • Surgical treatment if chylothorax does not resolve with chest tube (about 37%)⁷⁴

Infection (Central Line–Associated Bloodstream Infection)

• Remove the catheter
• Institute antibiotic therapy once cultures are obtained and while awaiting results
  • General recommendations are to cover common gram-positive and gram-negative organisms
  • In the setting of high prevalence of methicillin-resistant Staphylococcus aureus, vancomycin is recommended as the gram-positive coverage component
• Adjust antibiotic therapy once results of blood cultures and organism sensitivity testing are available
• Duration of antibiotic therapy depends on the organism involved and the presence of complications (eg, endocarditis)
  • Varies from 1 to 6 weeks

Knotting or Entanglement²⁷

• Never attempt to remove or manipulate a resistant catheter by applying more force
• Never attempt to continue injection by increasing the pressure if resistance is encountered
• Most catheters can be unknotted with simple maneuvers and/or assistance from an interventional radiologist
  • In a review of 113 cases, pulmonary artery catheters were responsible for more than two-thirds of knotted catheters²⁷
    • 62% were removed using various interventional radiology techniques and 32% required surgical removal
    • In 5 cases, open cardiotomy was required
    • In the remainder, the patient’s condition was too critical for removal and the catheter remained in place
• One-third will require surgical management with vascular surgery

Nerve Injuries

• Brachial plexus
  • No studies exist to inform treatment, but experience with similar nerve damage from other causes suggests that if surgical treatment is to be effective in restoring function it must occur early
    • Immediate neurologist or neurosurgeon consult in the case of suspected peripheral or phrenic nerve injury
    • Case reports suggest that early intervention (within 48 hours) improves chances of partial or full recovery⁴⁶
  • No studies are available that address medical therapy, such as steroids or antiinflammatory medications
• Horner syndrome
  • Most cases are transient and self-resolve
  • No specific recommendations
  • Ptosis can be surgically corrected
• Phrenic nerve
  • Respiratory support
  • Rarely require diaphragmatic plication⁴⁸
• Vagus or recurrent laryngeal nerve damage
  • Can spontaneously resolve but may take up to 12 months
  • Vocal fold surgery

Pneumothorax

• In a systematic review, the incidence of hemothorax or pneumothorax was 1.3% to 1.5%, with no significant difference in incidence between IJ and SC vein approach⁶
• Manage conservatively, if small and asymptomatic
  • Spontaneous resolution of small pneumothoraces is common
• Larger and/or symptomatic pneumothorax
  • May require tube thoracostomy
  • Supportive therapy such as supplemental oxygen, until air leak resolves
  • In one series, 57% of pneumothoraces required intervention⁵⁰

Follow-Up

Monitoring

• Catheter maintenance
  • Minimize catheter “indwelling” time and timely removal of catheters
  • Inspect and assess the need for the catheter daily³⁹
  • Use the electronic medical record to set reminders⁷⁵

Prognosis

• Mortality is rare, but in one series occurred in 2 of 730 cases (0.03)⁷⁶
• Disability is often significant: in a recent study of data from the Swedish National Patient Insurance Company, on insurance claims for injuries from central lines, about half of the patients who registered claims had suffered permanent disability of varying degrees³³
• In a 2023 review of 11 patients with inadvertent arterial cannulations during central venous catheter placement, all patients survived without neurologic complications at a mean follow-up of 5.4 months;⁷⁷ 10 inadvertent cannulations involved the right common carotid artery and 1 involved the right SC artery
  • 2 patients were treated with the “pull-and-pressure” technique, one of whom had unsuccessful manual compression followed by endovascular stent graft repair
  • 3 underwent open surgery
  • 3 underwent primary stent graft placement
  • 4 underwent percutaneous device closure
• Mortality from central line placement infections ranges from 0% to 35%¹⁰
• Mortality from chylothorax is up to 10%²⁵
• Mortality from knotted catheters or guidewires is 8%, most often because of patient’s critical condition and unrelated to catheter²⁷

Screening and Prevention

Prevention

• Specific precautions can be taken to mitigate various complications of central line placement. These preventative measures are presented by complication

Arterial Injury

• Ultrasonography
  • When used during line placement to identify vascular targets
    • Associated with a higher overall success rate
    • A higher first-attempt success rate
    • Reduced rate of arterial puncture,⁴ particularly when used during the IJ approach to placement
  • SC vein is less easily imaged. Although one study concluded that use of ultrasonography for SC line placement was not associated with changes in complications rates,⁷⁸ a more recent study found that it improved overall success rates, success rates on first attempts, decreased time to successful central venous line insertion, and reduced complications⁷⁹
  • One study of ultrasonography reduced the incidence of arterial puncture from 8.4% to 1.4% for IJ line placement.⁸⁰ A more recent systematic review also found that ultrasonography use was associated with a significant decrease in inadvertent arterial puncture (relative risk, 0.21)⁸¹
  • Published guidelines and clinical statements recommend the use of ultrasonography during central venous catheter placement, including:
    • National Institute of Excellence⁸²
    • American Society of Anesthesiologists³⁹
    • American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists⁸³
    • Experts from Intensive Care Medicine⁸⁴
  • Ultrasonography does not eliminate the placement of large-bore catheters in the artery; however, factors such as imaging of the needle, distinguishing the tip of the catheter from the tip of the needle, movement of the needle during placement, and skill of the operator with the ultrasonography reduces its incidence⁸⁵
• Pressure measurement during placement
  • Shown to reliably prevent arterial cannulations with large-bore catheters, even when arterial needle punctures occur⁴⁵⁸⁶
  • Tube manometry (Figure 5)
    • Pressure tubing can be attached to the hub of the introducer needle and first dipped below the level of the vein to allow it to fill with blood, then raised upward
    • Air-blood interface settles at the level where hydrostatic pressure in the tubing equals intravascular pressure
    • If the tubing is short, the blood may overflow the tubing if an arterial puncture has occurred
  • Small, single-use pressure transducers with guidewire ports are also available and can be placed in-line between the syringe and thin-wall needle during placement to allow direct arterial pressure measurement through the needle without having to attach or detach the tubing
  • Less reliable in hypotensive patients, where low arterial pressure may be mistakenly interpreted as venous pressure
• Fluoroscopy during placement
  • Although this method is commonly used in the radiology suite, cardiac catheterization laboratory, and for surgically implanted central venous catheters, it is uncommon to use it in the ICU, emergency department, or by anesthesiologists in the operating room
  • Can identify and image the entire course of the guidewire
  • Location of the guidewire is inferred by the location and course of the wire, and misplacement in an artery has nevertheless been demonstrated while using fluoroscopy⁴
• Transesophageal echocardiography during or after placement
  • Not commonly used during or after central venous catheter placement but can identify the location of the guidewire in the superior vena cava or right atrium

Venous Injury

• Avoid deep insertion of the dilator or wire during central line placement
  • Dilator’s purpose is to dilate the skin, subcutaneous tissue, and the wall of the target vein, all of which are relatively shallow. The dilator should generally never be inserted beyond 15 cm⁵⁵⁸⁷
• Ultrasonographic guidance and pressure measurement will not prevent entrapment of the wire
  • If difficulty in passing the guidewire is encountered, fluoroscopy can help assess whether the wire is trapped and can cause perforation
  • One author suggests moving the guidewire back and forth slightly during advancement of the large-bore catheter, to assure that the wire is not trapped⁴

Thrombosis—Vein

• American Society of Anesthesiologists recommends avoiding insertion of central line at femoral site, if possible, due to increased risk of thrombosis³⁹
• Use of saline or heparin flush after catheter injection or infusion

Thrombosis—Catheter

• In appropriate patients (such as those with a history of catheter-related deep vein thrombosis), anticoagulation may be indicated⁸⁸
• Saline or heparin flushes after use are often used

Air Embolism

• For access procedures²⁰
  • Whenever possible, correct risk factors such as hypovolemia
  • Positioning
    • Lower the head of the bed during central venous catheter placements in the neck or SC vein (Trendelenburg position)
    • For femoral line placements, maintain neutral bed position or slightly head up (reverse Trendelenburg) so that the insertion site is below the level of the heart
  • Avoid exposing the open end of the needle or catheter to the atmosphere, particularly during inspiration. Place a finger over the open end while manipulating the wire, for example. Ask awake patients who are breathing spontaneously to hold their breath during these maneuvers
  • Apply an occlusive dressing after placement—antibiotic ointment can help “seal” the catheter site under the dressing
• For maintenance of central lines²⁰
  • Connect all lines to a collapsible fluid source (eg, IV bag) that cannot entrain air
  • Ensure all stopcocks are turned off when not in use
  • Cap all lines after flushing when not connected to an IV fluid source
  • Regularly inspect lines for loose connections, cracks, or broken seals
  • Check all injecting syringes and remove any air before injection
  • Maintain occlusive dressing over catheter site: air can be entrained through the catheter tract and not just the catheter itself. During dressing changes, maintain occlusive covering with gauze
• For central line removal²⁰⁴⁴
  • Position the patient supine for central line removal
  • Awake patients should be asked to hold their breath and perform a Valsalva maneuver as the catheter is being removed. If a patient is spontaneously breathing but cannot cooperate, remove the catheter during exhalation
  • Cover the site immediately. Antibiotic ointment can help seal the site, followed by an occlusive dressing. Maintain an occlusive dressing for 24 hours
  • Various authors recommend that the patient remain supine for 30 to 60 minutes after central venous catheter removal⁸⁹⁹⁰

Arrhythmias

• ECG monitoring during procedure, particularly in patients with preexisting LBBB, so that if complete heart block occurs, recognition occurs early, and therapy is initiated immediately
• For patients with preexisting LBBB, both isoproterenol and capability of transcutaneous and/or IV pacing should be at hand
• Because the mechanism is believed to be an encounter of the guidewire or catheter with cardiac structures overlying the bundle of His, a strict protocol should be observed to avoid insertion of the guidewire or central venous catheters beyond 15 cm into the heart
• For placement of pulmonary artery catheters, some authors recommend use of a pacing catheter instead of a regular pulmonary artery catheter in patients with preexisting LBBB⁶⁹ and/or suggest consideration of prophylactic transvenous pacemaker placement.⁹¹ Other authors feel that the rate of complications is so low and cardiac pacing is reasonably rapid to institute; therefore, prophylactic placement of a pacemaker is unnecessary when placing a central venous catheter in a patient with preexisting LBBB⁹²

Guidewire or Needle Complications⁹³

• Inspect the wire for defects both before insertion and after withdrawal
• Never retract a guidewire through the placement needle: the needle bevel can sheer off fragments of the guidewire into the vessel. If the wire must be withdrawn, withdraw the needle together with it¹⁰
• Some authors suggest clamping a mosquito forceps or small artery forceps on the end of the guidewire after threading the dilator on the wire to prevent advancing the wire beyond the hub of the dilator⁹⁴
• Always confirm at the end of the procedure that the guidewire or needle is present in the tray and is intact⁹⁵
• Check postprocedure chest radiograph for wire and/or needle
• One study found that by using transesophageal echocardiography, the insertion length of the guidewire to reach the optimum position (cavoatrial junction) is 15 cm, irrespective of the height of the patient, and suggested that this be the limit for insertion of the guidewire and catheter to reduce complications⁵⁵

Chylothorax

• No known means of prevention have been reported
• Ultrasonography use does not appear to reduce the incidence¹⁰

Infection (Central Line–Associated Bloodstream Infection)²⁹³⁹⁷⁵

• Choice of insertion site: infection risk is higher with IJ line placement (8.6%) than with SC line placement (4%)⁶ and highest with femoral line placement¹⁰
• Aseptic technique
  • Focused training in aseptic technique improves outcomes
    • Simulation training improved compliance with aseptic measures such as handwashing, sterile gowns, gloves, masks, full-body drapes, and use of chlorhexidine antiseptic ranging between 65% and 85% to 100%, and was associated with a significant decrease in CLABSI from 2.72 per 1000 catheter days to 0.40 per 1000 catheter days⁹⁶
  • Enforce handwashing as well as use of sterile gowns, gloves, and masks for the proceduralist, and use of appropriate antiseptic skin preparation for the patient
  • Use a full-body drape for the patient⁹⁷
  • Use of catheter insertion kits (improves adherence to sterile technique, appropriate skin antisepsis, use of antibiotic-embedded catheters when bundled with the kit)⁹⁸
  • Use of catheter insertion checklists⁹⁸
• Appropriate skin preparation
  • Alcoholic chlorhexidine prep with at least 2% chlorhexidine is the standard of care²⁹ and is superior to povidone iodine (which is no longer recommended),⁹⁹ likely because of more rapid action
• Use of antibiotic-impregnated catheters, hubs, and caps
  • Catheters impregnated with chlorhexidine-silver sulfadiazine or minocycline-rifampin are effective in reducing CLABSIs^39100101
  • Increased cost of catheters may not justify the use in patient units that already have low incidence of CLABSIs, because studies suggest that they may not provide additional benefit in such settings¹⁰²
  • Antiseptic hubs and caps do reduce CLABSIs¹⁰³ but are not recommended for routine use, because they do not appear to be superior to manual decontamination¹⁰⁴
• Select sites with less infection potential whenever possible
  • Femoral catheterizations are associated with a higher rate of CLABSIs than SC or IJ approach
    • Infection risk is higher with IJ line placement (8.6%) than with SC line placement (4%)⁶
    • SC location has the lowest infection rates¹⁰⁵ and is the preferred site for central line placement in the intensive care setting¹⁰⁴
      • Lower risk of infection must be weighed against increased risks of mechanical complications of the catheter
      • Weigh lower risk of infection against factors such as patient comfort, coagulopathies, and anatomical variations
• Catheter fixation method
  • Techniques that require fewer perforations of the skin are preferable³⁹
• Insertion site dressings
  • Chlorhexidine dressings reduce risks of CLABSIs and are considered “essential practice”¹⁰⁴
  • Avoid use in patients younger than 2 months due to higher risk of severe contact dermatitis¹⁰⁶
• Catheter maintenance
  • Minimize catheter “indwelling” time and timely removal of catheters
  • Assess the need for the catheter daily³⁹
  • Use the electronic medical record to set reminders⁷⁵
  • Inspect catheter site for signs of infection and change or remove the catheter if site infection is suspected³⁹
  • If an infection is suspected, remove and replace the catheter whenever possible. Avoid changing catheters over a wire when replacement at a new site is feasible³⁹
  • Use aseptic techniques when accessing, aspirating, and injecting the catheters³⁹
• Routine prophylactic antibiotics are not recommended³⁹⁷⁵

Knotting or Entanglement

• Figure 4. A true knot formed in a central venous catheter.From Salazar A et al. Removal of a knotted pulmonary artery catheter using a percutaneous tracheostomy set. J Cardiothorac Vasc Anesth. 2022;36:1123-1126, Figure 1.

• Avoid placing multiple catheters or wires in the same vessel whenever possible
• If there are preexisting catheters or wires, fluoroscopy should be used to perform real-time assessment of possible catheter entanglement

Pneumothorax

• There is some evidence that use of ultrasonography during line placement may decrease the incidence of pneumothorax⁵⁰

Author Affiliations

Gail A. Van Norman, MD
Professor Emeritus
Anesthesiology and Pain Medicine
University of Washington

References