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 Table of Contents  
ORIGINAL RESEARCH REPORT
Year : 2018  |  Volume : 15  |  Issue : 2  |  Page : 96-101

Central venous catheter insertion in critical illness: Techniques and complications


1 Department of Anaesthesia, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Lagos, Nigeria
2 Department of Radiodiagnosis and Radiography, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Lagos, Nigeria
3 Department of Anaesthesia and Intensive Care Unit, Lagos University Teaching Hospital, PMB 12003, Lagos, Nigeria

Date of Web Publication21-May-2018

Correspondence Address:
Dr. Oyebola Olubodun Adekola
Department of Anaesthesia, College of Medicine, University of Lagos and Lagos University Teaching Hospital, PMB 12003, Surulere, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcls.jcls_49_17

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  Abstract 


Background: Werner Forssman, in 1929, first described central venous catheter (CVC) insertion when he canalized his own right atrium through the cephalic vein. It is now a routine procedure in critical care. We investigated the pattern of insertion of CVC in our intensive care unit. Patients and Methods: A prospective observational study conducted in a 5-bed general intensive care unit of a 770-bed university teaching hospital. All prospective patients admitted from January 2013 to June 2014 were recruited. The technique, site and complications following insertion were documented. All had postprocedure chest radiography performed to confirm catheter tip position. Results: The most common site and technique of CVC insertion were the right internal jugular vein (IJV) 71 (79.8%), and the anatomic landmark (AL) 66 (74.2%), respectively. The mean catheter depth was significantly shorter in the AL (15.0 ± 2.4) cm than the Peres' formula (16.5 ± 3) cm, P = 0.046. Catheter tips were correctly placed at the carina in 62 (69.7%) patients. The complication rate was 28 (31.5%), which was significantly higher in males 25 (45.5%) than females 3 (8.9%), P = 0.03, and increased by 57.9% with attempts >2. The most common complications were failure to insert 9 (10.1%), right carotid artery puncture (8.9%), and arrhythmias (5.9%). Pneumothorax was reported in (4.5%), all occurred with the subclavian approach. Conclusion: Central venous catheter insertion is more common through the right internal jugular vein, and with the anatomical landmark technique. The complication increased with attempts >2, male gender, and subclavian approach.

Keywords: Carina, central venous catheter, complications, critical illness, site, technique


How to cite this article:
Adekola OO, Irurhe NK, Raji VA, Desalu I. Central venous catheter insertion in critical illness: Techniques and complications. J Clin Sci 2018;15:96-101

How to cite this URL:
Adekola OO, Irurhe NK, Raji VA, Desalu I. Central venous catheter insertion in critical illness: Techniques and complications. J Clin Sci [serial online] 2018 [cited 2018 Aug 14];15:96-101. Available from: http://www.jcsjournal.org/text.asp?2018/15/2/96/232817




  Introduction Top


The internal jugular, subclavian, and femoral veins are common sites for central venous catheter (CVC) placement in the intensive care unit.[1] The central vein is commonly accessed using the anatomical landmark or simple formula techniques in low-resource nations.[2],[3],[4],[5] The recommended depth of insertion in adults is 15 cm from the puncture site.[2],[3] The insertion of catheter is not free of complications during and after the procedure, with an incidence between 5% and 19%.[6],[7] Early complications include failure to place catheter in (22%), arterial puncture (2.1%–14.28%), cardiac arrhythmia (36.37%), arterial hematoma (0.7%–3.7%), and catheter malposition (3.6%–60%).[8],[9] Late complications include infection, thrombosis, and sepsis.[6],[7],[8],[10] Life-threatening complications with an incidence <1% include pneumothorax, hemothorax, venous air embolism, nerve and thoracic duct injury, and asystolic cardiac arrest.[6],[7],[9],[11] A delay in diagnosis and intervention can lead to serious morbidity and mortality.[8],[10],[11] The site of CVC insertion is a known risk factor for complication.[1] Fewer rates of infection and thrombosis have been reported with subclavian CVC placement when compared with internal jugular and femoral CVC insertion.[1] The risk of pneumothorax is, however, higher with the subclavian approach, with rates varying between 1% and 6.6%.[1],[9] The highest risk of malposition occur with the right subclavian vein (SCV) in 9.1%, followed by the left internal jugular vein (IJV) (4.12%), and the right IJV (1.1%).[7] The use of ultrasound guidance has been recommended by the National Institute for Clinical Excellence (NICE) for proper localization and reduction in complications.[12] We investigated the pattern and complications following CVC insertion in critically ill patients at our institution.


  Patients and Methods Top


This was a prospective study of CVC inserted in a cohort of critically ill patients 18 years and older. The Human Research and Ethics Committee approval and informed consent was obtained from patients or their next of kin. Only Patients with sinus rhythm on electrocardiography were recruited. Those with cervical injury, obesity, arrhythmias, and electrolyte abnormalities were excluded. The sample size was based on a predetermined formula using proportions, with an incidence of 3.3% for misplacement of CVCs inserted through the IJV.[14] A sample size of 60 was considered adequate for the study.

Central venous catheter insertion

CVC insertion was performed by a consultant or senior registrar with proficiency in the procedure. The internal jugular or subclavian approach was used depending on the skill of the attending anesthetist. A multiparameter monitor (Mindray MEC-2000, Shenzhen Mindray Bio-Medical Electronics Co, Ltd., Shenzhen, China) was attached to the patient and baseline vital signs were measured. Thereafter, blood pressure, heart rate, oxygen saturation, and electrocardiogram were continuously monitored till the end of the procedure. The primary outcome determined the complications secondary to CVC placement, and the secondary outcome determined the site, technique for CVC placement, and compared the distribution of complication between different sites and techniques. Correctly sited catheter tip was defined as CVC tip at the level of the carina.[13],[14] Malposition catheter tip was defined as CVC tip above or below the carina, in the right atrium or any other vessel.[15] Complications were recorded as arterial puncture, arrhythmias, pneumothorax, hematoma, and others.[9],[10],[11]

All procedures were performed under aseptic technique. CVC insertion was through the IJV or SCV. The CVC depth was measured in the anatomic landmark (AL) method using a sterile disposable paper ruler from the proposed insertion site to the 3rd to 4th rib, and in the Peres' formula (PF) method by a calculation based on using the patient's height. The technique of choice was determined by the attending anesthetist.

The calculation of catheter length determination using PF of height:[4]









Internal jugular vein approach

The patient was positioned supine, the head of the bed was slightly tilted downward, and the patient's head was turned to the opposite side of needle insertion. The carotid pulse was palpated at the level of the cricoid cartilage. An 18-G needle was inserted at 30° lateral to the pulse, and directed toward the ipsilateral nipple; the syringe plunger was withdrawn gradually for backflow of venous blood as the needle was inserted. A 7.5Fr × 4” 20 cm long, triple lumen CVC was inserted using the Seldinger technique.[16]

Subclavian vein approach

The patient was positioned supine and the neck and infraclavicular region cleaned with antiseptic solutions and draped. A point at the junction of medial one-third and lateral two-thirds of the clavicle was identified and used as the puncture point. A local wheal was raised at the site of needle puncture with 1% lidocaine (0.5 mg/kg). An 18 G introducer needle was inserted at the puncture point, and directed toward the supra-sternal notch. After aspiration of the free flow of venous blood, a J-tipped guide wire was inserted, and the introducer needle was removed. The skin and subcutaneous tissue overlying the guide wire were dilated using the dilator provided with the Arrow guard Blue® Multi-Lumen Catheterization Kits (Arrow Deutschland GmbH, Germany, Teleflex Medical). A 7.5Fr × 4” 20 cm long, triple lumen CVC was then railroaded over the guidewire using a modified Seldinger technique.[16] Free flow of venous blood from the ports of CVC was confirmed.

Post-CVC insertion, each lumen was flushed with 0.5units/ml of heparinized saline. A postinsertion chest radiography (anteroposterior view) was immediately performed and reviewed by the consultant radiologist involved in the study.

Statistical analysis

Data collated included age, sex, duration of catheter insertion, duration of Intensive Care Unit admission, and the modified APACHE II score. The modified APACHE II score was calculated on admission, [Appendix 1].[17] Data were presented as frequencies, percentile, and mean ± standard deviation. The independent t-test, Chi-square, or Fisher's Exact Test were applied to test the significant differences between the groups. All data were analyzed using the Statistical Package for Social Sciences (SPSS, Chicago, IL). for windows; a P ≤ 0.05 was considered to be statistically significant.




  Results Top


The study was conducted on 89 patients, of whom 55 (61.8%) were males. The mean age, modified APACHE II score, duration of admission, and duration of catheter were 37.51 ± 15.95 years, 27.97 ± 12.91, 7.56 ± 4.83 days, and 5.08 ± 3.41 days, respectively. The most common site of CVC insertion was the right IJV 71 (79.8%), followed by the right SCV 15 (16.8%) and the left SCV with 3 (3.4%), [Table 1]. CVC insertion was performed with the AL in 66 (74.2%) and PF technique in 23 (25.8%). Catheter tips were correctly sited at the carina in 62 (69.7%) patients, [Figure 1]. The calculation of CVC depth using AL resulted in 49 (76.6%) successful placements compared to 15(60%) using Peres' formula, P = 0.22. However, there was no significant difference in mean duration of CVC insertion between the methods [Table 2]. Cather tips were inappropriately placed in the right atrium in 19 (21.4%) patients, above carina in 9 (10.1%), retrograde into the right IJV through the right subclavian approach in one patient (1.1%), and into the right brachiocephalic trunk (1.1%), [Figure 1], [Figure 2], [Figure 3]. [Table 1] shows the comparison of complications between CVC insertion through the internal jugular vein and subclavian vein.
Table 1: The frequency distribution central venous catheter insertion between internal jugular vein and subclavian vein

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Figure 1: Catheter tip in the right atrium

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Table 2: The comparison of pattern of central venous catheter between anatomical landmark and Peres' formula technique

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Figure 2: Catheter tip above the carina

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Figure 3: Catheter tip in the trunk of brachiocephalic

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The mean catheter depth was significantly shorter in the AL (15.0 ± 2.4) cm than the PF (16.5 ± 2.3) cm, P = 0.046 [Table 2]. The comparison of complications between anatomical landmark and Pere's technique is detailed in [Table 2].

The complication rate was 28 (31.5%), which was significantly higher in males 25 (45.5%) than females 3 (8.9%), P = 0.03, and increased by 57.9% with attempts >2. The most common complications were a failure to insert 9 (10.1%), right carotid artery puncture (8.9%), and arrhythmias (5.9%). Pneumothorax was reported in (4.5%), which occurred with the subcalvian approach, however, there was no incidence of hemothorax, [Table 2].


  Discussion Top


We have demonstrated that central venous catheterization in our intensive care unit is frequently performed through the right internal jugular approach. This is the pattern of observation in previous studies,[6],[8] which has been attributed to reports of increased success, and reduced complication rates with IJV catheterization.[6],[13] The peculiar anatomy of the jugular venous system and the design of the catheter has been reported to facilitate proper insertion.[13]

The incidence of complications in our study is higher than 11%–17.9% reported in other studies.[6],[7],[9] The frequency of complication increased with attempts at insertion >2, the subcalvian approach and male gender. This observation is in agreement with previous studies that reported a significantly higher complication rates with the subclavian approach than with the internal jugular approach, and in the male patients than their female counterparts.[6],[9] It has been reported that pneumothorax and hemothorax is more common with subclavian approach, while arterial puncture is more common with IJV catheter placement.[6],[7] This was further reiterated in our study with the presence of pneumothorax only in the subcalvian approach, however, there was no report of hemothorax. The diagnosis of pneumothorax was by post-CVC insertion chest radiography, and all had chest tube thoracostomy. This has led to the suggestion that routine post-CVC chest radiograph be performed to exclude immediate life-threatening complications such as pneumothorax and hemothorax.[2],[5]

We observed that the mean depth of catheter inserted was significantly shorter in the AL method 15.0 ± 2.37 cm than the PF method 16.5 ± 2.28 cm. In another study, Sharma et al.[18] evaluated the depth and position of central venous catheter using three different methods: Peres' formula, landmark, and endocavitory (atrial) ECG. They demonstrated that the mean depth of central venous catheter was significantly shoter with endocavitory (ECG) technique (8.18 ±0.74) cm than with anatomic Landmark (12.08 ±0.98) cm, or Peres' Formula (14.20 ±0.69) cm. The authors concluded that correct position of central venous catheter by endocavitory (atrial) ECG appears not only to reduce the procedure related complications but allow post procedure manipulation of catheter tip detected using post insertion chest X-ray. The mean depth in our study is within the accepted range of 13–16.5 cm described earlier.[18] The appropriate depth of catheter inserted has been shown to depend on the site of insertion, catheter length, patient's height and body habitus.[14] In critically ill Indians, the acceptable depth for correctly placed catheter was 11–14 cm, while a depth of 16 cm was suggested for the Western population.[19] CVC insertion with catheter length from 13 to 16 cm has been reported to result in a significantly greater proportion of safe catheter placements than CVC with 20 cm length.[20],[21]

In 32.6%, CVC tips were malpositioned, which is within the reported range of 1%–60%.[7] The abnormal site includes the right atrium, above the carina, and retrograde into the right IJV (through the right subclavian approach). All the malpositioned catheter tips were withdrawn before use. A case of CVC malposition into the right ventricle (RV) following catheter insertion through the right IJV using the high approach anatomic surface landmark technique was reported in our institution.[5] It was associated with complaints of severe chest pain during catheter insertion necessitating a postinsertion chest radiograph which revealed the presence of the catheter tip in the RV The procedure was, however, performed with relative ease.[5] The catheter tip was subsequently withdrawn into the proper position before use.[5]

The desired position of the tip of the catheter is just above the junction of the superior vena cava and the right atrium. Occasionally, however, despite proper technique, the tip of the catheter may not terminate at the desired level, resulting in aberrant placement in the internal thoracic vein, superior vena cava, azygos vein, accessory hemiazygos vein, or axillary vein.[20],[22],[23] The inadvertent cannulation of the azygos arch occurred in about 0.7%–1.2% of insertions, and the rate was about seven times higher when the left jugular vein was used than when the right one was used.[22],[23] The Food and Drug Administration in the USA advocated that CVC tips should not be placed in or allowed to migrate into the heart.[24] The NICE guidelines recommend the use of a 2-D imaging ultrasound guidance as a preferred method for inserting a CVC into the IJV in adults and children in elective situations and suggest that ultrasound guidance should be considered in most clinical situation where CVC insertion is necessary, whether the situation is elective or in emergency.[12]

The study was limited by the fact that neither the site nor the technique of CVP placement was randomized, which may contribute to bias on the part of the performer. This is because the site and technique of insertion depended on the proficiency of the attending intensivist. We concluded that CVC placement at our institution is more common through the right internal jugular vein and with the anatomical landmark technique. Complications such as arterial puncture, malposition, and pneumothorax are not uncommon, however, the frequency of complications increased with attempts >2, male gender and subclavian approach. We recommend regular training and the acquisition of skill in CVC insertion. We also suggest that our institution should imbibe the use of 2D Ultrasonography for CVC insertion as a standard of care.

Acknowledgment

We appreciate the support of the anesthetist residents and nursing staff of our intensive care unit during the study. “The research was supported (in part) by the Medical Education Partnership Initiative in Nigeria grant from the Fogarty International Center of the National Institutes of Health R24TW008878. The content is solely the responsibility of the authors and does not necessarily represent the official view of the National Institutes of Health.”

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Schuster M, Nave H, Piepenbrock S, Pabst R, Panning B. The carina as a landmark in central venous catheter placement. Br J Anaesth 2000;85:192-4.  Back to cited text no. 13
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Sivasubramaniam S, Hiremath M. Central venous catheters: Do we need to review practice on positioning? J Intensive Care Soc 2008;9:228-31.  Back to cited text no. 14
    
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Lessnau KD. Is chest radiography necessary after uncomplicated insertion of a triple-lumen catheter in the right internal jugular vein, using the anterior approach? Chest 2005;127:220-3.  Back to cited text no. 15
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Sharma D, Singh VP, Malhotra MK, Gupta KM. Optimum depth of central venous catheter – Comparison by Pere's, landmark and endocavitary (atrial) ECG technique: A prospective study. Anesth Essays Res 2013;7:216-20.  Back to cited text no. 18
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[PUBMED]    


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