Major complications occur about 3% of the time for experienced operators (>50 CVC catheters placed), regardless of which location is cannulated.¹ Ultrasound guidance has been shown to decrease rates of arterial puncture and hematoma while simultaneously increasing success rates for both IJ and femoral CVC placement, and decrease rates of arterial puncture and hematoma for subclavian vein CVC placement.2,3 However, ultrasound can also increase the risk of complications if used incorrectly.
- Use lots of lidocaine as needed (5-10ml), especially with Cordis and HD catheters as they require more subcutaneous dilation.
- Subclavian CVC placement has the highest failure rate (15%), followed by jugular (7%), and femoral vein placement (5%). Of note, the failure rate of femoral vein placement among obese patients is likely much higher. These failure rates from the 3SITES trial are derived from experienced operators who rarely used ultrasound, and it is likely the internal jugular vein success rate is much higher with ultrasound utilization.
Catheter malposition (4%)
- A clue that an IJ CVC is going to end up in the distal subclavian is feeling resistance from the wire at about 15-20 cm. If this occurs, try to turn the bevel of the needle and/or the curve of the J-tip towards the midline (caudad), as this may direct the wire towards the SVC instead of the subclavian vein.4
- If an IJ CVC ends up in the subclavian on the chest X-ray, get a new CVC kit. Sterilize the patient and the CVC, and use maximum sterile barrier precautions (gown, gloves, face mask, sterile drape, etc.). Place a new guide wire through the CVC. Remove the CVC over the wire. Thread the 18 gauge 6cm IV from the CVC kit over the wire. Retract the wire to 5cm, and try directing the J-tip towards the midline. Re-advance the wire to 25cm. If there is no resistance at 25cm, you are likely to be in the SVC. Thread a new CVC over the re-positioned wire.
Central-line associated blood stream infections (1%)
- The 3SITES trial, the first RCT to explore insertion site by risk, demonstrated that subclavian had the least number of infections, but there was no difference between femoral and jugular site infection rates.1
- Infection reduction strategies5
- Wash hands or use alcohol hand sanitizer prior to the procedure
- Chlorhexidine for at least 30 seconds, allowing 2 min to dry
- Maximal barrier precautions: cap, mask, face shield, sterile gloves, large sterile drape
- Remove CVC as soon as it is no longer needed. The risk of infection increases each day.
- Do not perform “routine line changes.” Fever with negative blood cultures is not an indication to exchange a CVC.
Deep vein thrombosis (1%)
- Femoral CVC has the highest risk of DVT, likely because the patient has to remain relatively bedbound with a femoral CVC.
- The longer a CVC remains, the higher the risk for DVT, so remove all CVC’s when no longer needed.
- Rarely cause major complications, and can usually be controlled with 5-10 minutes of direct pressure over the puncture site.
- Rare, but potentially fatal. Never swing the needle back and forth in deeper tissues. The cutting needle can cut the vein. If you are unsure of your needle tip location, it is safest to pull the needle tip back into subcutaneous tissue before adjusting to find a new angle of approach.
- Another preventive measure includes moving the guide wire back and forth slightly during insertion of the dilator and CVC to be sure the wire is not becoming trapped and kinked, which can lead to a venous wall perforation (see image).6
Arterial puncture (5%)
- Direct visualization to ensure blood is non-pulsatile and dark red has not been shown to be effective.6 Ultrasound guidance and confirmation of venous placement of the guide wire before dilation is the most effective method to prevent arterial puncture. For additional details, see “Confirm Venous Insertion.”
- If you puncture the artery with the finder needle, remove the needle and hold pressure for 5-10 minutes.
- If you have mistakenly dilated and/or threaded the catheter into the artery, DO NOT remove the catheter/dilator (high risk of hematoma, airway obstruction, stroke, and false aneurysm). 6 Instead, call vascular surgery STAT. Surgery may remove the CVC in the OR or get additional imaging.
Pneumothorax (about 1%)
- Most common with subclavian insertion sites1
- To prevent pneumothorax during IJ CVC placement, start your needle puncture at least 2-3 finger breadths above the clavicle. Pneumothorax usually occurs when the skin puncture site is too close clavicle.
- Another common mistake during IJ cannulation is inserting the finder needle too deep which results in the needle entering the thoracic cavity. You should almost NEVER hub the introducer needle unless the vein is about 5 cm deep as measured by ultrasound. Most IJ veins are 1-2 cm deep, so no more than ½ of the finder needle should be inserted in most cases. To prevent overly deep insertion of the finder needle, follow the needle tip on US. If you cannot see the needle tip well, do not insert the needle deeper than ½ its length and stay away from the clavicle.
- Catheter can be left in place if a pneumothorax is present.
- In order to preserve the patient’s remaining functional lung, do not attempt a CVC on the contralateral side of a hemo/pneumothorax. The femoral vein is appropriate in these cases.
- Rare, but most common with subclavian insertion sites1
- If you cannot aspirate blood from a catheter after placement in IJ or subclavian site, consider hemothorax. Confirm placement with a CXR, do not remove the catheter until you have assessed its location, as it may be plugging a pathway for the blood to flow into the pleural space and hemorrhage may worsen with blind removal.6 Fluoroscopy may be done in some cases with injection of contrast to visualize the tip of the catheter.
- In order to preserve the patient’s remain functional lung, do not attempt a CVC on the contralateral side of a hemo/pneumothorax. The femoral vein is appropriate in these cases.
- Very rare but fatal complication. Most often occurs during removal of central venous catheters.
- During removal of IJ or subclavian CVC, place the patient in Trendelenburg in order to get the puncture site below the level of the heart.
- Have the patient take a deep breath and hum. or remove the catheter while they are performing this Valsalva maneuver. The catheter should never be removed during inspiration.
- Apply immediate, firm pressure with a gauze pad as soon as the tip emerges from the skin.
- Patients at high risk for air embolism during insertion are those with very low CVP (e.g. sepsis, bleeding) which causes the vessel to collapse spontaneously with inspiration.
- This is best prevented by Trendelenburg during placement of CVC.8
- Lock all ports during CVC insertion. When the wire is about to come out of the CVC port, unclamp the port for as short a period of time as possible.
- Always avoiding flushing air into the patient.
- Treatment of air embolism
- High flow nasal cannula
- Place the patient in the left lateral decubitus position and trendelenburg
- Consider hyperbaric oxygen
- It is common to have runs of atrial or ventricular tachycardia when the wire is in too deep. The patient should ALWAYS be on cardiac monitor to detect these common arrhythmias.
- When an arrhythmia occurs, pull back the wire about 3 cm until the arrhythmia ceases.
- Very rarely does the arrhythmia persist after pulling the wire out of the heart, but a crash cart should be available in the event that cardioversion is needed.
- Rare, but any of the above complications can result in fatality.
- Parienti JJ, et al. “Intravascular Complications of Central Venous Catheterization by Insertion Site”.The New England Journal of Medicine. 2015. 373(13):1220-1229.
- Ortega, Rafael, et al. “Ultrasound-guided internal jugular vein cannulation.” N Engl J Med 362.16 (2010): e57.Cochrane reviews on US
- Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF. Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterization. Cochrane Database of Systematic Reviews 2015, Issue 1.
- Tripathi M, Dubey PK, Ambesh SP. Direction of the J-tip of the guidewire, in seldinger technique, is a significant factor in misplacement of subclavian vein catheter: a randomized, controlled study. Anesth Analg 2005; 100:21.
- Pronovost, P. An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. NEJM 2006; 355:2725-32
- Bowdle A. Vascular complications of central venous catheter placement: evidence-based methods for prevention and treatment. J Cardiothorac Vasc Anesth 2014; 28:358.