Central Line Complications

[Janders]

This article was posted in the General Section, but I know a lot of ya'll only read the EM section, and I thought it was full of relevent tidbits:

Kusminksy, RE. Complications of Central Venous Catheterization. JACS (J of the American College of Surgeons), April 2007, 204(4), pp 681-696.

posted online at:
http://www.freewebs.com/kimberlicox/CVC.pdf

Original Thread at:
http://forums.studentdoctor.net/showthread.php?t=395994

Here are a couple examples of points I found interesting in the full article:


"A more precise measurement
emerges from the study by Aslamy and colleagues,
which establishes convincingly that the right
tracheobronchial angle is the most reliable landmark to
assure that a catheter’s tip is at least 2.9 cm above the
pericardial reflection, even if it appears to lie within the
cardiac silhouette."
(not exactly how I was taught to locate the tip)

"Subclavian entry is followed by misplacement of the
CVC into the ipsilateral jugular vein in up to 15% of the
catheterizations. This can be avoided in a major fraction
of patients by simply assuring that the J tip of the
guidewire is pointing caudad during insertion. Additionally,
turning the head toward the insertion side narrows
the os of the IJV, and manual compression of the
jugular can avoid misdirection as well while the guidewire
is threaded."
(I've seen this, and I knew proper position of the J tip helped, but I hadn't heard of the other two suggestions.)

"The rate of thrombosis is reported at 1.9% for SCV access and 22% to 29%
after 4 to 14 days of indwelling time for a femoral CVC."
(not sure the level of clinical relevancy for these thromboses, but the rate is higher than I imagined)

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[Dr.Evil1]

The reason you want to keep the tip above the pericardium is that there is a tendency for a CVC that is left within the heart to erode through the myocardium and, if within the pericardium, cause pericardial tamponade. This complication occurs mostly with neonates and PICC feeding catheters but it is a known complication of CVCs that most are unaware of.
I saw a case report where a Cordis was inserted into a trauma code too far. When they power injected IV contrast for a CT chest with contrast they basically inserted 100 cc of contrast directly into the pericardial sac. The guy coded on the CT table and died.

 

[southerndoc]

The reason you want to keep the tip above the pericardium is that there is a tendency for a CVC that is left within the heart to erode through the myocardium and, if within the pericardium, cause pericardial tamponade. This complication occurs mostly with neonates and PICC feeding catheters but it is a known complication of CVCs that most are unaware of.
I saw a case report where a Cordis was inserted into a trauma code too far. When they power injected IV contrast for a CT chest with contrast they basically inserted 100 cc of contrast directly into the pericardial sac. The guy coded on the CT table and died.

I can't see how that could happen. How did a Cordis tip get that far? They aren't that long. Even with a right IJ approach, it shouldn't get to the atrium because the Cordis isn't long enough. Unless the patient is 3 feet tall. (???)

Some of our IR guys intentionally put catheter tips in the right atrium because they argue it has more flow and decreases the chances of a clot forming on the catheter tip. They primarily do this with permanent catheters (since they are more flexible), but I have seen them do it with dialysis catheters and PICC lines.

I have heard of the risk of perforation and erosion. However, this is not limited to the atrium. If a catheter tip sits up against the wall of the SVC, it can erode through it as well. Any object that sits against the wall of a vessel can erode through it.

 

[Aloha Kid]

My personal feelings is if you need a line, you need one - put it in and let the medicine guys deal with the complications. With that said, I haven't placed a femoral in a very long time - US guided IJ is where it's at. Placement in the SVC is the goal. Never seen an erosion/tamponade yet, although I've heard horror stories. Did recently see a surgical resident perforate the R ventricle in a little old lady with the guide wire. Patient coded, right after he secured the triple lumen. Nothing we do is benign.

 

[Dr.Evil1]

I can't see how that could happen. How did a Cordis tip get that far? They aren't that long. Even with a right IJ approach, it shouldn't get to the atrium because the Cordis isn't long enough. Unless the patient is 3 feet tall. (???)

Some of our IR guys intentionally put catheter tips in the right atrium because they argue it has more flow and decreases the chances of a clot forming on the catheter tip. They primarily do this with permanent catheters (since they are more flexible), but I have seen them do it with dialysis catheters and PICC lines.

I have heard of the risk of perforation and erosion. However, this is not limited to the atrium. If a catheter tip sits up against the wall of the SVC, it can erode through it as well. Any object that sits against the wall of a vessel can erode through it.

I don't know how the cordis tip got that far, our cordis introducer caths are 10 cm and I don't think that ours could get down that far. I did see the actual CT images, though, of a bolus of contrast dye being infused directly into the pericardium. It was an 8 french catheter inserted into the subclavian. Maybe it had something to do with patient positioning, as the patient had his arms raised above his head for the CT chest with contrast.

Yes, there is a risk of perforation and erosion wherever the catheter tip sits but the thorax is a much larger place to dump fluid into rather than the pericardium. This is why the we should keep the catheter tip out of the pericardium.

 

[southerndoc]

I don't know how the cordis tip got that far, our cordis introducer caths are 10 cm and I don't think that ours could get down that far. I did see the actual CT images, though, of a bolus of contrast dye being infused directly into the pericardium. It was an 8 french catheter inserted into the subclavian. Maybe it had something to do with patient positioning, as the patient had his arms raised above his head for the CT chest with contrast.

Yes, there is a risk of perforation and erosion wherever the catheter tip sits but the thorax is a much larger place to dump fluid into rather than the pericardium. This is why the we should keep the catheter tip out of the pericardium.

You saw the tip of the catheter in the pericardium on CT? I'm still having trouble picturing it going down that far. Impressive.