What is the most common cause of death related to central venous (central vein) catheter insertion?

Central Venous Catheter-Related Deaths: Most Common Cause

Catheter-related sepsis is the most common cause of death related to central venous catheter insertion. 1

Understanding CVC-Related Mortality

Central venous catheter (CVC) insertion carries significant risks, with complication rates ranging from 1-26%. While several complications can occur during and after insertion, catheter-related bloodstream infections (CRBSIs) represent the most significant mortality risk.

Major Causes of CVC-Related Deaths (In Order of Frequency)

1. Catheter-related sepsis

   • Can be life-threatening and is increasingly regarded as a measure of quality of care 1
   • The most serious CRBSIs occur with short-term nontunneled catheters placed via central veins 1
   • Infection rates increase exponentially over time with CVC use

2. Perforation of great vessels and myocardium

   • Can cause serious morbidity or mortality, typically occurring at insertion 1
   • May lead to bleeding into pleural space, pericardium, or peritoneum
   • Requires immediate intervention when recognized

3. Air embolism

   • May be fatal and can occur at any time from insertion to removal
   • Incidence may be as high as 0.8% 1
   • Presents with neurological, respiratory, or cardiovascular signs ranging from subtle to catastrophic

4. Pneumothorax

   • Incidence of 0.3-2.3%, highest with subclavian route 1
   • Can be particularly dangerous in patients on positive pressure ventilation 2
   • Delayed pneumothorax can occur and has been associated with mortality 2

5. Catheter/guidewire embolism

   • Risk increases during difficult or multiple cannulation attempts 1
   • Requires urgent radiological or surgical retrieval

Risk Factors and Prevention

Infection Prevention

• Upper body insertion sites (particularly subclavian) have lower infection rates than femoral sites 1
• Totally implantable devices have the lowest infection rates (0.1 per 1,000 catheter days) 1
• Tunneled CVCs have lower infection rates than non-tunneled CVCs (1.6 vs 2.7 per 1,000 catheter days) 1
• Chlorhexidine bathing reduces infection rates by 23-28% 1

Technical Considerations

• Ultrasound guidance significantly reduces arterial puncture rates (2.1% vs 7.2% without ultrasound) 3
• Operator experience is crucial - those with <25 insertions cause significantly more complications (25.2% vs 13.6%) 3
• Internal jugular vein approach has fewer overall complications than subclavian approach (17.7% vs 29.2%) 3
• Higher levels of supervision are associated with decreased complications (10.7% vs 23.8%) 3

Common Pitfalls and Caveats

1. Delayed complications

   • Pneumothorax may not be evident on initial post-procedure imaging 2
   • Maintain high suspicion for delayed complications, particularly in ventilated patients

2. Documentation issues

   • Deaths related to CVCs are often accompanied by poor documentation 1
   • Hospitals should have clear policies for insertion documentation (type, site, tip position)

3. Catheter malposition

   • Occurs in approximately 13.4% of insertions 4
   • Can lead to complications if unrecognized, though many malpositioned catheters function without incident

4. Underestimation of risks

   • CVC placement is often considered a relatively safe procedure but carries significant risks 5
   • Proper informed consent should include discussion of life-threatening risks

Conclusion on CVC-Related Deaths

While multiple serious complications can occur with central venous catheter insertion, catheter-related sepsis remains the most common cause of death associated with these devices. This is supported by the high incidence of CVC-related bloodstream infections and their potential to progress to severe sepsis and septic shock if not promptly recognized and treated.