Complications of Intravenous Cannulation
Intravenous cannulation carries risks of both mechanical and infectious complications, with the specific complication profile varying significantly by site—central venous access poses risks of pneumothorax, arterial puncture, and thrombosis, while peripheral access primarily causes phlebitis, infiltration, and local infection.
Central Venous Catheter (CVC) Complications
Mechanical Complications
Central venous cannulation carries substantial mechanical risks that must be weighed against infectious complications when selecting insertion sites 1:
- Pneumothorax - occurs with subclavian and internal jugular approaches 1
- Arterial puncture (subclavian artery) 1
- Vein laceration (subclavian vein) 1
- Hemothorax 1
- Air embolism 1
- Catheter misplacement 1
- Thrombosis - particularly with subclavian vein cannulation 1
- Subclavian vein stenosis - a critical complication that can preclude future ipsilateral arm vascular access 1
The internal jugular vein route has a lower risk of mechanical complications than the subclavian route 1, though subclavian access shows lower catheter-related bloodstream infection rates in critical care patients 1.
Site-Specific Risks
Avoid femoral vein access in adult patients due to higher infection risk 1. The subclavian site should be avoided in hemodialysis patients and those with advanced kidney disease specifically to prevent subclavian vein stenosis 1.
Infectious Complications
- Catheter-related bloodstream infection (CRBSI) - rates vary by insertion site, with subclavian showing lowest rates in critical care 1
- Exit site infection 1
- Tunnel tract infection 1
Use ultrasound guidance when available to reduce cannulation attempts and mechanical complications 1. Post-insertion chest x-ray is essential after internal jugular or subclavian insertion to confirm catheter tip position and evaluate for pneumothorax/hemothorax 1.
Peripheral Venous Cannulation Complications
Local Complications
Phlebitis is the primary indication for peripheral catheter removal, characterized by warmth, tenderness, erythema, or palpable venous cord 1.
Infiltration and extravasation represent the most common peripheral complications:
- Occurs when the needle tip perforates the vein wall, causing fluid leakage into surrounding tissue 1
- Results in swelling, bruising, and pain of varying severity 1
- For any size infiltration: apply ice for minimum 10 minutes and avoid maximizing blood pump speed 1, 2
- For moderate infiltration: withdraw the needle and apply manual pressure 1
- For large infiltration: apply ice and manual pressure for 30 minutes before considering re-cannulation 1
Hematoma formation can occur during insertion, during treatment, or after needle removal 1:
- Size ranges from small diffuse areas to large firm masses 1
- Large hematomas can compress vessels causing thrombosis 1
- May require 3 months resolution time before re-cannulation attempts 1
- Significant hematomas requiring skin sutures suggest venous outflow stenosis and warrant diagnostic angiogram 1
Infection Risk
- Local infection at insertion site 1
- Tissue necrosis if extravasation occurs with vesicant medications 1
Prevention Strategies
Remove peripheral catheters if phlebitis, infection, or malfunction develops 1. Routine replacement at 72-96 hours is not recommended 1.
Use midline catheters or PICCs instead of short peripheral catheters when IV therapy duration will likely exceed 6 days 1.
Avoid cannulation in limbs with lymphedema except in acute situations due to increased infection risk 1, 3.
Arterial Cannulation Complications
Vascular Complications
- Arterial occlusion - occurs in approximately 5-6% of radial artery cases 3
- Arterial spasm - affects >20% of patients, higher risk in younger patients, females, diabetics, and lower BMI 3
- Hematoma formation 3
- Pseudoaneurysm 3
- Arteriovenous fistula 3
- Hand ischemia - particularly with dominant radial artery, incomplete palmar arch, or occluded ulnar circulation 3
- Compartment syndrome in severe cases 3
Risk Mitigation for Arterial Access
Use ultrasound to assess vessel patency and size rather than Allen's test, which is unreliable 1, 3.
Limit arterial sheath size to 6-Fr or smaller when possible - larger sizes significantly increase radial artery occlusion risk 3. Notably, 14% of men and 27% of women have radial artery diameter smaller than a 6F sheath 3.
Administer therapeutic heparin to significantly reduce radial artery occlusion risk 3.
Employ "patent hemostasis technique" to maintain anterograde flow during hemostasis, which can reduce radial artery occlusion by 75% 3.
Hemodialysis Access-Specific Complications
Cannulation-Related Issues
Infiltration injury before successful 2-needle cannulation is associated with 56% lower odds of overall AVF maturation 1. This represents a critical complication that can permanently compromise vascular access.
Pain occurs commonly at various intensities - during cannulation, during treatment, or post-dialysis from hematoma, infiltration, or nerve irritation 1.
Prevention Protocols
Limit cannulation attempts to maximum of 2 before seeking expert advice 1.
Use experienced cannulators for at-risk accesses whenever possible 1.
Perform AV access assessment before every cannulation - ensure flow is present, determine flow direction, observe full access, and perform auscultation/palpation 1.
Apply pressure directly to bleeding sites without occluding outflow distal to the site to avoid increasing intraluminal pressure to arterial levels 1.
Critical Pitfalls to Avoid
Never use subclavian vein catheterization for temporary access in kidney failure patients - the associated central venous stenosis risk will preclude use of the entire ipsilateral arm for future vascular access 1.
Never apply pressure distal to an infiltration site as this increases intraluminal pressure and worsens the infiltration 2.
Do not remove gauze/opaque dressings for routine inspection unless the patient has clinical signs of infection 1.
Avoid peripheral insertion for solutions with osmolality >500 mOsm/L, pH <5 or >9, or access duration >2 weeks 1.