What are the common complications of central venous catheters and how should they be prevented and managed?

Central Venous Catheter Complications: Prevention and Management

Central venous catheters cause complications in approximately 20-30% of insertions, with infection being the most common delayed complication and arterial puncture/pneumothorax being the most frequent immediate complications; ultrasound guidance and maximal sterile barriers are mandatory to reduce morbidity and mortality. 1, 2

Immediate Procedural Complications

Cardiac Arrhythmias (23-25% incidence)

• Occurs when the catheter is advanced too far into the heart 1
• Monitor ECG continuously during insertion and immediately withdraw the catheter if arrhythmias appear 1

Arterial Puncture and Cannulation

• Arterial puncture with small needle (16.2 per 1000 catheters): Remove the needle immediately and apply firm pressure for 10 minutes while monitoring neurological, hemodynamic, and airway parameters 1, 2
• Arterial cannulation with large-bore catheter/dilator (2.8 per 1000 catheters): DO NOT remove the catheter—leave it in place and immediately consult vascular surgery or interventional radiology before any removal attempt 1
  • Case reports show severe complications (cerebral infarction, arteriovenous fistula, hemothorax) occur after immediate removal, but not when catheters are left in place for surgical repair 1
• Ultrasound guidance reduces arterial puncture by 80% (RR 0.20; 13.5 vs 68.8 events per 1000 catheters) 2

Pneumothorax (4.4 per 1000 catheters)

• Confirm diagnosis with chest X-ray 1
• Insert chest tube for drainage if no spontaneous recovery occurs 1
• Ultrasound guidance reduces pneumothorax by 75% (RR 0.25; 2.4 vs 9.9 events per 1000 catheters) 2

Hemothorax (0.1-11% incidence)

• Insert large-bore chest tube immediately to drain pleural blood 1
• Reserve thoracotomy for massive hemothorax 1

Air Embolism (rare but life-threatening)

• Immediately place patient in left lateral decubitus position with head down (Trendelenburg) 1
• Deliver 100% oxygen 1
• Perform procedure with patient in Trendelenburg position when clinically appropriate to prevent this complication 1

Catheter Malposition/Migration (20.4 placement failures per 1000 catheters)

• Obtain chest X-ray no later than early postoperative period to confirm tip position 1, 2
• Consult interventional radiology immediately for repositioning or removal 1

Catheter-Related Bloodstream Infection (CRBSI)

Epidemiology and Risk

• Most common complication in cancer patients with mortality of 12-25% 1
• Incidence: 4.8 events per 1000 catheter-days overall; 1.5 per 1000 CVC-days in cancer patients 1, 2
• Overall CRBSI occurs in 3-16% of catheterizations 1
• Implantable ports have lowest infection risk; non-tunneled CVCs have highest risk 1

Risk Factors

• Patient factors: aggressive hematological malignancies, pancreatic cancer, poor performance status, age >65 years 1
• Catheter factors: prolonged catheter stay, parenteral nutrition administration, cumulative utilization-days 1

Prevention Strategies (Mandatory)

• Use maximal sterile barriers: sterile gowns, sterile gloves, caps, masks covering mouth and nose, and full-body patient drapes 1
• Chlorhexidine-containing solution with alcohol for skin preparation in adults, infants, and children (use povidone-iodine or alcohol if chlorhexidine contraindicated) 1
• Use aseptic hand-washing techniques before insertion 1
• Consider antimicrobial-coated catheters for high-risk patients based on infectious risk, cost, and anticipated duration 1
• Use standardized equipment sets and checklists for placement and maintenance 1
• Select upper body insertion sites in adults to minimize thrombotic complications 1

Diagnosis

• Obtain blood cultures when fever, inflammation/purulence at insertion site, catheter dysfunction, hypotension, chills, or sudden sepsis occurs after catheter use 1
• Classify as: localized entrance infection, tunnel/port-pocket infection, or CRBSI 1

Management

• Follow local institutional guidance for treatment 1
• May require catheter removal depending on clinical situation 1

Catheter-Related Thrombosis

Incidence and Risk

• Deep vein thrombosis occurs at 2.7 events per 1000 catheter-days 2
• Left-sided catheter placement carries 2.6-fold higher risk than right-sided 3
• Central venous catheters account for approximately 32% of subclavian vein thrombosis cases 3

Risk Factors

• Improper catheter tip position, multiple insertion attempts, catheter material/size, duration of placement, previous CVC insertion 3
• Pinch-off syndrome (compression between first rib and lateral clavicle) 3
• Active malignancy and chemotherapy administration 3

Clinical Presentation

• Arm swelling and pain, catheter dysfunction, local burning during injection, venous engorgement, functional impairment 3
• May present with poorly functioning line or signs of superior vena cava obstruction 1

Diagnosis and Management

• Doppler ultrasound is first-line diagnostic test (sensitivity 56-100%, specificity 94-100%) 3
• Treat symptomatic thrombosis with full anticoagulation 1
• Anticoagulation not currently recommended for asymptomatic thrombosis or routine prophylaxis (except high-risk patients with previous DVT/PE) 1
• Decision to remove functioning CVC depends on clinical situation and ease of re-insertion 1

Pulmonary Embolism During/After Placement

Mechanism

• Thrombus forms on catheter/guidewire and dislodges during manipulation 4
• Risk factors: malignancy, sepsis, hypercoagulable states, vessel trauma during insertion 4

Clinical Presentation

• Sudden respiratory distress, hypoxemia, hemodynamic instability during or shortly after placement 4
• Symptoms range from mild dyspnea to profound shock 4

Management Algorithm

1. Assess hemodynamic stability immediately to distinguish high-risk from non-high-risk PE 4
2. Initiate unfractionated heparin with weight-adjusted bolus without delay 4
3. DO NOT immediately remove the central line—this could worsen the situation 4
4. Rule out air embolism (requires different management) 4
5. High-risk PE: Administer systemic thrombolytic therapy as first-line treatment; consider surgical embolectomy if thrombolysis contraindicated or fails 4
6. Non-high-risk PE: Continue anticoagulation with unfractionated heparin followed by oral anticoagulants 4

Critical Prevention Strategies to Reduce Overall Complications

Operator Experience

• Operators with <25 insertions cause significantly more complications (25.2% vs 13.6%) 5
• Trainees with <25 previous insertions should be supervised at all times 5
• Higher levels of supervision decrease complications (10.7% vs 23.8%) 5

Site Selection

• Internal jugular vein should be the primary target vessel 5
• Subclavian vein approach results in significantly more overall complications (29.2% vs 17.7%) 5
• Select insertion sites that are not contaminated or potentially contaminated (avoid burned/infected skin, inguinal area, adjacent to tracheostomy or open wounds) 1

Ultrasound Guidance

• Ultrasound guidance is mandatory and reduces major mechanical complications 1, 5, 2
• Reduces arterial puncture by 80% and pneumothorax by 75% 2

Catheter Selection

• Select smallest catheter size appropriate for clinical situation 1
• Proper catheter tip positioning is essential to minimize risk 4

Documentation and Protocols

• Use checklists or protocols for placement and maintenance 1
• Document catheter type, insertion site, and tip position clearly 1
• All hospitals should have clear, specific policies for CVC insertion and complication management 1

Composite Risk Assessment

Approximately 30.2 per 1000 patients (3%) with a CVC for 3 days will develop one or more serious complications (arterial cannulation, pneumothorax, infection, or DVT). 2