Central Venous Line Insertion Research Articles

Persistent left vena cava incidentally recognized during subclavian vein catheterization

Central venous line insertion is a routine procedure in the intensive care unit. But intensivists should be aware of the possibility of rare anatomic variants. We report an 84-year-old patient who was admitted to the intensive care unit for respiratory distress due to Guillain-Barre syndrome. After intubation of the trachea, a central venous catheter was inserted via the left subclavian vein. Th is was accomplished uneventfully with only one puncture. However, the post-procedural chest x-ray showed an unusual left-sided paramediastinal course of the catheter (Figure 1). We evocated an arterial placement fi rst, but the transduced waveform and the blood gas samples were compatible with an intrathoracic vein placement. So we hypothesized that the patient could present with a persistent left superior vena cava (LSVC). Th is diagnosis was confi rmed by trans oeso phageal echography: the injection of agitated saline via the right cubital vein resulted in opacifi cation of the dilated coronary sinus prior to reaching the right atrium and right ventricle, and this confi rmed the anatomic variant of LSVC associated with the absence of a right superior vena cava. Th ere were no other abnormalities concern ing heart or great vessels. Persistent LSVC occurs in 0.5% of the population and 5% to 10% of patients with congenital heart diseases. It usually drains into the right atrium through the coronary sinus, and it is associated with an absent right superior vena cava in 20% of cases [1]. Th e diagnosis can be made by bedside transthoracic or transesophageal echocardiography [2,3]. Computed tomography can also be useful [4]. Persistent LSVC is not a contraindication to subclavian vein catheterization but can make diffi cult the attempt to place a central venous line, pulmonary artery catheter, or pacemaker. Some authors described the uneventful use of a catheter placed in the LSVC for several days, after checking that the catheter tip was not in the coronary sinus [3]. Th e use of a pulmonary artery catheter has also been reported [1]. But manipulation of a

Pride and prejudice

Pride and prejudice

Acute myeloblastic leukemia in adult patients: ESMO Clinical Recommendations for diagnosis, treatment and follow-up

Risk assessment in AML includes the patient’s age, the initial leukocyte count, the AML subtype, karyotype data and selected molecular markers. AML with the chromosomal translocations t(15;17) (acute promyelocytic leukemia; APL), t(8;21) and t(16;16) (including acute myelomonocytic leukemia with preponderance of eosinophil granulocytes) are considered as favorable, as are AML with mutations in the C/EBPa gene, and the nucleophosmin gene [II, A]. An antecedent or concomitant myelodysplastic syndrome or a complex aberrant karyotype, alterations of the FLT3 gene are adverse prognostic factors. Preexisting medical conditions such as diabetes or coronary heart disease may affect the feasibility of intensive chemotherapy. Patients beyond the age of 60 years are more susceptible to treatment complications but also have an adverse prognosis due to more frequent unfavorable cytogenetics. If an infection is suspected, a thoracic CT scan, and an abdominal ultrasound or CT scan may be carried out to assess lung, liver, spleen, lymph nodes and kidneys for possible pathological alterations. Cardiac examination including echocardiography is recommended for patients with cardiac risk factors or a history of heart disease [A]. In addition to hematological and chemistry tests coagulation screening is to be carried out before the insertion of central venous lines and to detect leukemia-related coagulopathy (particularly if morphology suggests a diagnosis of APL). HLA typing of patients and their family members is carried out in patients who are candidates for allogeneic bone marrow or stem-cell transplantation [A].

Extrinsic Compression of the Left Atrium by a Mediastinal Hematoma Secondary to Inadvertent Carotid Puncture

We present the case of a 63-year-old man who underwent surgical closure of a paravalvular mitral leak. Immediately after surgery, transesophageal echocardiography revealed the appearance of a mediastinal hematoma encroaching on the left atrium and separating the esophageal probe from the posterior left atrial wall. The cause was an inadvertent puncture of the carotid artery, presumably during central venous line insertion prior to surgery.

Abdominal Paracentesis and Thoracocentesis

Abdominal paracentesis and thoracocentesis are common bedside procedures with diagnostic, therapeutic and palliative roles. We describe a useful and familiar a useful and familiar technique with the use of a multiple lumen catheter commonly used for central venous line insertion for drainage of ascites or moderate to large pleural effusions. The use of a multiple lumen catheter allows easier and more rapid aspiration of fluid with a smaller probability of the side holes being blocked as compared to the standard needle or single catheter methods. This is particularly useful in situations where the dedicated commercial kits for thoracocentesis and abdominal paracentesis are not readily available.

CENTRAL VENOUS PRESSURE LINE

Objective: To study the frequency of complications of central venous pressure line. S t u d y d e s i g n . Descriptiveobservational study. S e t t i n g : This study was carried out in surgical ward and intensive care unit of Fauji Foundation hospital Rawalpindiand Frontier Medical College Abbottabad. P e r i o d : From 2003-2007. M e t h o d s a n d Materials: One hundred consecutive surgical patientsneeding central venous line insertion above 14 years of age were included in the study. Patients under 14 years of age, with central venousline in situ at the time of admission, with thoracic trauma, chronic obstructive pulmonary disease, burns involving upper chest and neck areas,cardiovascular disease and bleeding disorders were excluded from this study. R e s u l t s : 100 cases were included in the study with the rangeof age between 16-82 years. There were 76% female and 24% male. Out of these 100 cases 40 were suffering from malignancy, 20 weresuffering from intestinal obstruction, 10 were with peritonitis and 30 cases were having miscellaneous disorders. Rate of complications ofcentral venous line was 30% in this study. Rate of infection was 20%, rate of misplacement of catheter was 8% and rate of pneumothoraxwas 2% C o n c l u s i o n : infection is the most common complication of the central venous line insertion followed by misplacement of catheterand pneumothorax, so it is important to take specific measures to minimize these complications

Airway Obstruction due to a Pre-vertebral Haematoma following Difficult Central Line Insertion – Implications for Ultrasound Guidance and Review of the Literature

We describe a case of airway obstruction secondary to a large pre-vertebral cervico-mediastinal haematoma following failed attempts at insertion of an internal jugular central venous line. The need for a high index of suspicion to diagnose this injury and early aggressive intervention to manage it are outlined. The role of ultrasound guidance in preventing such a complication is reviewed, as well as other possible mechanisms of haematoma development.

Right ventricular mural endocarditis presenting as an isolated apical mass in a non-addict patient with congenital deafness and aphasia

Right heart infective endocarditis presenting as an isolated apical mural mass is an extremely uncommon finding. A 24-year-old woman with congenital deafness and aphasia was admitted with recurrent attacks of fever and lobar pneumonia. Her past medical history was significant for an open operation for left nephrolithiasis five months before admission. She had no history of congenital heart defect, intravenous drug use or central venous line insertion. Diagnostic workup revealed a large pedunculated solid mass attached to the apex of the right ventricle and multiple septic foci in both lungs. Repeated blood cultures were negative. In spite of aggressive antibiotic therapy, she had progressively worsening respiratory distress. She was successfully operated for the mass and the pathologic findings were consistent with endocarditis. To our knowledge, the anatomical location of the mural endocarditis (apex of right ventricle) is a pretty uncommon condition.

Traumatic fracture of central venous catheter resulting in potential migration of distal fragment: a case report

We report a surgical retrieval of an indwelling portion of a traumatic rupture of the Central venous catheter following hair cutting by a confused patient secondary to Postoperative cognitive dysfunction. He had a dynamic compression screw for fixation of fractured neck of femur after previously failed surgical procedure. The second procedure was complicated with major blood loss, which required central venous and arterial line insertion for intra-operative and post-operative management. The patient was discharged to the ward following an uneventful stay on intensive care. While on the ward, he decided to trim his hair and in the process he inadvertently cut through the right internal jugular catheter. Complications and management resulting from embolisation of central line are reviewed.

Systematic Intervention to Reduce Central Line–Associated Bloodstream Infection Rates in a Pediatric Cardiac Intensive Care Unit

Our goal was to determine whether an intervention involving staff education, increased awareness, and practice changes would decrease central line-associated bloodstream infection rates in a pediatric cardiac ICU. A retrospective, interventional study using an interrupted time-series design was conducted to compare central line-associated bloodstream infection rates during 3 time periods for all patients admitted to our pediatric cardiac ICU between April 1, 2004, and December 31, 2006. During the preintervention period (April 2004 to December 2004), a committee was convened to track and prevent nosocomial infections. Pretesting demonstrated knowledge deficits regarding nosocomial infection prevention, and educational tools were developed. During the partial intervention period (January 2005 to March 2006), a comprehensive central line-associated bloodstream infection prevention initiative was implemented, including establishment of a unit-based infection control nurse position, education for physicians and nurses, real-time feedback on central line-associated bloodstream infection data, implementation of central venous line insertion, access, and maintenance bundles, and introduction of daily goal sheets on rounds that emphasized timely central venous line removal. Central line-associated bloodstream infection rates in the preintervention, partial intervention, and full intervention (April 2006 to December 2006) periods were compared. The estimated mean preintervention central line-associated bloodstream infection rate was 7.8 infections per 1000 catheter-days, which decreased to 4.7 infections per 1000 catheter-days in the partial intervention period and 2.3 infections per 1000 catheter-days in the full intervention period. The preintervention central line-associated bloodstream infection rate was significantly higher than the median rate of 3.5 infections per 1000 catheter-days for multidisciplinary PICUs reporting to the National Healthcare Safety Network. During the full intervention period, our central line-associated bloodstream infection rate was lower than this pediatric benchmark, although statistical significance was not achieved. A multidisciplinary, evidence-based initiative resulted in a significant reduction in central line-associated bloodstream infections in our pediatric cardiac ICU.

Medication Error: A Leading Cause of Anesthesia-related Morbidity and Mortality

We read with great interest the analysis of anesthesia-related deaths registered by the Danish Patient Insurance Association.1Hove et al. 1are to be congratulated for reporting these important results. The authors categorized 24 fatal cases by their underlying causes: airway management, ventilation management, placement of a central venous catheter, medication errors, transfusion error, infusion pump problems, and regional blockade. We noted that 8 of the 24 anesthesia-related deaths described were most likely attributable to a drug error: 4 overdoses (benzodiazepines, methohexital, thiopental, nitroglycerine), 3 infusion pump errors, and 1 patient likely received a large intrathecal dose of mepivacaine. Therefore, the frequency of medication-related incidents exceeded the 4 deaths that resulted from loss of the airway and 4 from complications related to central venous line insertion. It seems that the single most common cause of anesthetic-related death was a drug error.These findings are consistent with an analysis from the Canadian Medical Protective Association of closed medicolegal claims against anesthesiologists.2The Canadian Medical Protective Association provides malpractice insurance for most physicians in Canada. From 1998 to 2002, there were 232 closed legal actions against anesthesiologists. Medication error was the most common cause involving 52% of the claims. It is noteworthy that the American Society of Anesthesiologists Closed Claims Project reports the proportion of drug errors as 4%.2This number has been consistent throughout the 1980s and 1990s. Reasons for the discrepancy in the relative frequency of medication errors reported in the American Society of Anesthesiologists Closed Claims Database from those in Demark and Canada requires further exploration but may be attributed, in part, to differences in the categorization of root causes.The impact of drug error in anesthetic practice is not new and will not surprise experienced anesthesiologists. A survey by the Canadian Anesthesiologists' Society found that 85% of participants had experienced at least one drug error or “near miss.”3Most of these errors were of minor consequence; however, 1.8% resulted in major morbidity (cardiac arrest, stroke, permanent injury) or death. The misidentification of a syringe was the most common cause. In 1984, Cooper et al. 4published a classic analysis of critical incidents in anesthesia management. Breathing circuit disconnect was the most common identified factor; however, reanalyzing their data set indicates that medication-related events far exceeded airway and ventilation problems. Of a total of 507 incidents, 169 were attributed to errors or problems in drug administration. Equally important, when incidents with “substantive negative outcomes” were further analyzed (defined as mortality, cardiac arrest, cancelled operative procedure, or extended recovery room, intensive care unit, or hospital stay) approximately 25% of them resulted from a drug error.Together, these studies suggest that the impact of medication error has been underestimated by the lack of a common taxonomy for anesthesia-related adverse events. More importantly, the data beseech us to acknowledge the problem and develop innovative strategies to reduce the likelihood of a drug error in anesthetic practice.*University of Toronto, Toronto, Ontario, Canada. rachel.meyer@utoronto.ca

Valsalva manoeuvre for central venous cannulation

We report a case of a difficulty inserting a Hickman line that was overcome by asking the patient to perform a Valsalva manoeuvre. A middle-aged woman of short stature weighing 72 kg and BMI 33, required a line for long-term chemotherapy. A left-sided approach was chosen due to previous surgery on her right breast and axilla. We planned to insert a Bard single lumen 6.6 Fr Hickman line (Bard Access Systems, Crawley, UK) into the left axillary or subclavian vein. Ultrasound detected a small deep axillary vein and the subclavian vein was therefore selected. Cannulation was guided by fluoroscopy. The vein was punctured above the first rib using a micropuncture technique and the wire passed readily into the brachiocephalic vein. When the wire was advanced further it repeatedly passed into the ipsilateral internal jugular or the contralateral subclavian vein. Elevating or depressing the shoulders and turning the head made no difference to the course of the wire. Finally, we asked the patient to take a deep breath, hold her nose with her fingers, close her mouth and breath out maximally (like straining when passing stool), after which the wire passed immediately into the superior vena cava. In our experience of inserting over 1000 subclavian and axillary vein Hickman lines we have often encountered difficulty in directing the wire in to the superior vena cava. Indeed, 7% of jugular lines are reported to be misplaced in the axillary vein [1] and 5% of subclavian lines are incorrectly positioned in the ipsilateral jugular vein [2]. Howes and Dell recently reported a difficult central venous line insertion using the right subclavian approach [3] when the guide wire repeatedly passed in to the right jugular vein despite using ultrasound guidance and the superior vena cava could not be cannulated. If this occurs we advise removing the wire and injecting contrast to ensure that the vein is not thrombosed proximally. This is particularly important in patients who have had previous central line catheters as there is a 13% risk of thrombosis after long-term subclavian vein catheters and a 3% risk after internal jugular vein catheters [4]. Repositioning of the patient as described above can often facilitate wire placement but on occasions we have found the Valsalva manoeuvre to be successful. The application of 20 cmH2O of continuous positive airway pressure has been shown to maintain internal jugular vein patency and reduce the incidence of kinking and locking of the guide wire [5]. Asking the patient to take a deep breath may also straighten the great vessels and help wire positioning [6]. Alternatively, specialised directional wires or blockers can be used but are generally reserved for use by a skilled radiologist.

Developing Educational Materials to Facilitate Adherence: Pediatric Thrombosis as a Case Illustration

Developing Educational Materials to Facilitate Adherence: Pediatric Thrombosis as a Case Illustration

A comparison between ultrasound-guided central venous line placement and an anatomical landmark technique

Ultrasound has been introduced in the insertion of central venous lines to reduce the complications associated with the conventional landmark technique [1]. We compared both techniques; we noted the number of attempts, the duration of insertion and complications.

Haemothorax: A potentially fatal complication of subclavian cannulation—A case report

Central venous cannulation forms one of the mainstays of management of trauma and haemodynamically unstable patients. Frequently this procedure has to be done as an emergency in the emergency department. Ultrasound guidance has been recommended, especially for use by trainee members of the emergency department. We report a case of 44% full thickness burns with subclavian artery puncture due to a misplaced central venous catheter. This led to massive haemothorax, which eventually caused the patient to succumb. We re-emphasise the need for ultrasound guidance for insertion of central venous lines, especially in the emergency setting.

Investigation for cystic fibrosis in infants with jejunoileal atresia in the Netherlands: a 35-year experience with 114 cases

Cystic fibrosis (CF) is a relatively common autosomal recessive disorder with an incidence of 1 in 3600 live births in the Netherlands [1, 6]. CF is immediately suspected in neonates with meconium ileus. However in children with jejunoileal atresia (JIA), CF may be overlooked [2, 5]. In our hospital, investigation for CF in JIA-patients was performed only when clinical symptoms gave rise to it. The objective of this retrospective case study was to evaluate factors that might justify a change in our current strategy for investigation for CF in neonates with JIA. For this reason, the medical records of all patients with jejunoileal atresia and stenosis treated at our hospital in the period 1971–2005 have been reviewed. Intestinal perforation and microcolon were regarded as consequences of the JIA. Volvulus, omphalocele, gastroschisis, and intussusception were regarded as gastrointestinal anomalies that could have caused the atresia or stenosis. Cystic fibrosis was present in nine cases in 114 patients with JIA (8%). In seven neonates CF was diagnosed in the first month of life. In two patients investigation occurred much later. No statistically significant differences between birth weight, average growth per day (age 3 months), time at starting oral feeding, time at starting total oral intake and hospital stay were observed in the JIA-group with and without CF. There was also no statistically significant difference regarding sex, gestational age, number of gemelli, presence of short bowel, mortality, requirement of central venous line insertion for administration of total parenteral nutrition, number of prenatal diagnosed atresias and number of patients needing a temporary enterostomy. From the atresias in patients without CF, 61% were located in the jejunum, 7% in the jejunoileum and 32% in the ileum; compared to 78%, 11% and 11% in jejunum, jejunoileum and ileum, respectively, in those with CF. There was no difference in the classification of the atresias (Table 1) [3]. The number of patients with one or more associated anomalies did not differ significantly (60% in the non-CF-group versus 67% in the CF-group), even after correction for gastrointestinal anomalies that could well be cause or consequence of the atresia (45% versus 33%, respectively). The reported incidence of CF in infants with JIA in the Netherlands is not different from the international reported incidence of 10% [2, 5]. We could not find any difference in clinical symptoms, classification and location of the atresia and associated anomalies that might justify investigation for CF. Although Michaud suggested CF as a cause of apple peel atresia (type IIIb), we cannot support this suggestion with only 1 out of 9 CF-patients with this kind of atresia [4]. Different authors have already recommended testing for CF in all neonates presenting with JIA merely based on the significant association between jejunoileal atresia and cystic fibrosis [2, 5]. The findings of our study support this Eur J Pediatr (2007) 166:989–990 DOI 10.1007/s00431-006-0342-6

Minor Surgical Procedures - Survey of Hematologists To Determine Preferences Regarding Management of Hemophilia Patients.

Objective: To determine individual/institutional practices at hemophilia treatment centers (HTCs) regarding management of severe hemophilia patients during minor surgery (e.g., central venous line insertion, cataract surgery, lymph node biopsy), both in the absence and presence of low and high titer inhibitors to Factor VIII (FVIII).Background: The management of hemophilia patients undergoing surgery has changed over the past 20 years as product choice and availability has evolved. Individual preference and experience may affect treatment decisions in the absence of data from clinical trials.Methods: The survey was distributed to both adult and pediatric hematologists at HTCs listed on the CDC website. 93 surveys were successfully emailed. Survey questions evaluated management of minor surgery, both in the absence and presence of a low and high titer inhibitor to FVIII.Results: Surveys from 32 HTCs were received. Twenty-two respondents were affiliated with a University Hospital. For patients without inhibitor, the majority of respondents prefer a pre-operative bolus dose of FVIII 50 U/kg (73%, 22/30; range 25–50 U/kg); only 3 respondents reported a continuous infusion (range 4–8 u/kg/hr). For the post-operative dose, most (n=22) prefer a bolus dose (25–50 U/kg); only 6 reported using a continuous dose (range 2–8 U/kg/hr). Total number of days treated pre-operatively was reported as less than a day in 88% (23/26) respondents; days of post operative treatment ranged from 1–14 with a median of 4 days (n=22). Desired FVIII level ranged from 50–100% for 1–10 days. Fifty percent (15/30) reported adjuvant use of Amicar. For patients with high inhibitor levels no one reported a pre or post operative FVIII bolus or continuous infusion rate. Fifty percent (9/18) reported adjuvant Amicar use. The reported rFVIIa dose in patients with high titer inhibitors, ranged from 90–200 mcg/kg (most commonly 90 mcg/kg), usual frequency of every 2 hours, for a range of 1–10 days. The reported FEIBA dose in patients with high titer inhibitors, ranged from 50–100 U/kg (most commonly 75–100 U/kg with a frequency of every 12 hours, for 1–10 days.Conclusion: Substantial practice variations exist in managing minor surgeries in hemophilia patients, both with and without low and high titer inhibitors, as is evident with this survey.

State of the Science

Neonates in the neonatal intensive care unit experience painful procedures. Over the last 10 years, investigators have examined several pharmacologic and nonpharmacolgic treatment strategies to decrease or eliminate the pain associated with mechanical ventilation, endotrachial intubation, insertion of percutaneous or central venous lines, heel stick, and venipuncture. These procedures and others are addressed as well as the reported severity of pain associated with these procedures. Progress has been made in the past decade to establish evidence-based treatments that will help the clinician more effectively relieve neonatal stress and pain when performing many routine procedures.

Iatrogenic pseudo-aneurysm of the subclavian artery and dissection of the aorta, secondary to central venous line insertion: a treatment dilemma!

Iatrogenic pseudo-aneurysm of the subclavian artery and dissection of the aorta, secondary to central venous line insertion: a treatment dilemma!

Is the landmark technique safe for the insertion of subclavian venous lines?

The complications of central venous line insertion have been highlighted by the recent NICE report advising that ultrasound guidance should be used for central line insertion. We report a prospective audit of the complications of subclavian vein central venous line insertion for parenteral nutrition over a five-year period when ultrasound guidance was not used. In total, 201 lines were inserted for parenteral nutrition into a subclavian vein. A single consultant surgeon inserted 120 of the lines and year five or six surgical registrars performed the other line insertions. Five pneumothoraces occurred in four patients who had subclavian lines inserted and a chest drain was required in three cases. Four line tips were found to be going upwards rather than into the superior vena cava. Misplacement was more common with right subclavian insertion. Inability to site the line at that attempt was associated with previous line insertion in four of six patients. A low complication rate can be achieved for central line insertion for parenteral nutrition. It is likely that this is due to the small number of experienced operators.