Jugular Central Venous Access Research Articles

A Rare Malposition of a Left Internal Jugular Central Venous Catheter into the Left Internal Mammary Vein.

We describe a case of left internal jugular central venous access with rare malpositioning into the internal mammary vein. Despite various confirmatory measures at the time of placement including ultrasonography of the internal jugular vein, as well as blood gas analysis consistent with venous blood by oxygen saturation and good venous flow in all three ports of the catheter, subsequent imaging confirmed misplacement into the internal mammary vein. Central venous access is a frequently used procedure by emergency physicians for a variety of indications. Emergency physicians must be facile with both the technical process of central venous catheter placement, as well as possible pitfalls and complications of the procedure. Common complications, such as bleeding, pneumothorax, arterial injury, infection, and hematomas, are usually well known; less frequently encountered is malposition of the catheter despite seemingly appropriate placement.

Securing jugular central venous access devices with dressings fixed to a liquid adhesive in an intensive care unit population: a randomised controlled trial

BackgroundCentral venous access devices (CVADs) can have high rates of failure due to dressing-related complications. CVADs placed in the internal jugular vein are at particular risk of dressing failure-related complications, including catheter-associated bloodstream infection and medical adhesive-related skin injury. Application of Mastisol liquid adhesive (MLA) may reduce CVAD dressing failure and associated complications, by reducing the frequency of dressing changes. The aim of this study is to investigate whether, in an intensive care unit (ICU) population, standard dressing care with or without the addition of MLA, improves internal jugular CVAD dressing adherence.MethodsThis two-arm, parallel group randomised controlled trial will be conducted in three Australian ICUs. A total of 160 patients (80 per group) will be enrolled in accordance with study inclusion and exclusion criteria. Patients will be randomised to receive either (1) ‘standard’ (in accordance with local hospital policy) CVAD dressings (control) or (2) ‘standard’ dressings in addition to MLA (intervention). Patients will be followed from the time of CVAD insertion to 48 h after CVAD removal. The primary outcome is ‘dressing failure’ defined as requirement for initial CVAD dressing to be replaced prior to seven days (routine replacement).DiscussionThis study will be the first randomised controlled trial to evaluate the clinical effectiveness of MLA in the adult intensive care unit population and will also provide crucial data for patient-important outcomes such as infection and skin injury.Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN12621001012864. Registered on 2 August 2021

Choque séptico de origen biliar en la Unidad de Cuidados Intensivos

Se presenta un caso de choque séptico de origen biliar en un paciente de sexo masculino de 76 años, con antecedente de colecistitis aguda y su correspondiente resolución quirúrgica. Ingresa a la Unidad de Cuidados Intensivos (UCI) del Hospital General San Vicente de Paúl, de Ibarra, con apoyo de dispositivo de ventilación con presión positiva, RASS -5 con efectos de sedoanalgesia, presencia de acceso venoso central yugular derecho, abdomen con presencia de bolsa de Bogotá y sonda vesical permeable. Luego de 16 días en UCI, a pesar de tratamiento médico, evoluciona tórpidamente y fallece. Cabe recalcar que no se efectuaron exámenes post mortem. En términos generales, la sepsis biliar constituye la disfunción multiorgánica originada en el contexto de infección de la vía biliar principal (VBP) o vía biliar accesoria (VBA). En este caso se revisa la cronología de un paciente con diagnóstico de choque séptico de origen biliar, la clínica y el manejo. En efecto, establecer el diagnóstico tardío de colecistitis aguda determina consecuencias graves como la perforación vesicular, sepsis grave o choque séptico de origen biliar con el mal pronóstico consecuente. El tratamiento es quirúrgico y consiste en colecistectomía, lavado quirúrgico y drenaje, e incluso en la reparación de las complicaciones que se presenten. Gran parte de la mejora en la mortalidad asociada con el shock séptico está relacionada con el reconocimiento precoz combinado con la reanimación con líquidos intravenosos y la administración de antibióticos.

A 4-arm randomized controlled pilot trial of innovative solutions for jugular central venous access device securement in 221 cardiac surgical patients

PurposeTo improve jugular central venous access device (CVAD) securement, prevent CVAD failure (composite: dislodgement, occlusion, breakage, local or bloodstream infection), and assess subsequent trial feasibility. Materials and MethodsStudy design was a 4-arm, parallel, randomized, controlled, nonblinded, pilot trial. Patients received CVAD securement with (i) suture+bordered polyurethane (suture + BPU; control), (ii) suture+absorbent dressing (suture + AD), (iii) sutureless securement device+simple polyurethane (SSD+SPU), or (iv) tissue adhesive+simple polyurethane (TA+SPU). Midtrial, due to safety, the TA+SPU intervention was replaced with a suture + TA+SPU group. ResultsA total of 221 patients were randomized with 2 postrandomization exclusions. Central venous access device failure was as follows: suture + BPU controls, 2 (4%) of 55 (0.52/1000 hours); suture + AD, 1 (2%) of 56 (0.26/1000 hours, P=.560); SSD+SPU, 4 (7%) of 55 (1.04/1000 hours, P=.417); TA+SPU, 4 (17%) of 23 (2.53/1000 hours, P=.049); and suture + TA+SPU, 0 (0%) of 30 (P=.263; intention-to-treat, log-rank tests). Central venous access device failure was predicted (P<.05) by baseline poor/fair skin integrity (hazard ratio, 9.8; 95% confidence interval, 1.2-79.9) or impaired mental state at CVAD removal (hazard ratio, 14.2; 95% confidence interval, 3.0-68.4). ConclusionsJugular CVAD securement is challenging in postcardiac surgical patients who are coagulopathic and mobilized early. TA+SPU was ineffective for CVAD securement and is not recommended. Suture + TA+SPU appeared promising, with zero CVAD failure observed. Future trials should resolve uncertainty about the comparative effect of suture + TA+SPU, suture + AD, and SSD+SPU vs suture + BPU.

310 Comparison of Ideal Needle Insertion Location for Internal Jugular Central Venous Access: Anatomic Landmarks versus Ultrasonography Guidance Method

Study Objectives: Ultrasonography-guided central venous access of the internal jugular vein is considered superior to landmark-guided line placement. The use of ultrasonography has resulted in fewer attempts at line placement, shorter time for line placement and fewer complications. Current practice almost excludes using the landmark approach, except for patients in extremis undergoing emergent line placement. Complications of central lines are not uncommon and can be significant. Preliminary studies have shown conflicting data regarding the utility of US-guided access when compared to the “blind” or landmark approach to access. We were interested in determining whether or not there is a significant difference in the ideal needle insertion sites for the 2 methods of line placement. Methods: Our aim was to measure the distance between landmark and ultrasonography-guided needle insertion sites for internal jugular central line placement in a convenience sample of patients in our Level II urban academic emergency department (ED). Actual central line placement was not required. A convenience sample of 45 patients seen in the emergency department at Christus Spohn Memorial Hospital and were enrolled in this study from June to August 2011. Eligible participants include ED patients between the ages of 18 and 65 who were medically stable and able to be placed in Trendelenburg position without risks or complications. A study investigator, using anatomic landmarks in accordance with standard practice, drew an × on the skin with an invisible marker representing the location where the needle would be placed. Next, the second investigator, blinded to the first investigator's placement location, used bedside ultrasonography to identify the most ideal location for anterior approach for initial needle puncture by placing an ink mark in the exact location the initial needle puncture would have been placed in an actual line placement. The invisible pen marks were then illuminated with a black light and the distance between the “invisible” × and the ink was measured. The second investigator then also made note of the anatomical relationship of the carotid artery as compared to the internal jugular vein as well as any other anatomic variations. Results: Of the 45 sampled patients, 45% were found to reflect “normal” anatomy where the internal jugular lies lateral as compared to the carotid artery, 0% demonstrated the carotid artery superficial to the internal jugular, 55% demonstrated the carotid artery immediately deep compared to the internal jugular, and finally 0% were found to have a carotid artery more lateral when compared to the internal jugular. Measurements taken were found to have a range from 2.0 mm to as much as 150.0 mm with an arithmetic mean of 23.2mm and a standard deviation of 23.9. Seven of the 45 (15.5%) samples fell within the 5mm margin while the other 38 (84.5%) were greater than the acceptable 5mm margin for ideal initial needle insertion. Test value of 5.1 with a 95% confidence interval (10.8 to 25.2) and a significance level of P<0.0001. Conclusion: Ultrasonography guidance continues to be proven as a safer, more reliable, and more accurate means of placing central lines. This study reinforces the benefits of direct visualization to recognize the structural arrangement of the anatomy of the neck specifically that of the carotid artery and internal jugular vein, as well as identifying the most desirable location for initial needle insertion.

Central venous access sites for the prevention of venous thrombosis, stenosis and infection.

Central venous access (CVA) is widely used. However, its thrombotic, stenotic and infectious complications can be life-threatening and involve high-cost therapy. Research revealed that the risk of catheter-related complications varied according to the site of CVA. It would be helpful to find the preferred site of insertion to minimize the risk of catheter-related complications. This review was originally published in 2007 and was updated in 2011. 1. Our primary objective was to establish whether the jugular, subclavian or femoral CVA routes resulted in a lower incidence of venous thrombosis, venous stenosis or infections related to CVA devices in adult patients.2. Our secondary objective was to assess whether the jugular, subclavian or femoral CVA routes influenced the incidence of catheter-related mechanical complications in adult patients; and the reasons why patients left the studies early. We searched CENTRAL (The Cochrane Library 2011, Issue 9), MEDLINE, CINAHL, EMBASE (from inception to September 2011), four Chinese databases (CBM, WANFANG DATA, CAJD, VIP Database) (from inception to November 2011), Google Scholar and bibliographies of published reviews. The original search was performed in December 2006. We also contacted researchers in the field. There were no language restrictions. We included randomized controlled trials comparing central venous catheter insertion routes. Three authors assessed potentially relevant studies independently. We resolved disagreements by discussion. Dichotomous data on catheter-related complications were analysed. We calculated relative risks (RR) and their 95% confidence intervals (CI) based on a random-effects model. We identified 5854 citations from the initial search strategy; 28 references were then identified as potentially relevant. Of these, we Included four studies with data from 1513 participants. We undertook a priori subgroup analysis according to the duration of catheterization, short-term (< one month) and long-term (> one month) defined according to the Food and Drug Administration (FDA).No randomized controlled trial (RCT) was found comparing all three CVA routes and reporting the complications of venous stenosis.Regarding internal jugular versus subclavian CVA routes, the evidence was moderate and applicable for long-term catheterization in cancer patients. Subclavian and internal jugular CVA routes had similar risks for catheter-related complications. Regarding femoral versus subclavian CVA routes, the evidence was high and applicable for short-term catheterization in critically ill patients. Subclavian CVA routes were preferable to femoral CVA routes in short-term catheterization because femoral CVA routes were associated with higher risks of catheter colonization (14.18% or 19/134 versus 2.21% or 3/136) (n = 270, one RCT, RR 6.43, 95% CI 1.95 to 21.21) and thrombotic complications (21.55% or 25/116 versus 1.87% or 2/107) (n = 223, one RCT, RR 11.53, 95% CI 2.80 to 47.52) than with subclavian CVA routes. Regarding femoral versus internal jugular routes, the evidence was moderate and applicable for short-term haemodialysis catheterization in critically ill patients. No significant differences were found between femoral and internal jugular CVA routes in catheter colonization, catheter-related bloodstream infection (CRBSI) and thrombotic complications, but fewer mechanical complications occurred in femoral CVA routes (4.86% or 18/370 versus 9.56% or 35/366) (n = 736, one RCT, RR 0.51, 95% CI 0.29 to 0.88). Subclavian and internal jugular CVA routes have similar risks for catheter-related complications in long-term catheterization in cancer patients. Subclavian CVA is preferable to femoral CVA in short-term catheterization because of lower risks of catheter colonization and thrombotic complications. In short-term haemodialysis catheterization, femoral and internal jugular CVA routes have similar risks for catheter-related complications except internal jugular CVA routes are associated with higher risks of mechanical complications.

Nouvelle observation d’une embolie gazeuse au retrait d’un cathéter veineux central

Paradoxical gas embolism is rare but life threatening complication of central venous access. In this observation, we report a paradoxical gas embolism accompanied by an acute respiratory failure and a coma following a jugular central venous access withdrawal in a liver transplanted patient. Following this observation, we discuss the prevention of gas embolism accidents and the hyperbaric oxygen therapy for its management.

Jugular central venous access in neonates and infants below one year of age: Experience in 114 cases

Jugular venous catheter access is needed for chronic use in newborns and infants. Between 1st January 2004 to 31st December 2009, 114 venous catheters have been inserted in neonates and infants below the age of 1 year. Open technique was used in all cases. Details of indication, confirmation of placement, complications and difficulties in insertion were reported and analyzed. There were 82 neonates and 32 infants included in this study. The indications were: need for repeated venous access (71), gut failure (19), malignancy (17) and metabolic diseases (7). Operative difficulty was reported in 9 cases where we shift to left side due to anatomical abnormalities or thrombosis. Infection is the most common complication in 11 cases. Operative central venous catheter insertion is safe even in very small babies. Silicone type of catheter has more advantages than other types. The appropriate size for a definite indication is an important factor to minimize complications

Central Venous Access Sites for the Prevention of Venous Thrombosis, Stenosis, and Infection in Patients Requiring Long-Term Intravenous Therapy

BACKGROUND: Central venous access (CVA), in which a large bore catheter is routed through a vein in the neck, upper chest, or femoral area, is required to administered drugs that cannot be given by mouth or via a conventional cannula in the arm. OBJECTIVES: We sought to establish whether the jugular, subclavian, or femoral CVA routes result in a lower incidence of venous thrombosis, venous stenosis, or infection related to CVA devices. We also sought to determine whether the circumference of a long-term CVA device influences the incidence of venous thrombosis, venous stenosis, or infection related to CVA devices. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 4), MEDLINE, CINAHL, EMBASE (from inception to December 2006), reference lists of identified trials, and bibliographies of published reviews. We also contacted researchers in the field. There were no language restrictions. SELECTION CRITERIA: We included randomized controlled trials comparing central venous catheter insertion routes. DATA COLLECTION AND ANALYSIS: Two authors assessed potentially relevant studies. We resolved disagreements by discussion. Relevant outcomes were: venous thrombosis, venous stenosis, infection related to CVA devices, mechanical complications (e.g., misplaced catheter, minor bleeding, hematoma). MAIN RESULTS: We considered 83 studies for inclusion in the review. Six studies appeared eligible, but five were subsequently excluded because they did not randomize participants for either site of access or catheter circumference size. One study was a high quality block randomized controlled trial. Allocation concealment was good and randomization was by a central computer. In all, 293 patients were randomized to a femoral or a subclavian CVA group. Results from this one trial were as follows: Catheter-related infectious complications: Infectious complication (colonization with or without sepsis: the relative risk (RR) was 4.57 (95% confidence interval [CI]: 1.95–10.71) favoring subclavian over femoral access. Major infectious complications (sepsis with or without bacteremia): the RR was 3.04 (95% CI: 0.63–14.82) favoring subclavian access. Colonized catheter (>103 colony-forming units/mL of Gram-positive microorganisms): the RR was 3.65 (95% CI: 1.40–9.56) favoring subclavian access. Colonized catheter (more than 103 colony-forming units/mL of Gram-negative microorganisms): the RR was 5.41 (95% CI: 1.61–18.15) favoring subclavian access. Catheter-related mechanical complications: Overall complications (arterial puncture, minor bleeding, hematoma, misplaced catheter): the RR was 0.92 (95% CI: 0.56–1.51) favoring subclavian access. Catheter-related thrombotic complications: Catheter-related thromboses (fibrin sleeves, major, and complete thrombosis): the RR was 11.53 (95% CI: 2.80–47.52) favoring subclavian access. REVIEWER’S CONCLUSIONS: Subclavian CVA is preferable to femoral CVA. Further trials of subclavian versus femoral or jugular CVA are needed. Research on the impact of catheter circumference on catheter-related complications is required. CITATION: Hamilton HC, Foxcroft DR. Central venous access sites for the prevention of venous thrombosis, stenosis and infection in patients requiring long-term intravenous therapy. The Cochrane Database of Systematic Reviews, 2007, Issue 3: CD 004084. Copyright© 2005. The Cochrane Collaboration. Reproduced with permission.

Safer central venous access

Safer central venous access

Risk factors for failure and immediate complications of internal jugular central venous access (IJCVA) in cancer patients

Risk factors for failure and immediate complications of internal jugular central venous access (IJCVA) in cancer patients

Safe and efficient emergency transvenous ventricular pacing via the right supraclavicular route.

Infraclavicular and internal jugular central venous access are techniques commonly used for temporary transvenous pacing. However, the procedure still has a considerable complication rate, with a high risk/benefit ratio because of insertion difficulties and pacemaker malfunction. To enlarge the spectrum of alternative access sites, we prospectively evaluated the right supraclavicular route to the subclavian/innominate vein for emergency ventricular pacing with a transvenous flow-directed pacemaker as a bedside procedure. For 19 mo, 17 consecutive patients with symptomatic bradycardia, cardiac arrest, or torsade de pointes requiring immediate bedside transvenous pacing were enrolled in the study. The success rate, insertional complications, pacemaker performance, and patients' outcomes were recorded. Supraclavicular venipuncture was successful in all patients, in 16 of 17 at the first attempt. Adequate ventricular pacing was achieved within 1 to 5 min (median, 2 min) after venipuncture and within 10 s to 4 min (median, 30 s) after lead insertion (</=30 s in 15 of 17 patients). The median pacing threshold was 1 mA (range, 0.7 to 2.5 mA). No procedure-related complications were recorded. Throughout the pacing period of 1538 h (median: 62 h, range, 1-280 h) two reversible malfunctions caused by inadvertent lead dislodgement after 122 and 171 h were recorded; in one patient the pacemaker had to be removed because of local infection after 14 days of pacing. We conclude that the right supraclavicular route is an easy, safe, and effective first approach for transvenous ventricular pacing and might provide a useful alternative to traditional puncture sites, even in a preclinical setting. Temporary transvenous cardiac pacing can yield high complication rates especially under emergency conditions. We investigated emergency pacing via the right supraclavicular access in 17 consecutive hemodynamically compromised patients and found good safety, efficacy, and a low complication rate.

Safe and Efficient Emergency Transvenous Ventricular Pacing via the Right Supraclavicular Route

Infraclavicular and internal jugular central venous access are techniques commonly used for temporary transvenous pacing. However, the procedure still has a considerable complication rate, with a high risk/benefit ratio because of insertion difficulties and pacemaker malfunction. To enlarge the spectrum of alternative access sites, we prospectively evaluated the right supraclavicular route to the subclavian/innominate vein for emergency ventricular pacing with a transvenous flow-directed pacemaker as a bedside procedure. For 19 mo, 17 consecutive patients with symptomatic bradycardia, cardiac arrest, or torsade de pointes requiring immediate bedside transvenous pacing were enrolled in the study. The success rate, insertional complications, pacemaker performance, and patients’ outcomes were recorded. Supraclavicular venipuncture was successful in all patients, in 16 of 17 at the first attempt. Adequate ventricular pacing was achieved within 1 to 5 min (median, 2 min) after venipuncture and within 10 s to 4 min (median, 30 s) after lead insertion (≤30 s in 15 of 17 patients). The median pacing threshold was 1 mA (range, 0.7 to 2.5 mA). No procedure-related complications were recorded. Throughout the pacing period of 1538 h (median: 62 h, range, 1–280 h) two reversible malfunctions caused by inadvertent lead dislodgement after 122 and 171 h were recorded; in one patient the pacemaker had to be removed because of local infection after 14 days of pacing. We conclude that the right supraclavicular route is an easy, safe, and effective first approach for transvenous ventricular pacing and might provide a useful alternative to traditional puncture sites, even in a preclinical setting. Implications: Temporary transvenous cardiac pacing can yield high complication rates especially under emergency conditions. We investigated emergency pacing via the right supraclavicular access in 17 consecutive hemodynamically compromised patients and found good safety, efficacy, and a low complication rate.

Re: Chest radiography after placement of internal jugular central venous access devices.

Re: Chest radiography after placement of internal jugular central venous access devices.

Are routine chest radiographs necessary after image-guided placement of internal jugular central venous access devices?

The purpose of this study was to determine the value and cost of obtaining routine chest radiographs after image-guided placement of internal jugular central venous catheters. We reviewed the records of 424 patients in whom 572 internal jugular catheters were placed by sonographic and fluoroscopic guidance over a 2-year period. Inspiratory and expiratory chest radiographs obtained immediately after each procedure were also reviewed. Routine postprocedural chest radiographs revealed no complications and did not alter the treatment of any patient. Delayed pneumothorax was detected after placement of two catheters (0.5%) when patient symptoms prompted additional radiographs. Immediate postprocedural chest radiographs are not routinely needed after image-guided insertion of internal jugular central venous catheters and unnecessarily add to the cost of patient care.