Subclavian Central Venous Catheters Research Articles

Sex-disaggregated analysis of central venous catheter-related bloodstream infections in patients with cancer.

Men are generally more susceptible to bacterial infections than women. Central venous catheters (CVCs), often used to administer systemic treatment in patients with cancer, are an important source of infection. However, little is known about sex-specific differences of CVC-related bloodstream infections (CRBSIs) in patients with cancer. This study aimed to compare CRBSIs in men vs. women in a large cohort of patients with cancer. Data were derived from the SECRECY registry including non-selected patients with centrally inserted non-tunneled internal jugular or subclavian vein CVCs in 10 hematology and oncology sites in Germany. Only CRBSIs classified as definite CRBSI (dCRBSI) or probable CRBSI were included, and the combination of both was summarized as dpCRBSI. CVCs were matched 1:1 for underlying disease, anatomic site of CVC insertion, type of CVC dressing, antimicrobial coated CVC, complicated CVC insertion and CVC in situ time by propensity score matching (PSM). Endpoints were CRBSI rates and incidences in CVCs inserted in men vs. women. A total of 5075 CVCs registered from March 2013 to March 2024 were included in the analysis, of which 3024 comprises the PSM cohort. 1512 (50.0%) CVCs were inserted in men. Underlying diseases mainly were hematological malignancies (96.4%). While there was no statistically significant difference between men and women in the dCRBSI rate (5.4% vs. 4.1%; p=0.12) and the dCRBSI incidence (3.8 vs. 2.9/1000 CVC days; p=0.11), the rate of dpCRBSI (9.9% vs. 6.7%; p=0.002) and the dpCRBSI incidence (7.0 vs. 4.7/1000 CVC days; p=0.002) were significantly higher in men vs. women. The proportion of coagulase-negative staphylococci as causative agent of both dCRBSI and dpCRBSI was higher in men than in women (58.8% vs. 41.2%; p=0.07, and 61.5% vs. 38.5%; p=0.002, respectively). A multivariable regression revealed neutropenia as an independent risk factor for dCRBSI and male sex as risk factor for dCRBSI and dpCRBSI. In patients with hematological malignancies, men have a higher risk of CRBSI than women. This finding may be attributed to the high number of jugular vein inserted CVCs which in men may be associated with higher rates of skin colonization than in women. Special preventive measures such as earlier removal of CVCs in men may be studied in future.

Evaluation of Subclavian Central Venous Port Catheters Placed by Anesthesiologists: Single-Center Experience

Evaluation of Subclavian Central Venous Port Catheters Placed by Anesthesiologists: Single-Center Experience

Scheduled removal of central venous catheters (CVC) to prevent CVC-related bloodstream infections in patients with hematological disease or autologous stem cell transplantation: a registry-based randomized simulation-study

Although not generally recommended, scheduled central venous catheter (CVC) removal is sometimes carried out in order to reduce the CVC-related bloodstream infection (CRBSI) incidence. We conducted a simulation for scheduled CVC removal within the multicenter CRBSI registry (SECRECY). Non-tunneled jugular and subclavian CVC in patients with hematological disease or with germ cell tumors (including patients receiving autologous stem cell transplantation [SCT]) were included. Cases were randomized in a 1:1:1:1 ratio to either a simulated, scheduled CVC removal after 7, 14, and 21 days, or to non-simulated, unscheduled CVC removal (control group). The primary endpoint was definitive CRBSI incidence for a scheduled CVC removal after 14 days (dCRBSI-D14rmv). Among other, secondary endpoints were definite CRBSI incidence for a scheduled removal after 7 days (dCRBSI-D7rmv) and 21 days (dCRBSI-D21rmv). Data on 2984 CVC were included. Patients’ median age was 59 (range 16–95) years, 58.8% being male. The vast majority (98.4%) were patients with hematological malignancies. Jugular veins were the main insertion site (93.2%). dCRBSI-D14rmv was 3.10/1000 CVC days as compared to 4.15/1000 CVC days in the control group (p = 0.23). There was a significant difference between dCRBSI-D7rmv (0.86/1000 CVC days) and controls (p < 0.001), but not between dCRBSI-D21rmv (4.10/1000 CVC days) and controls (p = 0.96). Our data suggest that in patients with hematological diseases or autologous SCT recipients scheduled CVC removal after 14 days does not result in a lower CRBSI incidence compared to unscheduled removal.Trial registration: DRKS00006551, 2014/09/29, retrospectively registered.

Retrospective Assessment of Patient and Catheter Characteristics Associated With Malpositioned Central Venous Catheters in Pediatric Patients.

The primary objective was to determine the prevalence and characteristics associated with malpositioned temporary, nontunneled central venous catheters (CVCs) placed via the internal jugular (IJ) and subclavian (SC) veins in pediatric patients. Single-center retrospective cohort study. Quaternary academic PICU. Children greater than 1 month to less than 18 years who had a CVC placed between January 2014 and December 2018. None. The primary outcome was the CVC tip position located on the first postprocedural radiograph. CVC tip was defined as follows: "recommended" (tip location between the carina and two vertebral bodies inferior to the carina), "high" (tip location between one and four vertebral bodies superior to the carina), "low" (tip position three or more vertebral bodies inferior to the carina), and "other" (tip grossly malpositioned). Seven hundred eighty-one CVCs were included: 481 (61.6%) were in "recommended" position, 157 (20.1%) were "high," 131 (16.8%) were "low," and 12 (1.5%) were "other." Multiple multinomial regression (referenced to "recommended" position) showed that left-sided catheters (adjusted odds ratio [aOR], 2.00, 95% CI 1.17-3.40) were associated with "high" CVC tip positions, whereas weight greater than or equal to 40 kg had decreased odds of having a "high" CVC tip compared with the reference (aOR, 0.45; 95% CI, 0.24-0.83). Further, weight category 20-40 kg (aOR, 2.42; 95% CI, 1.38-4.23) and females (aOR, 1.51; 95% CI, 1.01-2.26) were associated with "low" CVC tip positions. There was no difference in rates of central line-associated blood stream infection, venous thromboembolism, or tissue plasminogen activator usage or dose between the CVCs with tips outside and those within the recommended location. The prevalence of IJ and SC CVC tips outside of the recommended location was high. Left-sided catheters, patient weight, and sex were associated with malposition. Malpositioned catheters were not associated with increased harm.

Practice Patterns of Central Venous Catheter Placement and Confirmation in Pediatric Critical Care.

Optimal practices for the placement of central venous catheters (CVCs) in critically ill children are unclear. This study describes the clinical practice of pediatric critical care medicine (PCCM) providers regarding CVC placement, including site selection, confirmation practices and assessment of complications. Two-hundred fourteen PCCM providers responded to an electronic survey, including 170 (79%) attending physicians, 30 (14%) fellow physicians, and 14 (7%) advanced practice providers. PCCM providers most commonly place internal jugular (IJ) and femoral CVCs, with subclavian CVCs and peripherally inserted central catheters (PICCs) placed less commonly (IJ 99%, femoral 95%, subclavian 40%, PICC 19%). The IJ is the most preferred site (128/214 (60%)); decreased infection risk is the most common reason for preferring this site. The subclavian is the least preferred site (150/214 [70%]) due to concern for increased risk of complications (51%) and personal discomfort with the procedure (49%). One-hundred twenty-six (59%) of respondents reported receiving formal ultrasound (US) or echocardiography training. Respondents reported using dynamic US guidance for placement in 90% of IJ, 86% of PICC, 78% of femoral, and 12% of subclavian CVCs. Plain radiography (X-ray) was the most preferred modality for confirming CVC tip position (85%) compared with US (9%) and no imaging (5%). Most providers reported using X-ray to evaluate for pneumothorax following upper extremity CVC placement, with only 5% reporting use of US and none relying on physical exam alone. This study demonstrates wide variability in PCCM providers' CVC placement practices. Potential training gaps exist for placement of subclavian catheters and use of US.

A Training Program for Real-Time Ultrasound-Guided Catheterization of the Subclavian Vein

Purpose:To develop and implement a comprehensive program to train providers to place subclavian central venous catheters (CVCs) using real-time ultrasound guidance.Study design:Simulation-based prospective study at an academic medical center. Of 228 anesthesia providers and intensivists eligible to participate, 106 participants voluntarily enrolled. The training program consisted of a didactic module, hands-on instruction and practice using a CVC simulator and a standardized patient. The success of the program was measured by pre and post knowledge tests and direct observation during the hands-on sessions.Results:Of 106 participants who enrolled, 70 successfully completed the program. Out of 20 possible procedure steps, an average of 17.8 ± 2.9 were correctly performed in the simulated environment. The average time to needle insertion, defined by positive aspiration of stained saline, was 3.35 ± 3.02 min and the average time to wire insertion with ultrasound confirmation was 3.85 ± 3.12 min.Conclusions:Participants learned how to successfully perform ultrasound-guided catheterization of the subclavian vein. Since ultrasound-guided subclavian CVC placement is a useful clinical skill that many practitioners are unfamiliar with, increasing competence and comfort with this procedure is an important goal. Other centers could consider adopting an approach similar to ours to train their providers to perform this technique.

Upper body peripherally inserted central catheter in pediatric single ventricle patients.

BACKGROUNDThere is risk of stenosis and thrombosis of the superior vena cava after upper extremity central catheter replacement. This complication is more serious among patients with single ventricle physiology, as it might preclude them from undergoing further life-sustaining palliative surgery.AIMTo describe complications associated with the use of upper extremity percutaneous intravenous central catheters (PICCs) in children with single ventricle physiology.METHODSA single institution retrospective review of univentricular patients who underwent superior cavopulmonary anastomoses as their stage 2 palliation procedure from January 2014 until December 2018 and had upper body PICCs placed at any point prior to this procedure. Clinical data including ultrasonography, cardiac catheterization, echocardiogram reports and patient notes were used to determine the presence of thrombus or stenosis of the upper extremity and cervical vessels. Data regarding the presence and duration of upper extremity PICCs and upper extremity central venous catheter (CVC), and use of anticoagulation were recorded.RESULTSSeventy-six patients underwent superior cavopulmonary anastomoses, of which 56 (73%) had an upper extremity PICC at some point prior to this procedure. Median duration of PICC usage was 24 d (25%, 75%: 12, 39). Seventeen patients (30%) with PICCs also had internal jugular or subclavian central venous catheters (CVCs) in place at some point prior to their superior cavopulmonary anastomoses, median duration 10 d (25%, 75%: 8, 14). Thrombus was detected in association with 2 of the 56 PICCs (4%) and 3 of the 17 CVCs (18%). All five patients were placed on therapeutic dose of low molecular weight heparin at the time of thrombus detection and subsequent cardiac catheterization demonstrated resolution in three of the five patients. No patients developed clinically significant venous stenosis.CONCLUSIONUse of upper extremity PICCs in patients with single ventricle physiology prior to super cavopulmonary anastomosis is associated with a low rate of catheter-associated thrombosis.

A Novel Inside-out Access Approach for Hemodialysis Catheter Placement in Patients With Thoracic Central Venous Occlusion

Left-sided internal jugular and all subclavian central venous catheters (CVCs) cause thoracic central vein occlusions (TCVOs) more often than right-sided internal jugular catheters. To enable right-sided CVC placement in patients with TCVO, an inside-out access (IOA) approach was established at 3 vascular access centers in Europe involving use of a novel IOA device advanced from the right femoral vein. In the current analysis, we assessed the eligibility and success rate of this IOA approach in a cohort of patients with TCVO requiring a tunneled dialysis catheter. Retrospective multicenter observational study. 36 patients with TCVO treated in Vienna, Austria; Oxford, England; or Cologne, Germany, who required hemodialysis access between July 2016 and June2018. Application of the IOA approach to gain vascular access. The primary end point was the success rate of passing the TCVO to gain dialysis access using the IOA approach. Secondary end points were catheter patency at 3 months and procedure-related complications (early infections, bleeding, hematoma, and pericardial effusions). Descriptive statistics to characterize eligibility, success rate, and complications of the IOA approach. 36 patients with TCVO and history of multiple CVCs and arteriovenous fistulas were referred to the participating centers for vascular access. 32 (89%) patients were eligible for the IOA approach. 39 treatments were performed, with 7 patients undergoing the IOA procedure a second time more than 3 months after initial CVC placement. Dialysis access was established successfully in 38 of 39 (97%) implementations of the IOA procedure. Median intervention time was 43 minutes. No complications occurred. No comparison to other methods to place CVCs and the observational study design. The IOA approach is a promising method to enable rapid access to the right jugular vein in the setting of pre-existing TCVO. Additional experience is needed to understand the generalizability of these observations.

When Your Central Line Decides to Go for a Stroll

SESSION TITLE: Procedures SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Central venous catheters (CVCs) are fastened at the skin, but their free, intra-vascular end has a tendency to become malposition. CASE PRESENTATION: A 76-year-old woman was intubated for worsening hypoxemia, and a pigtail catheter was placed into the left lower pleural space to drain an effusion. 700 cc of serous exudative fluid was drained. A 16 cm, 7 F left subclavian triple-lumen CVC was placed on the 1st attempt for vasopressor administration, with blood being easily aspirated from all ports. A follow-up CXR demonstrated a left apical pneumothorax for which another pigtail catheter was placed in the left anterior 2nd intercostal space, resulting in lung re-expansion. Over the next 2 days there was a dramatic increase in pigtail drainage and vasopressor requirements. Repeat pleural fluid analysis revealed a glucose level of 734 mg/dL. A norepinephrine drip with a dextrose carrier was being infused though the CVC. Later that day, the fluid turned milky after propofol was started through the CVC. Chest CT done concurrently for worsening hypoxemia revealed the CVC traversing the left lung apex before entering the left brachiocephalic vein. These findings were consistent with an extravascular catheter, with the proximal ports in the pleural space. Now we could aspirate blood only from the distal port. The CVC was replaced resulting in resolution of the pleural drainage and decrease in norepinephrine requirements. DISCUSSION: Late migration of CVCs often occurs inadvertently due to arm/neck movements, increase in intra-thoracic pressure due to PEEP, PPV or the patient coughing, and due to a ‘jet effect’ of drug infusions (1). These factors can cause CVC migration up to 2-4 cm. Another factor that may have caused this migration in our patient is trans-fixation of the lung apex during CVC insertion and its subsequent outward drag by the re-expanding lung. An intrapleural CVC can cause an effusion with a pleural fluid to serum glucose ratio > 1. The fluid is usually transudative with protein < 1 g/dL, but varies depending on the infusate, degree of pleural inflammation or hemorrhage, and fluid osmolality (2). CONCLUSIONS: Malpositioned CVCs should be replaced. Intra-pleural position causes an increase in pleural effusion with fluid analysis revealing similarities to infusing drugs. Reference #1: Ahuja V, Bhaga H. Late migration of subclavian venous catheter after initial correct placement. J Anesth. 2009;23(2):310-1 Reference #2: Sahn SA. Pleural effusions of extravascular origin. Clin Chest Med. 2006;27(2):285-308 DISCLOSURE: The following authors have nothing to disclose: Udit Chaddha, Jamie Kaghihara, Kavitha Bagavathy, Ashley Prosper, Ami Oren No Product/Research Disclosure Information

Comparative effectiveness of 30% trisodium citrate and heparin lock solution in preventing infection and dysfunction of hemodialysis catheters: a randomized controlled trial (CITRIM trial).

Central venous catheters (CVC) are the only option when hemodialysis is needed for patients without definitive vascular access. However, CVC is associated with complications, such as infection, thrombosis, and dysfunction, leading to higher mortality and expenditures. The aim of this study was to compare the effectiveness of 30% trisodium citrate (TSC30%) with heparin as CVC lock solutions in preventing catheter-related bloodstream infections (CRBSI) and dysfunction in hemodialysis patients. Randomized, double-blind controlled trial comparing the event-free survival of non-tunneled CVC locked with heparin or TSC30% in adult hemodialysis patients. The study included 464 catheters, 233 in heparin group, and 231 in TSC30% group. The CRBSI-free survival of TSC30% group was significantly shorter than that of heparin group. When stratified by insertion site, heparin was better than TSC30% only in subclavian CVC. The dysfunction-free survival was not different between groups in the main analysis, but there is also a shorter survival among subclavian CVC locked with TSC30% in stratified analysis. There was no difference on CRBSI-free or dysfunction-free survival between jugular vein CVC locked with heparin or 30% citrate. However, subclavian CVC locked with 30% citrate presented shorter event-free survival. This difference may be related to anatomical and positional effects, CVC design, and hydraulic aspects of the lock solution. CLINICALTRIALS. NCT02563041.

A comparative study of landmark-based topographic method versus the formula method for estimating depth of insertion of right subclavian central venous catheters.

Background and Aims:Subclavian central venous catheterisation (CVC) is employed in critically ill patients requiring long-term central venous access. There is no gold standard for estimating their depth of insertion. In this study, we compared the landmark topographic method with the formula technique for estimating depth of insertion of right subclavian CVCs.Methods:Two hundred and sixty patients admitted to Intensive Care Unit requiring subclavian CVC were randomly assigned to either topographic method or formula method (130 in each group). Catheter tip position in relation to the carina was measured on a post-procedure chest X-ray. The primary endpoint was the need for catheter repositioning. Mann–Whitney test and Chi-square test was performed for statistical analysis using SPSS for windows version 18.0 (Armonk, NY: IBM Corp).Results:Nearly, half the catheters positioned by both the methods were situated >1 cm below the carina and required repositioning.Conclusion:Both the techniques were not effective in estimating the approximate depth of insertion of right subclavian CVCs.

Peripherally Inserted Central Catheters (PICCs) Implantation in the Clinical Management of Oncohematologic Patients: Results of a Large Multicenter, Retrospective Study of the REL Group (Rete Ematologica Lombarda - Lombardy Hematologic Network, Italy)

Background: PICCs are vascular devices inserted from a peripheral vein of the upper third of the arm under ultrasound guide, and provide a central venous access (CVA) with an intermediate duration between short term central venous catheters (CVCs), such as jugular or subclavian CVCs, and long term ones (port-a-caths).PICC insertion is ease and safe with no pneumothorax or hemothorax risk. Their extremity reaches a central vein, and can be used for cytostatic drugs, hyperosmolar solutions, and antibiotics infusion. Furthermore, patients (pts) at high risk of hemorrhage for thrombocytopenia or coagulopathy are eligible for PICC insertion.Nevertheless, some concern exists about the risk of infectious and thrombotic complications associated with PICC use in immunocompromised cancer pts characterized by a prothrombotic state.In particular, few clinical data from large oncohematologic pts series are available on PICCs' implants and their complications.Aims: To analyze the results of a large multicenter, retrospective study of the REL group (Rete Ematologica Lombarda-Lombardy Hematologic Network, Italy) aimed at clinically characterizing PICC use in oncohematologic patients management.Methods: Four REL Hematology Centers participate to the study. The clinical data of 453 implanted PICCs from January 2010 to June 2015, were retrospectively collected, for a total of 44,577 catheter days.Pts median age was 61 yrs (range 10-88).Patients' diagnoses were 197 non-Hodgkin's lymphoma, 10 chronic lymphocytic leukemia, 105 acute myeloid leukemia, 45 acute lymphoblastic leukemia, 33 Hodgkin's lymphoma, 39 multiple myeloma, 12 myelodysplastic/myeloproliferative syndrome, 6 miscellaneous.All pts received intravenous chemotherapy, long term anti infectious drugs (antibiotics and antifungals), and hypertonic solutions.PICCs were inserted by ultrasound-guided puncture of a peripheral vein of the arm, by microintroducer technique, under strict asepsis.Chest X-ray was performed to verify correct tip location (ideally in the proximity of cavo-atrial junction).Data on PICCs' lumen number are available in 423 cases: 292 (69%) were single-lumen and 131 were double-lumen (31%).Results: Median PICC life-span was 90 days (range 1-760, Kaplan-Meier method). No major insertion-related complications were observed.Late complications occurred in 172/453 PICCs (38%, 3.8/1000 catheter days): 93 infectious (20%, 2/1000 catheter days), 38 thrombotic (8%, 0.8/1000 catheter days), 37 mechanical (8%, 0.8/1000 catheter days), 5 (1%, 0.1/1000 catheter days) miscellaneous complications (patient intolerance, local pain and hematoma).Among infectious complications, we reported 24 cases (5%, 0.5/1000 catheter days) of fever of unknown origin (FUO) and 69 (15%, 1.5/1000 catheter days) catheter-related bloodstream infections.Mechanical complications consisted of 3 (1%) catheter dislocations, 19 accidental removals (4%), 16 (3%) lumen occlusions and 3 (1%) breakages of the external section of PICC.In 376/453 (83%) cases PICC was removed due to end of intravenous therapy in 160 patients (35%), death in 98 (22%) and to various complications in 118 (26%) cases. Specifically, FUO lead to PICC removal in 10 (2%), infection in 40 (9%), venous thrombosis in 25 (5%) cases, catheter dislocation or accidental removal in 22 (5%), lumen occlusion in 13 (3%), breakage of the external section of PICC in 2 (0,5%), other mechanical complication in 4 (1%), local pain and miscellaneous 2 (0,5%) each.In the case of a complication occured, the incidence of PICC removal was 68% (118/172): FUO/infections represented the removal cause in 50/172 (29%), mechanical complications in 40/172 (23%), thrombosis in 25/172 (14%) cases.Conclusions: Traditional CVCs are associated with significant complications, reported at varying frequencies in highly heterogeneous oncohematologic pts series: infections are reported from 4.6 to 23% and thromboses from 1.2 to 30.2% of the cases.We have clinically characterized a large series of PICCs in oncohematologic patients. Our data suggest that their implant, as an alternative to traditional CVCs, is a safe and effective way to provide oncohematologic patients at high risk of hemorrhagic and infective complications with a CVA. PICCs compare favorably with traditional CVCs reported complications, and facilitate the proper management of complex and prolonged therapeutic programs. DisclosuresNo relevant conflicts of interest to declare.

Subclavian central venous catheters guidance and examination by ultrasound: a randomized controlled study versus landmark method

Catheterization under ultrasound (US) guidance of the central venous catheters is now a part of recommendations. It was already validated for the jugular way, allowing to decrease the failures, to obtain a faster venous access and to reduce the complications. The US can allow also the check of the good position and the absence of complications.

A quantitative analysis of the relation between the clavicular tilt angle and subclavian central venous catheter misplacement.

ObjectiveThe aim of the present study was to investigate the relation between shoulder position and subclavian central venous (SCV) catheter misplacement. The shoulder position was estimated using clavicular tilt angle (CTA) values observed on anteroposterior chest X-ray images.MethodsA retrospective case-control study was conducted on all adult patients who underwent SCV catheterization in the emergency department during a 12-month period. Collected data included patient age, sex, diagnosis, catheterization side, catheter misplacement, and physician’s level of experience in catheterization. The CTA and other radiological variables such as the ipsilateral transverse length of the thorax and thickness of the clavicle were investigated.ResultsAmong all central venous catheterizations (n=1,599), the subclavian route was used 981 times (61.4%). There were 51 misplacements of SCV catheters (5.2%) during the study period. There were no differences in the sex, age, blood pressure, and diagnosis between the two groups. The CTA values were 28.5°±7.3° and 22.6°±6.3° in the misplacement group and control group, respectively (95% confidence interval, 3.6 to 8.1; P<0.001).ConclusionIn this study, the CTA was found to be 5.9° larger in the misplacement group than in the control group. Assuming that CTA indicates the shoulder position, our findings suggest that the chance of SCV catheter misplacement may be reduced by avoiding the shoulder elevated.

Radiographic mislead: apparent arterial placement of subclavian central venous catheter due to mediastinal shift

Optimal placement of central venous catheters (CVC) is essential for accurate monitoring of central venous pressure (CVP) in major surgeries and ensuring long-term use of the catheter for managing the critically ill patient. Accidental subclavian artery catheterization is one of the most serious complications of the procedure. Radiography is commonly used to ensure optimal placement of CVC tip and rule out subclavian artery catheterization in the absence of Doppler ultrasound and a pressure transducer. We present a case of a haemodynamically unstable and hypoxaemic patient with mediastinal shift, in which the anaesthesiologist was in a dilemma about the arterial placement of the right subclavian CVC. The CVC crossing the midline due to mediastinal shift gave the false impression of it being placed in subclavian artery rather than the vein. Subsequently, it was proved to be correctly placed in the subclavian vein.

Subclavian Central Venous Catheters and Ultrasound Guidance: Policy vs Practice

Policy statements recommend the use of ultrasound guidance (USG) to improve patient safety during placement of central venous catheters (CVCs). Studies have conclusively demonstrated greater success rates and fewer complications with the use of USG in catheter placement using the internal jugular vein approach. Data supporting the use of USG for the subclavian vein (SCV) approach, however, have been less conclusive, and USG for SCV cannulation is rarely used in clinical practice. We compared USG placement versus anatomic placement during subclavian insertion of a CVC. A prospective randomized study was performed in March 2010 using a simulation model. Ultrasound guidance did not provide a statistically significant benefit for successful cannulation of the SCV (93.3% with USG and 100% without; P=0.15 or 2) or for rate of inadvertent arterial puncture (3.3% with USG and 0% without; P=0.31). The use of USG to access the SCV utilizing a task trainer did not improve time to cannulation or success rates. Further study is required to delineate why USG for SCV cannulation has not been widely adopted in clinical practice.

Essential, but at what risk? A prospective study on central venous access in patients with haematological malignancies

Central venous catheters (CVC) are integral to modern haematology practice; however, they are associated with a range of complications. This prospective study aimed to determine the rate of CVC-related complications and risk factors in haematology patients, who are vulnerable because of their underlying pathology and treatments. All inpatients that had a non-tunnelled CVC inserted in a 14-month period in the haematology ward at St Vincent's Hospital were enrolled. Complications (immediate and late), demographics, type of device, insertion technique and duration of dwell, were examined using multivariate analysis. One hundred and seventy-four CVC in 84 patients were recorded, representing 3016 catheter-days. At least one complication was found in 43 (24.7%) patients. Immediate complications occurred in 13 (7.5%) insertions, with a higher rate in those inserted after ≥2 attempts compared with one (P = 0.02). Catheter-related bloodstream infection occurred at a rate of 7.6 per 1000 catheter-days, with acute lymphoblastic leukaemia associated with a higher rate (P = 0.02), and subclavian vein CVC had a lower rate compared with other locations (P < 0.01). Thrombosis was found in seven (4.0%) patients, with subclavian CVC carrying an increased risk (P = 0.02). This prospective observational study found almost a quarter of haematology patients experience a CVC-related complication. An association was found with a number of attempts at insertion and immediate complications; other risk factors included anatomical location, underlying disease and duration of catheterisation. The relatively high complication rate, compared with reports of non-haematology patients, highlights the need to improve CVC management, a vital part of care for this population.

Characterization of central venous catheter–associated deep venous thrombosis in infants

Deep venous thrombosis (DVT) is a frequent complication in infants with central venous catheters (CVCs). We performed this study to identify risk factors and risk-reduction strategies of CVC-associated DVT in infants. Infants younger than 1 year who had a CVC placed at our center from 2005 to 2009 were reviewed. Patients with ultrasonically diagnosed DVT were compared to those without radiographic evidence. Of 333 patients, 47% (155/333) had femoral, 33% (111/333) had jugular, and 19% (64/333) had subclavian CVCs. Deep venous thromboses occurred in 18% (60/333) of patients. Sixty percent (36/60) of DVTs were in femoral veins. Femoral CVCs were associated with greater DVT rates (27%; 42/155) than jugular (11%; 12/111) or subclavian CVCs (9%; 6/64; P < .01). There was a 16% DVT rate in those with saphenofemoral Broviac CVCs vs 83% (20/24) in those with percutaneous femoral lines (P < .01). Multilumen CVCs had higher DVT rates than did single-lumen CVCs (54% vs 6%, P < .01), and mean catheter days before DVT diagnosis was shorter for percutaneous lines than Broviacs (13 ± 17 days vs 30 ± 37 days, P = .02). Patients with +DVT had longer length of stay (86 ± 88 days vs 48 ± 48 days, P < .01) and higher percentage of intensive care unit admission (82% vs 70%, P = .02). Deep venous thrombosis reduction strategies in infants with CVCs include avoiding percutaneous femoral and multilumen CVCs, screening percutaneous lines, and early catheter removal.

Placement of Central Venous Catheters in Patients Undergoing Major Maxillofacial Surgery - A Retrospective Clinical Audit

The subclavian vein is thought to be the most appropriate route for central venous access in major maxillofacial surgery. Evidence suggests that left-sided central venous catheters should lie below the carina and be angulated at less than 40 degrees to superior vena cava wall. This reduces perforation risk. With this in mind we audited our current practice for placement of central venous catheters for major maxillofacial surgery. The criteria against which we compared our practice were: 1) all catheter tips should lie below the carina and 2) the angle of the distal 1 cm of the catheter should be no more than 40 degrees to the superior vena cava wall. Left subclavian central venous catheters placed on a weekly operating list between September 2005 and August 2008 were identified retrospectively: 83 patients were identified; 22 were excluded. The angle of the central venous catheter tip and distance from the carina were measured on the first post-procedure chest-X ray. All central venous catheters used were 16 cm long. 82% of the catheter tips were located above the carina while 61% were angulated at greater than 40 degrees ; 11% of central venous catheters met both standards; 14% of central venous catheters placed by a consultant and 12% of catheters placed by a trainee met both standards. 89% of the central venous catheters were not correctly placed. The majority of central venous catheter tips above the carina were at an adverse angle to the superior vena cava wall. We suggest that for left subclavian central lines, 20 cm catheters be used.

Risk of Extravasation after Power Injection of Contrast Media via the Proximal Port of Multilumen Central Venous Catheters: Case Report and Review of the Literature

Multilumen central venous catheters (CVCs) are not commonly used for power injection. However, in critically ill patients, CVCs-- most of which do not have FDA approval for power injection--may be the only available venous access. The pitfalls of multilumen CVCs are illustrated by a case report of a patient in whom extravasation of intravenously administered contrast medium occurred after power injection in a triple-lumen CVC using the lumen with the port furthest from the catheter tip. The underlying mechanisms for the displacement of the initially correctly placed right subclavian CVC could include elevation of both arms of the obese patient or the power injection itself. The distances between port openings and catheter tips of various commercially available multilumen CVCs are assessed. We examine the possible caveats of ECG-guided CVC placement for optimal tip position, discuss technical difficulties related to power injection via CVCs, and review commonly used drugs that may cause extravasation injury. Knowledge of the distances between CVC port openings and the catheter tip are essential for safe intravasal administration of fluids.