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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 26  |  Issue : 2  |  Page : 147-150

Mechanical complications of central venous catheter insertions


Department of General Surgery, Government Medical College, Kozhikode, Kerala, India

Date of Submission09-Aug-2020
Date of Decision13-Aug-2020
Date of Acceptance14-Oct-2020
Date of Web Publication07-Nov-2020

Correspondence Address:
Dr. M K Nikhil
Department of General Surgery, Government Medical College, Kozhikode, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ksj.ksj_28_20

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  Abstract 


Introduction: Central venous pressure (CVP) catheterisation is an important procedure in emergencies. The complications associated with it are common. This article aimed to study the rate of mechanical complications of CVP catheter insertion in 201 patients. Materials and Methods: This was a prospective longitudinal study. Patients were aged above 13 years of both sexes who had CVP catheter introduced. Patients with complications before the procedure and those who had structural malformation of chest wall, bleeding disorders, etc., were excluded from the study. Consecutive sampling was performed. Data were analysed using Chi-square test for testing the strength of association in SPSS version 19.0. Results: The common indication for CVP line was lack of peripheral access (57.2%). Majority had right-sided (81.6%) catheter insertion and 56.7% had multiple percutaneous punctures. A statistically significant association was found in patients with body mass index >25 kg/m2, in the occurrence of multiple percutaneous punctures (P = 0.04). Multiple punctures were associated with complications (P < 0.05). We observed 12.9% of mechanical complications – failure to place the catheter (8.5%), arterial puncture (6%), pneumothorax (2%) and haematoma (1%). Multiple complications were observed in 3.9% of patients. Conclusions: Factors contributing to various complications were number of punctures, presence of comorbidities and female gender.

Keywords: Central venous catheterisation, complications, mechanical complications


How to cite this article:
Nikhil M K, Muhammed Basheer O T, Prasad P. Mechanical complications of central venous catheter insertions. Kerala Surg J 2020;26:147-50

How to cite this URL:
Nikhil M K, Muhammed Basheer O T, Prasad P. Mechanical complications of central venous catheter insertions. Kerala Surg J [serial online] 2020 [cited 2020 Dec 2];26:147-50. Available from: http://www.keralasurgj.com/text.asp?2020/26/2/147/300236




  Introduction Top


Central venous pressure (CVP) catheters are fundamental for daily clinical practice. For catheter placement, usually, internal jugular vein in the neck, subclavian vein below the clavicle and femoral vein below the inguinal ligament are selected depending on the situation, indication and patient characteristics. It allows the measurement of haemodynamic variables that cannot be measured by non-invasive means. Its main indications are lack of peripheral access, administration of drugs used exclusively in large veins, administration of parenteral diet and access for haemodialysis.

The rate of complications of central venous puncture is estimated at 15%.[1] Complications related to this procedure can be mechanical or infectious. Mechanical complications are reported to occur in 5%–19% of patients.[2] The most common mechanical complications are arterial puncture, haematoma and pneumothorax. Haemothorax, arrhythmia, thoracic duct injury, cardiac tamponade, air embolism or guidewire embolism are rarer but potentially more severe complications. Using the proper technique for the procedure, the majority of these complications can be avoided. Infectious complications (especially catheter-related bloodstream infection) however, besides being potentially serious, are classically associated with high morbidity, mortality and high hospital costs and are reported in 5%–26% of patients.[2]


  Materials and Methods Top


This article aimed to study the rate of mechanical complications of central venous catheter insertion in patients received in casualty and admitted in wards under the department of general surgery/allied specialities in Kozhikode Medical College. It was a prospective longitudinal study for a period of 1 year, conducted on patients aged above 13 years of both sexes who had CVP catheter introduced after taking informed written and valid consent. Consecutive sampling was used. A sample size of n = 200 was calculated using the following formula: sample size = 4PQ/D2, where P = lowest prevalence from other studies, Q = 100 − P (85) and D = 20% of P.[3] Patients who already had complications before the procedure, those who had structural malformation of chest wall or bleeding disorders and patients with a history of surgery at the anatomical location of central line insertion were excluded from the study.

A central line was inserted below the clavicle into the vein. After confirming the position, the guide wire was removed, the central line was fixed and the patient was watched for any distress. Vitals were monitored for 24 h and sent for chest X-ray. Patients were observed for mechanical complications such as pneumothorax, arterial puncture, haematoma, haemothorax, arrhythmia, cardiac tamponade, embolism, thoracic duct injury and phrenic nerve injury.


  Results Top


The mean age of the participants was 57.06 ± 11.48 years; 70 (34.8%) participants belonged to the age group of 61–70 years and 60 (29.9%) were between 51 and 60 years of age [Figure 1].
Figure 1: Distribution of the study participants based on age

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Of the 201 study participants, 132 (65.7%) were male and 69 (34.3%) were female. Majority (57.7%) had normal body mass index (BMI), whereas 52 (25.9%) were overweight and 16.4% were underweight. Majority (159 [79.1%] had no comorbidities; 19 had chronic obstructive pulmonary disease (COPD) and 23 had coronary artery disease (CAD). Lack of peripheral access was the indication for 115 (57.2%) patients, followed by total parenteral nutrition (43 [21.4%]) and elective prior to surgery (43 [21.4%]). Central venous catheter was inserted on the right side in majority (81.6%) and 18% on the left, while 114 (56.7%) had multiple percutaneous punctures. Eighty-seven (43.3%) participants had single percutaneous puncture. A total of 175 (87.1%) catheter insertions were achieved without any mechanical complications, whereas 26 (12.9%) had pneumothorax – 4 (2%), haematoma – 2 (1%), failure to place – 17 (8.5%) and arterial puncture – 12 (6%). Other rarer complications such as arrhythmia, cardiac tamponade, thoracic duct injury, embolism, haemothorax and phrenic nerve injury were not noticed in any of the participants. Multiple complications were noticed in eight participants [Figure 2]. These included both arterial puncture and failure to place in four of them; pneumothorax with failure to place in two of them; failure to place and haematoma in one participant and a combination of arterial puncture, pneumothorax and failure to place in one participant. There was no mortality in the study.
Figure 2: Rate of complications following central venous pressure catheter introduction

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Eight out of 26 patients developing complications had comorbidities, but there was no statistically significant association between comorbidity and complication (P = 0.184). Right side needed 87 (53.4%) against left 27 (73%) punctures. There was no statistically significant association (P = 0.73) between the side of puncture and occurrence of pneumothorax – 3 (1.8%) on the right and 1 (2.7%) on the left. Similarly, there was no statistically significant association (P = 0.35) between the side of puncture and occurrence of arterial puncture – 11 (6.7%) on the right and 1 (2.7%) on the left. There was no statistically significant association (P = 0.24) between the side of puncture and occurrence of haematoma – right 1 (0.7%) and left 1 (2.7%). There was a statistically significant association (P = 0.02) between the side of puncture and number of percutaneous punctures [Table 1].
Table 1: Association between side of puncture and complications

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There was no statistically significant association between the comorbidities and occurrence of pneumothorax (P = 0.46) – 3 (1.9%) in patients with no comorbidities, 1 (5.3%) in patients with COPD and nil in patients with CAD. Similarly, there was no statistically significant association between comorbidities and occurrence of arterial puncture (P = 0.92) – 10 (6.3%) in patients without comorbidities, 1 (5.3%) in patients with COPD and 1 (1.4%) in patients with CAD. A statistically significant association was observed between comorbidities and occurrence of haematoma (P = 0.02) – nil in patients without comorbidities, 1 (5.3%) and 1 (4.4%) in patients with CAD. Patients with comorbidities were more likely to have haematoma as a complication than patients without comorbidities. Chi-square test showed that the relation was not statistically significant (P = 0.47), as detailed in [Table 2].
Table 2: Association between comorbidities and complications

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The association between gender and occurrence of complications showed that there was no statistically significant difference between males (16 (12.1)) and females (10 (14.5)), with P = 0.14. The relation between gender and occurrence of arterial puncture was not statistically significant, P = 0.48. The relation between gender and occurrence of haematoma was however statistically significant (P = 0.04). Females were more likely to have haematoma than males. The relation between gender and failure to place the central venous catheter was not statistically significant, P = 0.93. The relation between sex and number of percutaneous punctures was also not statistically significant (P = 0.34) [Table 3].
Table 3: Association between gender and complications

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The association between BMI and occurrence of complications showed that there was no statistically significant difference between different BMI (P = 0.28). The relation between BMI and occurrence of pneumothorax was also not statistically significant (P = 0.22). The relation between BMI and occurrence of arterial puncture was also not statistically significant (P = 0.21). The relation between BMI and occurrence of haematoma was however statistically significant (P = 0.05). The relation between BMI and number of percutaneous punctures was also statistically significant (P = 0.04). These are depicted in [Table 4].
Table 4: Association between body mass index and complications

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The relation between number of percutaneous punctures and occurrence of complications was statistically significant (P < 0.05). The relation between number of percutaneous punctures and occurrence of pneumothorax was not statistically significant (P = 0.45).


  Discussion Top


Complications after CVP introduction are common. Pneumothorax is more common in subclavian approaches, whereas arterial puncture is more common for the femoral and jugular veins. Infectious complications appear more common in the femoral and jugular approach when compared to the subclavian approach. Catheter insertion at subclavian vein is thus preferred to femoral and jugular accesses.[4] Other variables may also influence the rate of complications, such as the use of ultrasonography to guide the procedure, the time of the procedure and the amount of training of the professional performing it. The complication rate increased with the number of percutaneous punctures, with a rate of 54% when more than two punctures were required.[3],[5]

There is no specific training for inserting central venous lines in most of the teaching hospitals. From the present longitudinal study, the rate of mechanical complications was found to be 12.9%. Previous studies reported mechanical complications ranging from 5% to 289%,[6] which included arterial puncture, haematoma, haemothorax, pneumothorax, arteriovenous fistula, venous air embolism, nerve injury, thoracic duct injury (left side only), intraluminal dissection, malposition, catheter dislodgements and retained guide wire.

There was no statistically significant difference in the occurrence of overall mechanical complications between the two genders. In a previous study, complications were more common in male and obese patients.[7]

We found COPD and CAD as comorbidities. Others found coagulopathy[5] also as a cormorbidity. This was similar in those without any comorbidities. In the present study, pneumothorax and multiple punctures were not found to be significantly related. Pneumothorax was one of the most common complications in other studies.[8],[9] In our study, the mortality rate was zero. Others have reported high mortality rates.[10],[11]


  Conclusions Top


Central venous catheterisation is widely used in our day-to-day clinical practice. We observed a significant rate of mechanical complications such as failure to place the catheter, arterial puncture, pneumothorax and haematoma. Multiple complications were observed in 3.9% of patients. Factors contributing significantly to these complications were number of punctures, presence of comorbidities and female gender.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sznajder JI, Zveibil FR, Bitterman H, Weiner P, Bursztein S. Central vein catheterization. Failure and complication rates by three percutaneous approaches. Arch Intern Med 1986;146:259-61.  Back to cited text no. 1
    
2.
Beheshti MV. A concise history of central venous access. Tech Vasc Interv Radiol 2011;14:184-5.  Back to cited text no. 2
    
3.
Wigmore TJ, Smythe JF, Hacking MB, Raobaikady R, MacCallum NS. Effect of the implementation of NICE guidelines for ultrasound guidance on the complication rates associated with central venous catheter placement in patients presenting for routine surgery in a tertiary referral centre. Br J Anaesth 2007;99:662-5.  Back to cited text no. 3
    
4.
Pappas P, Brathwaite CE, Ross SE. Emergency central venous catheterization during resuscitation of trauma patients. Am Surg 1992;58:108-11.  Back to cited text no. 4
    
5.
Mansfield PF, Hohn DC, Fornage BD, Gregurich MA, Ota DM. Complications and failures of subclavian-vein catheterization. N Engl J Med 1994;331:1735-8.  Back to cited text no. 5
    
6.
Odendaal J, Kong VY, Sartorius B, Liu TY, Liu YY, Clarke DL. Mechanical complications of central venous catheterisation in trauma patients. Ann R Coll Surg Engl 2017;99:390-3.  Back to cited text no. 6
    
7.
Craft PS, May J, Dorigo A, Hoy C, Plant A. Hickman catheters: Left-sided insertion, male gender, and obesity are associated with an increased risk of complications. Aust N Z J Med 1996;26:33-9.  Back to cited text no. 7
    
8.
Hind D, Calvert N, McWilliams R, Davidson A, Paisley S, Beverley C, et al. Ultrasonic locating devices for central venous cannulation: Meta-analysis. BMJ 2003;327:361.  Back to cited text no. 8
    
9.
Deere M, Singh A, Burns B. Central venous access of the subclavian vein. Stat Pearls Publishing LLC, 2020, Bookshelf ID. NBK 482224, PMID. 29489182.  Back to cited text no. 9
    
10.
Atilla A, Doǧanay Z, Kefeli Çelik H, Demiraǧ MD, Kiliç SS. Central line-associated blood stream infections: Characteristics and risk factors for mortality over a 5.5-year period. Turk J Med Sci 2017;47:646-52.  Back to cited text no. 10
    
11.
Mushtaq A, Navalkele B, Kaur M, Krishna A, Saleem A, Rana N, et al. Comparison of complications in midlines versus central venous catheters: Are midlines safer than central venous lines? Am J Infect Control 2018;46:788-92.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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