Central Venous Catheter (CVC)

Indications

Intravenous Infusion of Total Parenteral Nutrition (TPN) (see Total Parenteral Nutrition, [[Total Parenteral Nutrition]])

  • Common Indication

Intravenous Infusion of Vasoactive Medications

Agents Where Administration Via Central Venous Catheter is Recommended

Clinical Efficacy – Central Venous Catheter vs Peripheral IV in Intensive Care Unit (ICU) Patients

  • French Randomized Trial Comparing Risks and Benefits of CVC vs Peripheral IV Access in ICU Patients (Crit Care Med, 2013) [MEDLINE]
    • Study: randomized cross-over trial studying assignment of initial venous access in 3 French ICU’s (n = 135 CVC’s + 128 non-midline peripheral IV’s)
      • Primary Endpoint: 28-day incidence of major catheter-related complications
        • Mechanical Complications: pneumothorax, arterial puncture, hematoma, CVC insertion site changes, peripheral venous catheter insertion difficulty, infiltration
        • Infectious Complications: erythema, phlebitis, bacteremia, catheter-related infection
        • Thrombotic Complications: thrombosis of vessel
      • Seconary Endpoints
        • Minor Complications
        • Mortality
        • Amount of Medical/Paramedical Time Used
    • Main Findings
      • Significantly Increased Major Catheter-Related Complications in Peripheral IV Group (133), as Compared to the CVC Group (87) (p=0.02)
      • Trend Toward Increased Minor Catheter-Related Complications in Peripheral IV Group (248), as Compared to the CVC Group (251) (p=0.06)
      • No Difference in Kaplan-Meier Probabilities of Survival Between the Groups

Inadequate Peripheral Venous Access

  • Common Indication

Intravenous Administration of Other Medications

  • Chemotherapy
  • Hypertonic Saline (see Hypertonic Saline, [[Hypertonic Saline]])
  • Nicardipine (Cardene) (see Nicardipine, [[Nicardipine]])
  • Potassium Chloride (KCl) (see Potassium Chloride, [[Potassium Chloride]]): when more rapid replacement is required

Intravenous Fluid Resuscitation in Hypotension/Shock States (see Hypotension, [[Hypotension]])

  • Cardiogenic Shock (see Cardiogenic Shock, [[Cardiogenic Shock]])
  • Distributive Shock
    • Anaphylactic Shock/Anaphylaxis (see Anaphylaxis, [[Anaphylaxis]])
    • Septic Shock/Sepsis (see Sepsis, [[Sepsis]])
    • Systemic Inflammatory Response Syndrome (SIRS) (see Sepsis, [[Sepsis]])
    • Endocrine/Nutritional Deficiency-Associated Hypotension
    • Hematologic Disease-Associated Hypotension
    • Neurogenic Shock (see Neurogenic Shock, [[Neurogenic Shock]])
    • Drug/Toxin-Associated Hypotension
  • Hemorrhagic Shock (see Hemorrhagic Shock, [[Hemorrhagic Shock]])
  • Hypovolemic Shock (see Hypovolemic Shock, [[Hypovolemic Shock]])
  • Obstructive Shock

Monitoring of Central Venous Pressure (CVP) (see Hemodynamics, [[Hemodynamics]])

  • Common Indication

Central Venous Catheter (CVC) Placement

Ultrasound-Guided Central Venous Catheter Placement

Agency for Healthcare Quality Research (AHRQ) Recommendation

  • Use of ultrasound for CVC placement is recommended by AHRQ as patient safety practice

Advantages of Vascular Ultrasound

  • Identifies Vein by Compressibility: although it is harder to compress subclavian vein
  • Identifies Vein and Artery by Doppler Flow
    • Red = flow toward probe
    • Blue = flow away from probe
  • Identifies Increase in Vein Size with Valsalva

Use of Ultrasound in Internal Jugular Location

  • Can Identify Artery-Vein Transposition, Absent Vein, <5 mm Vein, or Thrombosis: one of these is present in 4.3% of cases
  • Decreases Procedure Time
  • Decreases Number of Attempts
  • Decreases Failed Catheter Placements and Complication Rates: mainly due to avoidance of inadvertent carotid puncture at IJ site

Use of Ultrasound in Subclavian Location

  • Decreases Failed Catheter Placements and Complication Rates

Use of Ultrasound in Femoral Location

  • Decreases Number of Attempts

Impact of Ultrasound on CVC Infection Rates

  • No Impact on Infection Rate

Complications of Central Venous Catheter

Air Embolism (see Air Embolism, [[Air Embolism]])

  • Increased risk in internal jugular and subclavian, as compared to femoral location
  • Air embolism most often occurs with catheter hub fractures or disconnections rather than during the insertion of the catheter

Central Venous Catheter Infection

Epidemiology of Central Venous Catheter Infection

  • Incidence of Central Venous Catheter Infection
    • Infection is the most common CVC complication
    • 3-7% of CVC’s become infected
  • Risk of Infection Relative to Peripheral IV: CVC’s have a much higher risk of infection than peripheral IV
  • Impact of Central Venous Catheter Infection: nosocomial bloodstream infections increase morbidity, duration of hospitalization, and cost per patient

Risk Factors for Central Venous Catheter Infection

  • Administration of Total Parenteral Nutrition (TPN)
  • Catheter Insertion into Femoral or Internal Jugular Sites
    • French Multi-Center, Randomized Trial Examining Complication Rates of Three Different Central Venous Catheter Insertion Sites (2015) [MEDLINE]
      • Study: multi-center, randomized trial (n = 3471)
      • Main Findings
        • Subclavian Site: 1.5 central venous catheter-related infections per 1000 catheter-days
        • Internal Jugular Site: 3.6 central venous catheter-related infections per 1000 catheter-days
        • Femoral Site: 4.6 central venous catheter-related infections per 1000 catheter-days
  • Heavy Colonization at Cathterization Site
  • Increasing Severity of Illness
  • Need for Mechanical Ventilation
  • Prolonged Duration of Cathterization
  • Prolonged Hospitalization Before Catheterization

Microbiology of Central Venous Catheter Infection

Factors Which Decrease Bacterial Colonization of Central Venous Catheter

(note: plastic shields over Swan do not decrease catheter bacterial colonization)

  • Tunneling of Central Venous Catheter
    • Tunneling increases the distance between skin site (which is the main site of entry of the bacteria) and the bloodstream
    • Several trials have shown that tunneling decreases rates of catheter-related sepsis
  • Heparin-Bonding of Central Venous Catheter
    • Heparin (whether bonded to CVC, infused, or given SQ) decreases thrombus formation
    • Heparin also decreases the incidence of catheter-related bacteremia
  • Silver-Impregnation of Central Venous Catheter Cuff
  • Antimicrobial-Impregnation of Central Venous Catheter
    • Using minocycline + rifampin or chlorhexidine + silver sulfadiazine
    • Antimicrobial CVC impregnation decreases the incidence of catheter-related bacteremia
    • Antimicrobial effectiveness decreases with duration of CVC catheterization

Prevention of Central Venous Catheter Infection

  • Remove Central Venous Catheter as Soon as Possible
  • Minimize Manipulation of Central Venous Catheter: hand washing before contact
  • Use Safer Geographic Sites of Insertion
  • Use Good Sterile Technique During Central Venous Catheter insertion
    • Routine replacement of Central Venous Catheters prophylactically does not decrease risk of infection
  • Antibiotic or Antiseptic-Impregnated Central Venous Catheter: although may decrease rates of CVC infection, they are not recommended at this time (except possibly in high-risk immunocompromised patients)
    • However, adverse reactions to chlorhexidine CVC’s has been reported in Japan and effect on antibiotic resistance has not been evaluated
    • Systematic Review of Impregnation, Coating, or Binding of Central Venous Catheters in Preventing Catheter-Related Bloodstream Infection (Cochrane Database Syst Rev, 2016) [MEDLINE]
      • Catheter Impregnation Decreased Catheter-Related Bloodstream Infection (High-Quality Evidence)
      • Catheter Impregnation Decreased Catheter Colonization (Moderate-Quality Evidence, Downgraded Due to Substantial Heterogeneity)
      • Catheter Impregnation Did Not Decreased Rate of Clinically-Diagnosed Sepsis, All-Cause Mortality, and Catheter-Related Local Infections
      • In Subgroup Analysis for Catheter Colonization, Catheter Impregnation Conferred Benefit in ICU Patients, But Not in Hematologic-Oncologic Patients or Patients Who Required CVC for Chronic TPN: no variation between groups was observed for the outcome of of catheter-related bloodstream infection
      • No Difference Between Risks of Thrombosis/Thrombophlebitis, Bleeding, Erythema, or Insertion Site Tenderness Between Impregnated and Non-Impregnated Catheters
  • Use of Central Venous Catheter Dressing/Securement Device
    • Systematic Review of Central Venous Catheter Dressing/Securement Devices (Cochrane Database Syst Rev, 2015) [MEDLINE]: most studies were conducted in the ICU setting
      • Medication-Impregnated Dressings Decrease the Incidence of Catheter-Related Bloodstream Infection, as Compared to All Other Dressing Types
      • Some Evidence that Chlorhexidine Gluconate-Impregnated Dressings, as Compared to Polyurethane Dressings, Decrease the Frequency of Infection Per 1000 Patient Days, Risk of Catheter Tip Colonization, and Possibly the Risk of Catheter-Related Bloodstream Infection
      • Sutureless Securement Devices are Likely the Most Effective at Decreasing Catheter-Related Bloodstream Infection, Although Data Quality is Low

Prognosis of Central Venous Catheter Infection

  • Patients that develop nosocomial bloodstream infections are 15-20x more likely to die than those that do not

Factors influencing Management of Suspected Central Venous Catheter Infection

  • Whether There is Frank Evidence of Infection at Insertion Site
  • Whether or Not Septic Shock is Present
  • Blood Culture Results and the Specific Organism Recovered
  • Risk of Placing a New CVC

Techniques to Manage Suspected Central Venous Catheter Infection

  • Central Venous Catheter Removal/Replacement at New Site
    • Indications for CVC Removal
      • Presence of Septic Shock
      • Presence of Infection with Staphylococcus Aureus, Candida species, and most GNR’s
        • These have increased risk of persistent infection, metastatic infection, and/or higher mortality if treated with antimicrobial agents through the existing CVC
        • In a multicenter, prospective, observational study of patients with Candidemia, mortality rate for patients in whom the CVC was retained was 2x that of patients in whom the CVC was removed
  • Guidewire CVC Exchange
    • Culture CVC Tip (distal 5 cm): if positive with >15 cfu, replacement CVC should be removed and reinserted at new site
  • Retention of Current CVC
    • Staphylococcus Epidermidis CVC-related infection can usually be managed with CVC left in place

Inadvertent Central Venous Catheter Placement Into Pleural Space

Pneumothorax (see Pneumothorax, [[Pneumothorax]])

  • Epidemiology
    • French Multi-Center, Randomized Trial Examining Complication Rates of Three Different Central Venous Catheter Insertion Sites (2015) [MEDLINE]
      • Study: multi-center, randomized trial (n = 3471)
      • Main Findings: subclavian central venous catheters had a 3x higher risk of pneumothorax requiring chest tube insertion (1.5% of cases), as compared to internal jugular sites (0.5% of cases)

Septic Embolism to Lungs (see Septic Embolism, [[Septic Embolism]])

  • Epidemiology: associated with chronic CVC use

Venous Thrombosis

  • Deep Venous Thrombosis (DVT) (see Deep Venous Thrombosis, [[Deep Venous Thrombosis]])
    • Lower Extremity Deep Venous Thrombosis
    • Subclavian Deep Venous Thrombosis
  • Internal Jugular Vein Thrombosis (see Internal Jugular Vein Thrombosis, [[Internal Jugular Vein Thrombosis]])
    • Epidemiology: when CVC placed is in the internal jugular vein
      • 63.5% of patients have detectable internal jugular thrombus (by Doppler U/S) after CVC removal [MEDLINE]
        • No correlations was found between thrombus formation and the basic disease, duration of cannulation, the type of catheters used, and the mode of heparinization
        • Local inflammation signs and local hematoma were more frequently observed in patients with internal jugular thrombus

References

  • Duplex Sonographic Detection of Internal Jugular Venous Thrombosis after Removal of Central Venous Catheters. Clin Cardiol 1993; 16(1): 26–29 [MEDLINE]
  • Subclavian hemodialysis catheter infections: a prospective, randomized trial of an attachable silver-impregnated cuff for prevention of catheter-related infections. Infect Control Hosp Epidemiol 1995; 16:506-511 [MEDLINE]
  • Therapeutic approaches in patients with candidemia. Evaluation in a multicenter, prospective, observational study. Arch Intern Med 1995; 155:2429-2435 [MEDLINE]
  • Tunneling short-term central venous catheters to prevent catheter-related infection: a meta-analysis of randomized, controlled trials. Crit Care Med 1998; 26:1452-1457 [MEDLINE]
  • Benefit of heparin in central venous and pulmonary artery catheters: a meta-analysis of randomized controlled trials. Chest 1998; 113:165-171 [MEDLINE]
  • A comparison of two antimicrobial-impregnated central venous catheters. N Engl J Med 1999; 340:1-8 [MEDLINE]
  • Prevention of intravascular catheter-related infections. Ann Intern Med 2000; 132:391-402 [MEDLINE]
  • Guidelines for the management of intravascular catheter-related infections. Clin Infect Dis 2001; 32:1249-1272 [MEDLINE]
  • Guidelines for the prevention of catheter-related infections. MMWR 2002; 51:1-29 [MEDLINE]
  • Preventing complications of central venous catheterization. N Engl J Med 2003; 348:1123-1133 [MEDLINE]
  • Central venous catheterization. Crit Care Med. 2007 May;35(5):1390-6 [MEDLINE]
  • Central or peripheral catheters for initial venous access of ICU patients: a randomized controlled trial. Crit Care Med. 2013 Sep;41(9):2108-15. doi: 10.1097/CCM.0b013e31828a42c5 [MEDLINE]
  • Intravascular Complications of Central Venous Catheterization by Insertion Site. N Engl J Med. 2015 Sep 24;373(13):1220-9. doi: 10.1056/NEJMoa1500964 [MEDLINE]
  • Dressings and securement devices for central venous catheters (CVC). Cochrane Database Syst Rev. 2015 Sep 10;(9):CD010367. doi: 10.1002/14651858.CD010367.pub2 [MEDLINE]
  • Catheter impregnation, coating or bonding for reducing central venous catheter-related infections in adults. Cochrane Database Syst Rev. 2016 Mar 16;3:CD007878. doi: 10.1002/14651858.CD007878.pub3 [MEDLINE]