06. Complications of Central Lines

Vascular

Arterial puncture: a feared complication of central line placement is inadvertent arterial puncture. Rates have improved significantly with use of ultrasound but remain as high as 4-9%.

  • Arterial puncture with needle only: withdraw needle and apply pressure for at least 15 minutes (longer if patient with coagulopathy).
  • Arterial puncture with dilator or catheter: surgical emergency. Leave line/dilator in place, STAT Vascular Surgery consult.  
    • Immediate removal of catheter can result in uncontrolled hemorrhage, pseudoaneurysm, or AV fistula formation.
  • Prolonged arterial catheterization can result in thrombus formation and resultant CVA/neurologic deficit.

Hematoma: often not life-threatening and usually improved with compression. Rates ~5%.

  • Can become superinfected.
  • Can lead to hemothorax or hemomediastinum if uncontrolled.
  • If significant concern for coagulopathy, IJ and femoral sites preferred due to easy compressibility.
  • No definitive data around correcting coagulopathy prior to central line placement.

Infection

See Infectious Disease sections Catheter-Related Bloodstream Infections and Fever in Critically Ill Patients for more details. Rates of infection significantly improved with sterile technique with insertion and catheter site care. Brief summary of Catheter Related Bloodstream Infection (CRBSI) or Central Line-Associated Bloodstream Infection (CLABSI) is discussed here:

  • Micro: (coag neg Staph, Staph aureus, Enterococcus, Candida) > (Klebsiella, E. coli, Enterobacter, Pseudomonas).
  • Diagnostic evaluation: blood cultures x2, try to obtain at least one peripherally. Try to obtain DTTP culture, though data surrounding utility is mixed.
  • Empiric therapy: MRSA coverage +/- GNR coverage based on gram stain results.
  • Line management: line removal > salvage (line retention with antibiotics) > guidewire exchange.

Pneumothorax (PTX)

Risk factors:

  • Patient factors: underlying pulmonary disease (COPD, emphysema), abnormal BMI, congenital vascular anomalies (persistent L SVC), emergency placement, mechanical ventilation, prior surgery/trauma/radiation in area of line.
  • Catheter factors: site (subclavian > IJ), catheter type (larger size, dialysis catheters).

Clinical evaluation:

  • Post-procedural US > CXR (better sensitivity and specificity).
  • Monitor for symptoms: SOB, chest pain, tachycardia/hypotension, hypoxia.
  • Monitor for changes in mechanical ventilation: acute elevation in peak and plateau pressures, acute drop in expired TV, vent asynchrony.

Management:

  • Small → serial CXR; if mechanically ventilated, consider chest tube placement due to high risk of expansion.
  • Moderate to large → consider IR vs CT surgery for guided chest tube placement.
  • If HD instability → needle decompression (place 14-16G angiocatheter in 2nd intercostal space at midclavicular line, remove needle and leave open to air until emergent chest tube can be placed).

Arrhythmias

Ventricular arrhythmia and bundle branch block: usually triggered by guidewire irritation of R heart.

  • Usually self-limited.
  • Very rarely can lead to cardiac perforation.
  • Prevention: limit guidewire insertion to <16cm on RIJ.
  • If persistent VT or symptomatic bradycardia, follow ACLS.

Air Embolism

Pathophysiology: air entering central line down pressure gradient (when CVP < atmospheric pressure) leading to PE, stroke, or other venoarterial embolism.

  • Can occur during placement of line, use of line, and/or removal of line.

Risk factors: upright positioning, low CVP, spontaneous inhalation during instrumentation.

Prevention:

  • Placement: Trendelenburg position, occlusion of needle hub and catheter, prime line with sterile saline.
  • Removal: Trendelenburg position, Valsalva while pulling (avoid pulling during inspiration), pull at beginning of expiratory phase for ventilated patient.

Clinical presentation: signs/symptoms of PE (dyspnea, cough, chest pain, hypoxia, tachycardia), signs of stroke (focal neuro deficit, seizure, AMS).

Management: 

  • Positioning: left lateral decubitus position, with Trendelenburg if venous embolism; supine if arterial embolism.
  • Oxygen: initially give high FiO2 with high flow or intubation as indicated.
  • Hyperbaric oxygen: indicated for hemodynamically unstable patients, focal neurologic deficits, end organ damage.

 

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McGee DC, Gould MK.  Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123-1133.

Merrer J, De Jonghe B, Golliot F, et al.  Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial.  JAMA 2001;286:700-707.

Ruesch S, Walder B, Tramer MR. Complications of central venous catheters: internal jugular versus subclavian access--a systematic review. Crit Care Med 2002;30:454-460.

Theodoro D, Krauss M, Kollef M, Evanoff B. Risk factors for acute adverse events during ultrasound-guided central venous cannulation in the emergency department. Acad Emerg Med. 2010;17(10):1055-61.