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June 1996
Volume 60 |
Number 6
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| Central Line Complications
From the ASA Closed Claims Project |
T. Andrew Bowdle, M.D., Ph.D.
Among the 3,533 claims in the ASA Closed Claims Project database,
there are 48 claims involving problems with central venous catheters
or pulmonary artery catheters. Eighteen of the claims involved
fatalities. Despite the widespread perception that pulmonary artery
catheters are more dangerous than central venous catheters, only
two of the 48 claims were explicitly related to pulmonary artery
catheters.
A variety of technical misadventures resulted in injuries or deaths
[Table 1]. Some of the
complications may have been unavoidable, but most appear to be
the result of operator errors. Presumably, we can learn from these
mistakes and reduce the occurrence of morbidity in the future.
The majority of the 48 claims were accounted for by three classes
of problems: perforation of the heart with pericardial tamponade
(11 claims), catheter or wire embolism (12 claims) and injury
to veins or arteries other than the pulmonary artery (13 claims).
These problems are preventable in most cases by paying meticulous
attention to technique.
The Food and Drug Administration (FDA) and various manufacturers
have expressed their concern for the incidence of complications
from central lines and have promoted educational messages to practitioners;1
for example, the FDA, in cooperation with various private organizations,
recently released a series of three educational videotapes titled
"Central Venous Catheter Complications" (available from
the National Audiovisual Center, 8700 Edgeworth Drive, Capitol
Heights, MD 20743-3701; telephone: (800) 788-6282).
In addition, manufacturers provide a variety of "package
inserts" in central line kits, containing warnings and recommendations
for avoiding complications. Judging from the explicit and detailed
warnings in package inserts, manufacturers consider perforation
of the heart and pericardial tamponade to be a major problem.
Interestingly, this complication was the most common cause of
death in the central line-related claims from the ASA Closed Claims
Project. Of the 11 patients with cardiac tamponade, 10 died. Numerous
reports in the literature confirm the seriousness of the problem.1-8
The scenario usually involves a central venous catheter with the
tip inside the right atrium or abutting the wall of the superior
vena cava at an acute angle. With repeated motion of the catheter
tip against the heart or vena cava, perforation may eventually
occur. Blood or intravenous fluid can then enter the mediastinum
or pericardium, depending upon the location of the perforation.
Blood or intravenous fluid in the pericardium may result in pericardial
tamponade. This complication usually presents postoperatively,
after the catheter has been in place for hours or days, although
it may occur immediately following catheter placement.8
The key to prevention of pericardial tamponade is to keep the
central venous catheter outside of the heart. Chest X-rays should
be obtained and carefully reviewed as soon as possible following
placement of the catheter.5,7 For catheters placed
in the operating room, X-rays are usually obtained postoperatively
in the recovery room or intensive care unit.
When reviewing the chest X-ray, three key features should be assessed.
First, the catheter should lie in the vena cava, outside of the
cardiac silhouette. Second, the catheter should be relatively
parallel to the walls of the vena cava. Third, the catheter tip
should not abut the wall of the vena cava.7 An example
of the use of chest X-rays to detect potential problems is shown
in Figure 1, taken from
the author's practice.
A central venous catheter placed via the right internal jugular
vein was found initially not to lie parallel to the walls of the
superior vena cava. Advancement of the catheter by a few centimeters
resulted in a safer placement. Continuous monitoring of the pressure
waveform may also be useful; while the waveforms obtained in the
superior vena cava and right atrium are indistinguishable, the
waveform from the right ventricle can be identified easily.
An exception to the rule of keeping the catheter out of the heart
may reasonably be made for aspiration of air emboli during sitting
neurosurgical procedures or other procedures prone to venous air
embolism.9 However, such catheters should be placed
very carefully and should be withdrawn from the right atrium at
the earliest possible time.
The 12 claims involving catheter or wire embolism were not as
serious as cardiac perforation, since no deaths were recorded.
Although it was impossible to know the precise cause of each of
these events from the information in the ASA Closed Claims Project
database, the usual causes of these problems are well-known and
avoidable. Wires or catheters should virtually never be withdrawn
through a needle because of the risk of shearing. The proximal
end of a wire should always be under the control of the operator
in order to prevent the entire wire from entering the blood vessel
while the catheter is being advanced.
Of the 13 claims involving injuries to veins or arteries (other
than the pulmonary artery), the most serious problems resulted
in hemothorax or hydrothorax; of the nine patients affected, five
died. Although the exact cause of these complications was not
evident in every case, in some of the cases, the apparent cause
was the inadvertent insertion of an introducer sheath or large
bore catheter into an artery instead of a vein, resulting in injury
to the artery. This problem should be avoidable. After placement
of a needle in the blood vessel, the vessel should be positively
identified as a vein prior to cannulation. Numerous methods have
been used for this purpose, including the subjective evaluation
of the force with which blood appears to spurt from the needle,
the color of the blood, assessment of blood gases and transduction
of a pressure waveform.
Of these methods, the author strongly prefers the transduction
of a pressure waveform as the most convenient and reliable technique.10
Many central line kits are now supplied with tubing and connections
designed specifically for transducing a waveform prior to cannulation
of the vein, and package inserts describe this procedure.
There are two take-home messages from this review of central line
complications in the ASA Closed Claims Project database. The first
lesson pertains to the positioning of central venous lines. Unless
clinical needs dictate the placement of a catheter tip in the
right atrium or ventricle, the tip of the central venous catheter
should be located in the superior vena cava with the catheter
oriented parallel to the vessel walls. The chest X-ray is the
key to making this assessment; monitoring the pressure waveform
will identify a catheter that has entered the right ventricle.
The second lesson pertains to inadvertent cannulation of an artery.
The vein should be positively identified prior to cannulation;
the author recommends examination of the pressure waveform as
the most convenient and reliable method for distinguishing between
the venous and arterial systems.
References:
1. Scott WL. Complications associated with central venous catheters.
A survey. Chest. 1988; 94:1221-1224.
2. Brandt RL, Foley WJ, Fink GH, et al. Mechanism of perforation
of the heart with production of hydropericardium by a venous catheter
and its prevention. Am J Surg. 1970; 119:311-316.
3. Sheep RE, Guiney WB. Fatal cardiac tamponade: Occurrence with
other complications after left internal jugular vein catheterization.
JAMA. 1982; 248:1632-1635.
4. Bar-Joseph G, Galvis AG. Perforation of the heart by central
venous catheters in infants: Guidelines to diagnosis and management.
J Ped Surg. 1983; 18:284-287.
5. Collier PE, Ryan JJ, Diamond DL. Cardiac tamponade from central
venous catheters -- A report of a case and review of the English
literature. Angiology. 1984; 35:595-600.
6. Maschke SP, Rogove HJ. Cardiac tamponade associated with a
multilumen central venous catheter. Crit Care Med. 1984;
12:611-613.
7. Tocino IM, Watanabe A. Impending catheter perforation of superior
vena cava: Radiographic recognition. Am J Roentgenol. 1986;
146:487-490.
8. Jiha JG, Weinberg GL, Laurito CE. Intraoperative cardiac tamponade
after central venous cannulation. Anesth Analg. 1996; 82:664-665.
9. Bunegin L, Albin MS, Helsel PE, et al. Positioning the right
atrial catheter: A model for reappraisal. Anesthesiology.
1981; 55:343-348.
10. Jobes DR, Schwartz AJ, Greenhow DE, et al. Safer jugular vein
cannulation: Recognition of arterial puncture and preferential
use of the external jugular route. Anesthesiology. 1983;
59:353-355.
T. Andrew Bowdle, M.D., Ph.D., is Associate
Professor of Anesthesiology and Pharmaceutics, University of Washington
School of Medicine, Seattle, Washington.
Send e-mail to Dr. Bowdle
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