Safer central venous access

AnaesthesiaVolume 60, Issue 6 p. 617-619 Free Access Safer central venous access First published: 18 May 2005 https://doi.org/10.1111/j.1365-2044.2005.04240.x A response to a previously published article or letter can be submitted to the Online Correspondence section at http://www.anaesthesiacorrespondence.com. A selection of this correspondence is published several times a year in Anaesthesia. All correspondence intended for publication in Anaesthesia should be addressed to Dr David Bogod, Editor-in-Chief, and submitted as an e-mail attachment to anaesthesia@nottingham.ac.uk. For multi-author letters, a covering letter signed by all authors must be submitted either by post, fax (44 (0) 115 962 7670) or by e-mail as a scanned document before correspondence can be published. Alternatively, letters may be submitted typewritten on one side of paper, double spaced with wide margins to Anaesthesia, 1st Floor, Maternity Unit, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK. 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Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat We would like to offer our opinion on ways to improve on the safety of central venous access, as has been expertly reviewed by Drs Hall and Russell [1]. We agree that the external jugular site is an excellent alternative after difficulties with accessing the internal jugular vein are encountered. However, the external jugular vein is a less reliable conduit for achieving central venous access [2]. Even with a realistic pressure waveform, one cannot be assured that the tip of the cannula is in the superior vena cava (SVC) [3]. Another potential danger of central venous cannulation via the external jugular, the left internal jugular or a subclavian vein is the tip of the cannula abutting on the wall of a major vessel such as the SVC, causing erosion and, potentially, a puncture over time. If possible, a radiological assessment should be made afterwards. One also needs to remember there is a risk of thoracic duct puncture during left internal jugular venous access. Finally, there is the option of peripherally inserted (PICC) lines as an alternative to the aforementioned lines. They are less expensive and associated with fewer mechanical problems and lower infection rates [4, 5]. Some clinicians access a central vein with a saline-containing aspirating needle. Recommended in the Advanced Cardiac Life Support and implied in the Advanced Paediatric Life Support manuals [6, 7], this practice has the disadvantage of making venous blood look bright and more difficult to distinguish from arterial blood [8], thus removing a valuable tool to detect inadvertent arterial puncture. We disagree that the dilator should be passed a few centimetres to the depth of the vein, as that would cause a hole in the vein larger than that of the catheter and risk a haematoma in susceptible patients [9]. We believe it is seldom necessary to pass the dilator much beyond 1 cm [9]. We agree that the catheter should not pass beyond the 13 cm mark on the right side of the neck, especially during cardiac surgery, when the surgeon may snare the SVC. One must avoid choosing an excessively long catheter for a small person because the opening of a proximal lumen in a multilumen catheter may become extravascular. Using the same argument, one should not use regular length intravenous catheters to cannulate any central vein other than the external jugular vein. There is always the danger of the tip of the cannula slipping out of the vein during positioning and turning of the neck. Disaster could occur if an unsuspecting clinician infused large volumes of fluid, blood products or life-saving medications through the line. A. M.-H. Ho, C. R. Jenkins and M. K. KarmakarThe Chinese University of Hong Kong Shatin, NT, Hong Kong SAR E-mail: hoamh@cuhk.hk References 1 Hall AP, Russell WC. Toward safer central venous access: ultrasound guidance and sound advice. Anaesthesia 2005; 60: 1– 4.DOI: 10.1111/j.1365-2044.2004.04074.x Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 2 Belani KG, Buckley JJ, Gordon JR, et al. Percutaneous cervical central venous line placement: a comparison of the internal and external vein routes. Anaesthesia and Analgesia 1980; 59: 40– 4. CrossrefCASPubMedWeb of Science®Google Scholar 3 Ho AMH. Sore throat after central venous cannulation. Journal of the Royal Society of Medicine 1999; 92: 199. CASPubMedWeb of Science®Google Scholar 4 Pearson ML. Hospital Infection Control Practices Advisory Committee. Guidelines for the prevention of intravascular device related infections. Infection Control and Hospital Epidemiology 1996; 17: 438– 73. PubMedWeb of Science®Google Scholar 5 Raad I, Davis S, Becker M, et al. Low infection rates and long durability of non-tunneled silastic catheters. A safe, cost-effective alternative for long-term venous access. Archives of Internal Medicine 1993; 153: 1791– 6.DOI: 10.1001/archinte.153.15.1791 CrossrefCASPubMedWeb of Science®Google Scholar 6 Cummins RO. Advanced Cardiac Life Support. Dallas: American Heart Association, 1997: 6– 9. Google Scholar 7 Advanced Life Support Group. Advanced Paediatric Life Support – The Practical Approach, 2nd edn. London: BMJ Publishing Group, 1997: 197– 208. Google Scholar 8 Ho AMH, Chung DC, Tay BA, et al. Diluted venous blood appears arterial: implications for central venous cannulation. Anaesthesia and Analgesia 2000; 91: 1356– 7. CrossrefCASPubMedWeb of Science®Google Scholar 9 Ho AMH, Karmakar MK. Vascular injury secondary to dilator insertion during internal jugular vein cannulation. Anaesthesia and Analgesia 2003; 96: 911. CrossrefPubMedWeb of Science®Google Scholar The recent editorial on central venous line placement was timely [1]. This procedure is employed increasingly and has become a core anaesthesia skill. While agreeing with most of the content of the editorial, two assertions must be challenged, namely that a chest X-ray (CXR) is mandatory following line placement and that the tip of the line must not enter the right atrium. There are a number of situations where a CXR is unnecessary and others where it is of dubious value [2]. If the line has been placed peri-operatively for monitoring purposes, without obvious complication, especially if it has been transduced and been seen to reflect venous waveforms, a CXR is usually unnecessary. Equally, if the line has been placed with the aid of image intensification, no CXR is required [3]. In all situations, a protocol should exist that calls for the taking of a CXR whenever a patient who has had a central venous catheter placed shows symptoms or signs of pneumothorax development. This should also apply to patients who may have had a normal CXR immediately following line placement, as a significant pneumothorax may take many hours to develop [3]. The advice on catheter length to prevent the tip entering the right atrium is widely given, but there is much evidence that this advice may be misplaced [4-8]. This is of major importance when placing long-term venous access devices such as Hickman catheters and Portacaths. There is evidence that distal placement, with the catheter tip in the distal superior vena cava or in the right atrium greatly reduces the incidence of thrombosis and fibrin sheath formation at the catheter tip. This leads to fewer infections and thromboembolic episodes, prolongs the life of these devices and lessens patients' exposure to the hazards of repeat line placement. These benefits are real, tangible and worth the very small risk that might result from right atrial tip placement. A. J. McShaneSt. Vincent's University Hospital Dublin 4, Ireland E-mail: L.McNicholas@st-vincents.ie References 1 Hall AP, Russell WC. Toward safer central venous access: ultrasound guidance and sound advice. Anaesthesia 2005; 60: 1– 4. Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 2 Farrell J, Walshe J, Gellens M, Martin KG. Complications associated with insertion of jugular venous catheters for hemodialysis: The value of postprocedural radiograph. American Journal of Kidney Diseases 1997; 30: 690– 2. CrossrefCASPubMedWeb of Science®Google Scholar 3 Chang TC, Funaki B, Szymski GX. Are routine chest radiographs necessary after image-guided placement of internal jugular central venous access devices? American Journal of Roentgenology 1998; 170: 335– 7. CrossrefCASPubMedWeb of Science®Google Scholar 4 Puel V, Caudry M, Le Metayer P, et al. Superior vena cava thrombosis related to catheter malposition in cancer chemotherapy given through implanted ports. Cancer 1993; 72: 2248– 52. Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 5 Namyslowski J, Patel NH. Central venous access: a new task for interventional radiologists. Cardiovascular and Interventional Radiology 1999; 22: 355– 68. CrossrefCASPubMedWeb of Science®Google Scholar 6 Nightingale CE, Norman A, Cunningham D, Young J, Webb A, Filshue JA. Prospective analysis of 949 long-term central venous access catheters for ambulatory chemotherapy in patients with gastrointestinal malignancy. European Journal of Cancer 1997; 33: 398– 403. CrossrefPubMedWeb of Science®Google Scholar 7 Stanislav GV, Fitzgibbons RJ, Bailey RT, Mailliard JA, Johnson PS, Feole JB. Reliability of implantable central venous access devices in patients with cancer. Archives of Surgery 1987; 122: 1280– 3. CrossrefCASPubMedWeb of Science®Google Scholar 8 Racadio JM, Doellman DA, Johnson ND, Bean JA, Jacobs BR. Pediatric peripherally inserted central catheters: complication rates related to catheter tip location. Paediatrics 2001; 107: E28. CrossrefCASPubMedWeb of Science®Google Scholar We read with interest the excellent editorial on ‘safer central venous access’ by Drs Hall and Russell [1]. However, we were surprised that the authors were so strongly opposed to line changes ‘over the guide-wire’. The controversy arises in the case of a patient with unexplained pyrexia where catheter related sepsis is a possibility. Although intuitively it seems probable that this practice will lead to poorer patient outcome, the evidence does not confirm this [2]. It appears that the issue comes down to a balance of risks. On the one hand there is an increased chance of catheter related bacteraemia, whilst on the other there is an increased likelihood of a mechanical complication from the replacement line insertion. Indeed, others have concluded that, so long as there is no evidence of pus or erythema at the entry site and so long as the railroaded line is removed if a positive culture is obtained from the original line, then guide-wire exchange is the method of choice [3]. It therefore seems reasonable to use the guide-wire exchange technique at least in some cases of possible catheter related sepsis. The actual likelihood of the catheter being infected, the level of experience of the operator, the degree of microbiological support and the technical difficulty of line insertion in any particular patient are all factors that could reasonably be considered. G. Strandvik and M. MayallKent & Canterbury Hospital Canterbury, Kent E-mail: strandviks@dsl.pipex.com References 1 Hall AP, Russell WC. Toward safer central venous access, ultrasound guidance and sound advice. Anaesthesia 2005: 60, 1– 4. Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 2 Pearson ML for the Hospital Infection Control Practices Advisory Committee. Guideline for the prevention of intravascular-device-related infections. Infection Control and Hospital Epidemiology 1996; 17: 438– 73. PubMedWeb of Science®Google Scholar 3 Cook D, Randolph A, Kernerman P, et al. Central venous catheter replacement strategies: a systemic review of the literature. Critical Care Medicine 1997; 25: 1417– 24. CrossrefCASPubMedWeb of Science®Google Scholar A reply We thank all of the authors for their interest in our editorial. We agree that the external jugular vein (EJV) approach and peripherally inserted central catheter (PICC) lines are useful alternatives to direct central venous access though not always easily performed or reliable in their results. We did not develop these themes further in the article since our aim was to concentrate more on direct central venous cannulation. The EJV may be readily cannulated as with any peripheral vein and will accommodate a large diameter, short cannula with ease. Though the tip is not centrally placed, evidence would suggest that the venous pressure at this point correlates well with central venous pressure (CVP) [1]. In an emergency situation where haemodynamic monitoring is required, this may be an adequate approximation of CVP. It will certainly allow a pressure ‘trend’ to be followed and can readily be replaced by more formal central venous access when the opportunity and expertise become available. If a longer cannula is passed into the EJV, central placement within the superior vena cava (SVC) is possible. Difficulty may be encountered at the point where the vein passes through the deep fascia, though this may be circumvented by elevating (‘shrugging’) the shoulder. Reliable positioning in the SVC is harder to achieve since the line may become misdirected across the midline or even cranially but, again, this may not matter clinically. A chest radiograph will confirm the line position and, though not ideal, an overgenerous line may be withdrawn slightly, resutured and dressed. We agree that the ACLS/APLS recommendations mentioned by Ho and colleagues regarding a saline containing aspirating needle syringe represent basic ‘landmark’ technique practice and, while not ideal, may still find some use in an emergency situation. Regarding the passage of the dilator, we appear to be in agreement that this should only be passed a little beyond the depth of the vein to facilitate canulation. Sometimes as shallow as 1 cm in slim individuals, one will need to go further in the obese. We disagree that further passage leaves a hole in the vein greater than the catheter. The dilator reaches its full diameter close to the tip. The danger of over-inserting the dilator relates to its perforating across the other wall or through a more distal flap, or pocket, or deviation into which the guide-wire may have lodged down the course of the vein. We maintain our belief in the importance of the postprocedure chest radiograph. If, however, fluoroscopy has been used in siting the line [2], this has in effect already occurred and does not need repeating. The image may be printed. One must not forget that the chest radiograph is also a means of clear documentation of placement and positioning that may be useful to subsequent clinicians and also as a medico-legal record. An ultrasound image is transient and its printout relatively meaningless after the procedure has occurred. McShane raises an interesting point regarding the position of the catheter tip. Our attempts to limit the risk of cardiac erosion by ensuring placement of the catheter outside the right atrium may well be increasing the incidence of catheter-related thrombosis [3, 4]. Placing the catheter tip within the right atrium may reduce the incidence of thrombosis. However, though cardiac perforation is rare, it is almost universally fatal and this has been a significant driving force in the recommendations to keep the catheter clear of the heart. Finally, there is the issue of line changes over a guide-wire addressed by Strandvik and Mayall. We believe that the increased infection risk with this practice is self-evident. The review of catheter replacement strategies by Cook et al.[5] made clear that there was a trend toward an increase in both catheter colonisation and catheter-related bacteraemia in the guide-wire exchange groups. We agree that one must balance any increased infective risk with an increased risk of mechanical complications if a new line is sited elsewhere. However, as we made clear, the use of ultrasound guidance should dramatically reduce mechanical complications even in ‘difficult’ patients. A. P. Hall and W. C. RussellLeicester Royal Infirmary Leicester LE1 5WW, UK E-mail: andrew.p.hall@uhl-tr.nhs.uk References 1 Parker JL, Flucker C, Maguire A, Russell W, Thompson JP. Comparison of external jugular and central venous pressures in mechanically ventilated patients. Anaesthesia 2002; 57: 596– 600. Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 2 Chang TC, Funaki B, Szymski GX. Are routine chest radiographs necessary after image-guided placement of internal jugular central venous access devices? American Journal of Roentgenology 1998; 170: 335– 7. CrossrefCASPubMedWeb of Science®Google Scholar 3 Puel V, Caudry M, Le Metayer, et al. Superior vena cava thrombosis related to catheter malposition in cancer chemotherapy given through implanted ports. Cancer 1993; 72: 2248– 52. Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 4 Nightingale CE, Norman A, Cunningham D, Young J, Webb A, Filshue J. A prospective analysis of 949 long-term central venous access catheters for ambulatory chemotherapy in patients with gastrointestinal malignancy. European Journal of Cancer 1997; 33: 398– 403. CrossrefPubMedWeb of Science®Google Scholar 5 Cook D, Randolph A, Kernerman P, et al. Central venous catheter replacement strategies: a systematic review of the literature. Critical Care Medicine 1997; 25: 1417– 24. CrossrefCASPubMedWeb of Science®Google Scholar Volume60, Issue6June 2005Pages 617-619 ReferencesRelatedInformation