Central venous catheter complications

Because of the need for repeated venous access, a central venous catheter or infusion port is placed prior to starting treatment. These devices are useful not only for delivery of chemotherapy but also to support patients during periods of myelosuppression. Infection and bleeding complications are the primary cause of mortality in patients with leukemia. 

Central PN refers to the administration of PN via a large central vein, and the catheter tip must be positioned in the vena cava. Central PN allows the infusion of a highly concentrated, hypertonic nutrient admixture. The typical osmolarity of a central PN admixture is about 1500 to 2000 mOsm/L. Central veins have much higher blood flow, and the PN admixture is diluted rapidly on infusion, so phlebitis is usually not a concern. Patients who require PN administration for longer periods of time (greater than 7 days) should receive central PN. One limitation of central PN is the need for placement of a central venous catheter and an x-ray to confirm placement of the catheter tip. Central venous catheter placement may be associated with complications, including pneumothorax, arterial injury, air embolus, venous thrombosis, infection, chylothorax, and brachial plexus injury.1,20... 

Patients receiving central PN are at increased risk of developing infectious complications caused by bacterial and fungal pathogens.1,50 Infections maybe related to placement of a central venous catheter, contamination of a central venous catheter or... 

Mechanical complications of PN are related to catheter placement and the system and equipment used to administer PN. A central venous catheter must be placed by a trained professional, and risks associated with placement include pneumothorax, arterial puncture, bleeding, hematoma formation, venous thrombosis, and air embolism.1,20 Over time, the catheter may require replacement. Problems with the equipment include malfunctions of the infusion pump, intravenous tubing sets, and filters. 

Monreal M, Davant E. Thrombotic complications of central venous catheters in cancer patients. Acta Haematol 2001 106(l-2) 69-72. 

After rapid intravenous administration hypotension, shock, and atrioventricular block can occur and can be fatal (2). The rate of infusion should not exceed 5 mg/minute. Qther adverse effects reported during intravenous infusion include sinus bradycardia (236), facial flushing, and thrombophlebitis (236-239). The risk of this last complication can be reduced by infusing the drug into as large a vein as possible and preferably via a central venous catheter, or perhaps by using a very dilute solution of the drug (240). 

Central venous catheters are reluctantly used as blood access for hemodialysis because of safety concerns and frequent complications, for example sepsis, thrombosis, and vessel stenosis. Nevertheless, 20% or more of all patients rely on atrial catheters for chronic dialysis because of lack of other access. Potentially fatal risks related to central venous catheters include air embolism (1), severe blood loss (2), and electric shock (3). These specific risks have been substantially eliminated by the inherent design and implantation of Dialock (Biolink Corporation, USA). Dialock is a subcutaneous device consisting of a titanium housing with two passages with integrated valves connected to two silicone catheters. The system is implanted subcutaneously below the clavicle. The tips of the catheters are placed in the right atrium. The port is accessed percutaneously with needle cannulas. 

Fracture of a central venous catheter due to compression between the clavicle and the adjacent first rib has been reported (5). A pinched-off sign on X-ray indicates the need to remove the catheter, because of a significant risk of subsequent fracture, which has an incidence of 0.9%. Catheters lying anterior to the subclavian vein between the clavicle and the first rib are hable to be compressed and to fracture subsequently. This is a potentially life-threatening complication that can be averted by correct placing of the central venous catheter and by immediate chest radiography to search for evidence of catheter kinking or compression. 

With peripheral blood stem cell harvesting, the most frequent problems relate to central venous catheter occlusion and bone pain in association with the G-CSF priming. Infectious complications during harvesting were experienced in 16% of patients during the PBSC harvesting. 

These studies suggest that transient hypothyroidism is common in preterm infants exposed to iodinated contrast media, and more frequent than complications arising from wrongly-positioned central venous catheters. We are unaware of any ongoing work in this area (e.g., there are none registered with National Research Register UK or the National Institute of Health USA). Because of the potential for permanent neurodevelopmental compromise in infants exposed to iodide toxicity, we believe that it is important to establish the true incidence of transient hypothyroidism associated with exposure to iodinated contrast media. 

Pittiruti M, Hamilton H, Biffi R, MacFie J, Pertkiewicz M (2009) ESPEN guidelines on parenteral nutrition central venous catheters (access, care, diagnosis and therapy of complications). Clin Nutr 28(4) 365-377... 

Clarke DE, Raffin TA (1990) Infectious complications of indwelling long-term central venous catheters. Chest 97 966 972... 

Hicks ME, Openshaw KL et al. (1994) Interventional radiologic placement of Hohn central venous catheters Results and complications in 100 consecutive patients. J Vase Interv Radiol 5 111—115... 

Massicotte MP, Dix D, Monagle P, Adams M, Andrew M. Central venous catheter related thromhosis in children analysis of the Canadian Registry of Venous Thromho-emhoUc Complications. J Pediatr 1998 133 770-6. 

In our opinion, the introduction of a central venous catheter through a femoral vein should be avoided, since this approach carries too many dangerous complications. 

Inaba K, Sakurai Y, Furuta S, Sunagawa R, Isogaki J, Komori Y, Uyama I. Delayed vascular injury and severe respiratory distress as a rare complication of a central venous catheter and total parenteral nutrition. Nutrition 2009 25(4) 479-81. 

Dialysis vascular access is currently the lifeline for hemodialysis patients. Unfortunately, due to the many complications associated with dialysis vascular access, it is also the Achilles heel of hemodialysis. A relatively ignored aspect of dialysis vascular access pertains to patient safety. The first part of this chapter will describe patient safety issues in the traditional context of arteriovenous fistulas (AVFs), arteriovenous grafts (AVGs) and tunneled central venous catheter (tCVC). In the second half of this chapter, however, we will make the case that a nontraditional approach which emphasizes (a) individualization of care, and (b) patient preferences and patient involvement maybe our best opportunity to improve patient safety in hemodialysis patients. 

McCann M, Moore ZE Interventions for preventing infectious complications in haemodialysis patients with central venous catheters. Cochrane Database Syst Rev 2010 CD006894. 

Catheter-related bacteraemia (CRB) and catheter dysfxmction are major sources of morbidity and mortality when central venous catheters (CVCs) are used as long-term vascular access devices in haemodialysis patients. Attempts have been made to minimise these complications by the prophylactic use of catheter locking solutions. The current study aims to describe the recent advances in the field of lock solutions and discusses the benefits and risks associated with the routine use of antimicrobial and/or antithrombotic lock solutions [ll J. These solutions may improve patency and CRB, but at the same time, these may be cost-prohibitive. 

Central Venous Catheters Central venous catheters (CVCs) are widely used in hospital practice indeed it has been estimated that, in the United States alone, about 5 million of these units are inserted annually [52]. The widespread use of CVCs is associated with potential infective complications, with the annual incidence of catheter-related bloodstream infection estimated at around 80000 cases in the US [53, 54]. 

There is some disagreement as to whether infectious complications differ with the use of different types of chronic central venous access devices in patients with cancer. In one study there was no significant difference in the risk of infection between subcutaneous ports and external catheters (26). However, this has been disputed by other workers, who found that in children with cancer there was a lower infection rate when subcutaneous ports were used compared with external catheters (27). The differences between the studies and the conclusions reached may be the result of their size and design, rather than real differences. 

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