Venous access 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. 

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. 

Infective endocarditis is a serious complication of centrally placed venous access devices. The successful treatment in situ of a large thrombus associated with the tip of the catheter has been described (29). The antibiotic regimen was gentamicin and vancomycin, both delivered via the venous access device vancomycin was allowed to remain in situ between each 8-hourly dosing. This regimen successfully eradicated the thrombus within 3 weeks, without removal of the hue. 

Keung YK, Watkins K, Chen SC, Groshen S, Silberman H, Douer D. Comparative study of infectious complications of different types of chronic central venous access devices. Cancer 1994 73(ll) 2832-7. 

Venugopalan P, Louon A, Akinbami FO, Elnour IB. Endocarditis with a large thrombus complicating a central venous access device. Ann Trop Paediatr 1999 19(l) 101-3. 

Central catheter site of procedure (bedside vs. operating room), radiographic confirmation of placement, supplies used for site care Peripheral line nursing time, supplies used for site care Routine laboratory and clinical measurements, changes in therapy to prevent complications or toxicities, nutrition support clinician time Mechan/ca/ treatment of specific complication Infectious cost of antibiotic therapy or venous access replacement Metabolic increased clinical and laboratory measurements, possible waste of PN solution... 

A thorough understanding of the venous anatomic structures of the head, neck, and upper extremities are imperative for safe venous access (Fig. 4.2) (41). The precise location and orientation of the internal jugular, innominate, subclavian, and cephalic veins are important for safe venous access (42). Their anatomic relation to other structures is crucial in avoiding complications. The venous anatomy of interest from a cardiac pacing and ICD point of view starts peripherally with the axillary vein (43). 

Byrd underscores the concept of thoroughly understanding anatomy with his description of the anteriorly and posteriorly displaced clavicle (44). The posteriorly displaced clavicle commonly seen in chronic obstructive pulmonary disease patients can make venous access from the percutaneous point of view extremely hazardous. Similarly, the anteriorly displaced clavicle, as found in the elderly kyphoscoliotic patient with interiorly bowed clavicles, renders percutaneous venous access next to impossible. An appreciation of these anatomic variations is essential to avoid the complications of pneumothorax, hemopneumothorax, and unsuccessful venipuncture. It should also be appreciated that the right ventricle is an anterior structure, the apex of which is usually located anteriorly and to the left (Fig. 4.5). Although the normal location is distinctly to the left of the midline, occasionally it can be rotated anteriorly... 

Frequently, the solution to one problem creates another problem. A case in point is this author s proposed extreme medial subclavian percutaneous technique. Although this approach is safe, avoids the complication of pneumothorax, and expedites venous access, it has been implicated in the case of... 

The external jugular vein is less frequently used for venous access because it is more interiorly located and there is a higher risk of pneumothorax as well as vascular complications it is less precise, and successful caimulation may be more frustrating. 

Permanent pacemakers have also been implanted using the inferior vena cava via a retroperitoneal approach (Fig. 4.63) (117). This is usually in the setting of complex congenital anomahes and subsequent corrective procedures. Venous access to the right atrium and ventricle is complicated by loss of continuity between the right atrium and the superior vena cava. Bipolar active fixation screw-in electrodes are used for both the atrium and ventricle. The pulse generator is usually implanted in a subcutaneous pocket formed on the anterior abdominal wall. 

A review of the incidence of complications associated with venous access suggests a 1% incidence of pneumothorax. Arterial puncture, somewhat more common, occurs at a rate of 3%. A list of pacemaker complications... 

Venous access. In adnlt pacemaker practice, it is common to obtain a cut-down on the cephalic vein that will accommodate one or two leads. However, in children, becanse of the size of the vein, this is less likely. Still, the cephalic approach is preferable to the snbclavian approach, when available, as it completely avoids the complication of subclavian crush injury to the lead (39,40). Subclavian crnsh injnry resnlts from entrapment of the lead between the clavicle and the first rib, where it is subject to great stress with patient movement. 

In patients being upgraded from an existing pacemaker or ICD to a CRT system, venous access and venous narrowing may hamper placement of the additional coronary sinus lead. One potential complication with difficult passage of a lead is venous perforation. In Fig. 18.36, the sheath used for introduction of the coronary sinus lead has perforated the vein, and dye was injected to determine the sheath position. The dye is shown in the mediastinum. In this patient, the sheath was withdrawn and redirected into the lumen of the vein, and the patient remained hemodynamically stable. 

The femoral vein is used in a similar manner as any other more conventional access site. The tunnel or pocket is created on the lower abdominal wall or even the lower chest wall. It is important to widely separate the catheter exit site or pocket from the venous access site to minimize infectious complications. 

Ellis PK, Kidney DD,DeutschLS (1997) Giant right atrial thrombus a life-threatening complication of long-term central venous access catheters. J Vase Interv Radiol 8(5) 865-868 Ferral H, Bjarnason H, Wholey M, Lopera J, Maynar M, Castaneda-Zuniga WR (1996) Recanalization of occluded veins to provide access for central catheter placement. J Vase Interv Radiol 7 681-685... 

Hinke DH, Zandt-Stastny DA, Goodman LR, Quebbeman EJ, KrzywdaEA, Andris DA (1990) Pinch-off syndrome a complication of implantable subclavian venous access devices. Radiology 177 353-356... 

Macdonald S, Watt AJ, McNally D, Edwards RD, Moss JG (2000) Comparison of technical success and outcome of tunneled catheters inserted via the jugular and subclavian approaches. J Vase Interv Radiol 11(2 Pt 1) 225-231 Mauro MA (1998) Delayed complications of venous access. W. B. Saunders Co. 

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