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Morbid and mortal complications associated with prolonged central venous cannulation
Morbid and Mortal Complications Associated with Prolonged Central Venous Cannulation Awareness,
Recognition,
and Prevention
JOHN
H. HENZEL,
M. S. DeWEESE,
In recent months indwelling venous catheters have gained increasing popularity for purposes of prolonged central venous pressure monitoring and administration of hyperosmolar parenteral alimentation. As experience has accumulated with this modality, various complications associated with its utilization have become apparent. In our own experience with some 350 central venous cannulations over the last four years, we observed more complications during the last twelve months than were encountered during our first three years of vena cava catheter placement. The purpose of this communication, which includes five cases of serious but preventable catheter complications, is to relate factors apparently responsible for the increased number of complications, and to outline and emphasize precautions which should minimize untoward sequelae associated with utilization of indwelling large vein catheters. Case
Reports
CASE I. The patient (CB), a twenty-one year old woman, had a diverting colostomy performed for large bowel necrosis and pericolonic abscess which occurred in association with agranulocytosis. During a postoperative period complicated by wound dehiscence, fecal fistula, and sepsis, a number 240 polyethylene catheter was inserted by external jugular cutdown into what was believed to be superior vena cava, in order to monitor central venous pressure. Forty-eight hours later, unexpected cardiac decompensation and arrest occurred which were resistant to all attempts at resuscitation. During postmortem examination, transmyocardial penetration of the right ventricle was discovered. Approximately 1 inch of the catheter was lying free in a pericardial sac which was taut with some 300 ml of clear fluid.
From the Department of Surgery, University of Missouri Medical Center, Columbia, Missouri.
600
MD, Columbia, Missouri MD, Columbia, Missouri
CASE II. The patient (DS), a fifty-three year old woman, was referred to the University of Missouri Medical Center with renal shutdown seven days after uncomplicated cholecystectomy and common bile duct exploration had been performed. Initial evaluation disclosed a jaundiced, obtunded patient who had a freely draining T tube, and who was anuric with an elevated blood urea nitrogen level and decreased serum sodium. The surgeons were consulted to place a catheter for monitoring central venous pressure, and a number 190 polyethylene catheter was threaded into the superior vena cava via infraclavicular right subclavian puncture, and anchored to the skin with two separate number 3-O silk sutures. Approximately three hours later, the surgical resident was notified that the catheter had “withdrawn beneath the skin surface.” Chest roentgenogram disclosed that the distal end of the radiopaque tubing was in the supracardiac superior vena cava, but technic and superimposition of structures precluded localizing the proximal end of the catheter. While the patient was being returned to the Radiology Department for additional films, cardiopulmonary arrest occurred and although initial resuscitation was successful, she died some nine hours later. Although the follow-up x-ray studies again disclosed that the distal tip of the catheter was in the superior vena cava, the polyethylene tube was found coiled within the right ventricle at autopsy. Since chest films were not obtained after resuscitative efforts, we do not know whether the catheter worked its own way into the heart (case III), or was iatrogenically advanced into the right ventricle during external cardiac message.
CASE III. WT, a twenty-eight year old man, had a SVC catheter inserted via external jugular vein cutdown at the time of celiotomy for multiple gunshot wounds. During the early postoperative period leakage occurred at the adaptor-polyethylene junction, and a 1’7 gauge needle was substituted for the routinely used blunt cannula. Approximately thirty-six hours later, when massive leakage of intravenous fluid recurred, it was discovered that the needle point had completely transected the catheter, and that the distal end had
The American
Journal
of Surgery
Prolonged
withdrawn beneath the skin surface. Chest roentgenogram revealed that the entire length of catheter was coiled within the right ventricle. Shortly thereafter irreversible cardiac arrest occurred in association with septicemia, and postmortem examination confirmed the roentgenographic interpretation. CASE IV. The patient (JR), a twenty-eight year old truck driver, arrived at UMMC after a collision in which his vehicle burst into flames. Because of the extent and location, predominantly in the upper torso, of an estimated 50 per cent deep thermal injury, a central catheter was threaded into the inferior vena cava via percutaneous puncture of the left common femoral vein. During the first seventy-two hours of fluid replacement, at least two surgeons involved in the patient’s care commented about the potential morbidity associated with femoral catheters. Nonetheless, because of the persistent difficulty in recording accurate venous pressure via a separate external jugular catheter, the left femoral site was maintained, although the area was redressed in sterile fashion every third day. On the sixth day after injury, high-output renal failure became evident, and by the ninth day the blood urea nitrogen level had reached 145 mg per cent. During preparations for dialysis, the patient had pleuritic chest pain and hemoptysis, and shortly thereafter an acute terminal episode was characterized by cyanosis, neck vein distention, hypotension, and irreversible cardiac arrest. Although permission for autopsy was denied, edema of the left leg was appreciably greater than that of the right leg. Iliofemoral thrombophlebitis, either precipitated by or related to the indwelling catheter, was considered to be the etiologic factor. CASE v. The patient (LB), a thirty-two year old man, had subclavian catheters placed without incident on five separate occasions during pre and postportacaval shunt management of bleeding esophageal varices. A sixth attempt at catheter insertion via the left subclavian route met with failure, and because numerous peripheral cutdowns had been performed prior to his transfer to the surgical service, a polyethylene catheter was threaded into the inferior vena cava through a cutdown of the proximal left greater saphenous vein. In an effort to preserve venous flow, the catheter was inserted into the greater saphenous vein through a small nick about 1 inch below the fossa ovalis, and the vein was not ligated below this level. The cutdown site had been prepared with alcohol and Betadine@, and bacitratin ointment was spread over the incision and around the catheter before a sterile dressing was taped in place. On the third and the sixth day after cutdown the dressing was removed, and the skin cleansed with alcohol and Betadine prior to new applications of bacitracin ointment and sterile redressing. When sepsis occurred on the seventh day after catheter placement, the femoral catheter was removed. Blood cultures were obtained, as were cultures of the femoral cutdown site
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and the tip of the catheter. The culture of the catheter was lost, but the blood cultures revealed Streptococcus fecalis, which was the same organism from the cutdown site.
Comments In the twenty-five years since Meyers [I] first used a plastic catheter for administering intravenous fluids, the over-all merits of indwelling venous cannulation have greatly outweighed the untoward sequelae which occasionally have been associated with this clinical modality. Although a certain incidence of complications is to be anticipated during applicatkon of any contemporary therapeutic modality, the five serious complications which we encountered within the past twelve months were more than we had observed during three preceding years’ experience with vena caval catheters. In reviewing our morbidity and mortality, it became apparent that complications could be directly attributed to two primary factors : a more relaxed attitude toward critical points of catheter placement as we attained experience with this modality, and delegation of catheter care to inexperienced personnel once the polyethylene cannula has been inserted. In this communication we wish to emphasize that complications occur not only during placement but also during maintenance of indwelling central vein catheters. The most serious complication which we encountered, fatal catheter perforation of the right ventricle, was first recorded by Brown and Kent [2] in 1956. Ten years later Johnson [3] reported another instance in which an intravenous catheter penetrated the right atrium and caused the patient’s death, and in 1968 Friedman and Jurgeleit [4] reported a third fatality. Within recent months two additional cases of cardiac penetration have appeared [5], and in one of these patients irreversible cerebral damage occurred during resuscitation from associated pericardial tamponade. Although postmortem examination revealed that catheter tips had been sharpened in the first two reported cases, the fact that cardiac penetration has occurred after percutaneous subclavian puncture (in which the tubing is not beveled) confirms that blunt catheter tips can also penetrate myocardium. Avoidance of cardiac perforation and pericardial tamponade depends upon roentgenographic confirmation that the tip of a radiopaque catheter lies within the su,perior vena cava, and not the right heart. When obesity or other anatomic factors make it difficult to delineate catheter position on routine chest roentgenogram, simple dye injection
601
Henzel and DeWeese
Arrangement for anchoring and stabilizing perFigure 1. cutaneous catheters (ideally number 32-35 monofilament wire sutures). A, suture anchoring catheter at site of cutaneous puncture. f3, second anchoring suture to decrease chance of angulation-obstruction at cutaneous puncture site. C, third suture not only anchors redundant loop, but also attaches catheter to cannula.
will facilitate localization. Since catheters which are initially positioned low in the supracardiac superior vena cava occasionally advance into the right heart, our nursing staff is instructed to assure that respiratory excursion is observable in the manometric column each time that the venous pressure is recorded. The complication described in cases II and III has been well documented ‘in the literature. In 1954 Turner and Sommers [6] recorded the first clinical case of catheter embolus to the right atrium. In Moncrief’s [ 7’1 series of 135 femoral catheter placements, there were three instances of “lost tubing,” and two of these patients died as a result of fatal septic thrombophlebitis at the site where the catheter segments were found in the femoral vein. In the third patient, who was alive and well at the time of Moncrief’s report in 1958, the lost segment was never found, and there had not been any dificulty in the intervening two years since its loss. In 1963 Taylor and Rutherford [S] reported a fatal outcome in seven of nine instances of catheter embolism, and in five patients the catheter was considered instrumental in the patient’s death. In 1967 Doering, Stemmer, and Connolly [9] cited twentysix cases from the literature, and then added twenty-three additional cases of catheter embolism from various Los Angeles hospitals. Of these fortynine cases, fourteen catheter segments ended up in either the right heart or pulmonary artery. Four early deaths were directly attributable to catheter
602
embolism, one fatality which ensued a year after catheter embolism was due to shock and atria1 fibrillation, and two deaths occurred because of unrelated causes. Five catheters were successfully removed, and two patients remained asymptomatic without treatment. The potential for catheter embolization can be minimized by adhering to the recently advocated principle that “all catheters should be inserted, maintained, and evaluated exclusively by [personnel experienced in catheter placement]” [IO]. Ideally, whenever leakage, cessation of flow, backbleeding, or any other problem associated with catheter function occurs, the person who placed the catheter should be contacted. Needles are no longer utilized as adapters, and their use is to be condemned since blunt adapter cannulas are now universally available. In our own experience, leakage at the adapter-catheter juncture is usually related to one of three causes. During percutaneous insertion, number 190 catheter is threaded through a 14 gauge thin-wall needle. Since the proximal end of some polyethylene tubing has been flared to permit direct attachment to intravenous tubing when the catheter is inserted by cutdown, the flared portion must be transected before the percutaneous needle can be removed over the tubing. Although usually it is not possible to withdraw the needle back over the tubing if the flare has not been transected at or below its junction with uniform-diameter catheter, this is not always the case. In such instances the appropriate adapter fits loosely into the flared segment. It is important to recognize this cause of leakage since transection of an additional few millimeters of polyethylene will permit a leakproof union. A second source of adapter-catheter leakage is infrequent, but on occasion, after threading the polyethylene into the subclavian vein, one discovers that the catheter does not fit snugly onto the appropriate adapter. This problem is avoided by assuring water-tight adapter-catheter mating prior to venous puncture. In those instances in which a catheter has been placed, and leakage occurs and persists after we have secured the catheter-adapter suture (as illustrated in Figure I), we prefer to substitute the larger PE 240 adapter, rather than place a new catheter. In attempting to position a catheter as far proximal as possible onto any adapter, but particularly with the larger PE 240 cannula, we occasionally encounter a third source of leakage, that is, iatrogenic laceration of the polyethylene. Whenever a crack occurs at the adapter juncture, an additional segment of catheter should be transected
The
American
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Prolonged Central Venous Cannulation
and the adapter cannula carefully replaced. Although an autopsy was not obtained in case IV, the symptoms preceding the terminal episode and the clinical picture of right heart strain at the time of cardiopulmonary arrest were classical for pulmonary embolism. In addition, edema of the leg was markedly greater on the side of the percutaneous femoral catheter. In all likelihood, insertion of the caval catheter through the femoral route either precipitated local thrombophlebitis at the site of vein puncture, or thrombus developed on the tip of the catheter. As early as 1949 Duffy [11] reported two instances of local phlebitis in twentyeight patients with femoral catheters. Two years later Bonner [12] emphasized the hazards of venous thrombosis in association with long-term femoral vein cannulation, after discovering clot formation about the catheter in five of forty-one patients, one of whom had a nonfatal septic pulmonary embolus. Moncrief identified eighteen instances of venous thromboses proved at autopsy among the ninety-one patients who had 135 femoral vein catheters at the Brooke Army Burn Center, and in four of these patients the thromboses were the direct cause of death [IO]. Bansmer, Keith, and Tesluk [13] recorded a 46 per cent incidence of clinical complications in twenty-four patients who had vena caval catheters. In twenty-two instances the catheters had been placed by percutaneous femoral puncture, and in the other two patients definitive saphenofemoral cutdown had been performed. Seventeen of the patients died, and autopsy revealed mural thrombus within the catheter-containing venous channel in sixteen instances. Although catheters had been in place for periods ranging from one to thirty-six days, in each of the three documented instances of pulmonary embolism, the duration was twelve days or less. Bansmer observed that clinical complications were few when catheters were removed before the seventh day. In Bogen’s [14] series of patients with saphenous vein catheters, there were three fatalities in which a clinical diagnosis of pulmonary infarction had been made shortly before death, and in two of these cases embolization was confirmed at autopsy. Accumulated experience leaves little doubt that with the possible exception of small infants, it is best to avoid placement of indwelling cannulas in veins in the lower extremity. In case v a groin cutdown site became infected and was a proved source of sepsis. Excellent retrospective and prospective studies have demonstrated the importance of managing the catheter site as ‘an open surgical wound. In 1953 Erwin,
Volume 121. May 1971
Strickler, and Rice [15] observed that once erythema became evident at a cutaneous puncture site, ascending inflammation would develop if the catheter was allowed to remain in place for another twenty-four hours. In 1958, Phillips and Wand Eyre [16] reported three instances of staphylococcal septicemia which occurred after catheters had been in place for four, five, and seven days, respectively. In each instance the offending organism was cultured from the site of percutaneous puncture. In 1963 Druskin and Siegel [.Z71 removed intravenous catheters in sterile fashion and cultured the distal tips. None of the catheters remaining in place for less than forty-eight hours demonstrated growth, although the incidence of positive cultures after forty-eight hours was 52 per cent. In 1964 Chaney and Lincoln [18] who reported an incidence of culture-positive catheter tips approximating 10 per cent, cleansed catheter puncture sites with Zephiran@ and tested the efficacy of 3 per cent Achromycin@ ointment in lowering the incidence of local reactions. Single applications of the antibiotic failed to reduce either the incidence of phlebitis or the incidence of positive cultures. More recently Moran, Atwood, and Rowe [I91 carried out a prospective double-blind study in which they evaluated the efficacy of repeated applications of broad spectrum antibiotic ointment in decreasing wound infection and catheter sepsis. The number of positive cultures was nearly four times as great in wounds which were not treated with the ointment, and although phlebitis developed in 53 per cent of placebo-treated patients, only 37 per cent of those treated with the antibiotic ointment developed this complication. Two of five patients in whom septicemia developed were in the antibiotic-treated group, whereas the other three had been treated with the placebo. During the past nine months we have employed only broad spectrum antibiotic (Mycitracina, Upjohn) at the catheter skin juncture, after alcoholBetadine cleansing of catheter sites every three days. Since initiating this regimen, we have had no further instances of catheter sepsis, and none of thirteen catheter tips submitted for culture by one of us (JHH) has demonstrated bacterial growth. Case v also exemplifies a good reason for preferring superior vena caval cannulation over the inferior cava in most instances. Since numerous cutdowns and five percutaneous subclavian catheters had exhausted all readily available routes to the superior vena cava, the right femoral vein was cannulated percutaneously when the fifth subclavian catheter became dislodged during an episode
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TABLE
I
Guidelines for Preventing Complications Associated with Central Venous Cannulation
1. Avoid venous 2. 3. 4.
5. 6.
7.
8.
9.
10.
11.
12. 13. -
cannulation in the leg in all patients except infants. Carry out surgical skin preparation for all cannulations, whether percutaneous or by direct cutdown. Assure proper adapter-catheter fit prior to percutaneous venous puncture. (Never use needle for adapter.) Place the patient’s head down when inserting subclavian or jugular catheters to avoid air embolism. When attempted subclavian puncture is unsuccessful, obtain roentgenogram of the chest before attempting puncture on the contralateral side. Utilize specific length of radiopaque tubing; do not bevel catheter tips. Remeasure catheter after removal. Whenever catheter does not advance through needle with ease, remove needle and tubing. Do nut attempt to withdraw catheter through needle. Allow at least 3 inches of catheter length exterior to the skin surface, and assure respiratory excursion of fluid column before anchoring catheter. Obtain chest roentgenogram routinely after catheter insertion to assure supracardiac location of catheter tip and absence of pneumothorax. Use broad spectrum antibiotic at catheter-skin juncture. Redress and culture catheter site every third day. Whenever open wound (such as tracheostomy) is in or near the vicinity of the catheter, apply waterproof tape to assure occlusive sterile dressing. Remove catheter at first suggestion of local inflammation, whenever any unexplained temperature spike occurs, when unable to withdraw blood (suggesting thrombus at catheter tip), and at the earliest date that catheter does not contribute to patient’s care. Measure length of extracted catheter and submit distal tip for culture. Expend every effort to locate and retrieve lost catheters.
of postshunt variceal hemorrhage. In spite of persisting hypotension, tachycardia, and oliguria, inferior vena cava venous pressure levels were repeatedly greater than 20 cm H,O. After reinsertion of a subclavian catheter revealed venous pressures that were consistently below 3 cm HzO, we realized that hepatomegaly, ascites, and shunting of an elevated portal pressure into the inferior vena cava had all combined to produce a grossly elevated inferior vena caval pressure in spite of hypovolemia and diminished return to the right heart. In most instances in which patients are sufficiently ill to require monitoring, the superior vena cava probably provides a more accurate reflection of venous pressures. As evidenced by the recent report of Wilmore and Dudrick [IO] and personal experience since critically reviewing complications in our series, it can be seen that long-term central venous cannulation can be accomplished with minimal sequelae when careful and persistent attention is directed to certain details of catheter placement and
604
maintenance. In Table I we have listed guidelines which will prevent occurrence of the most dangerous complications associated with use of indwelling caval catheters, and minimize the frequency with which the others will occur. Central venous cannulation is a proved clinical adjunct in the management of critically ill patients. When employed with the proper care, few complications will detract from its unquestionable value. Summary
During the past few years clinical use of central venous cannulation has increased, principally because of the recognized benefits derived from monitoring central venous pressure and providing hyperosmolar parenteral alimentation. As experience has accumulated with placement and maintenance of vena caval catheters, various associated complications have become apparent. During recent months it seemed that complications were occurring at a rate out of proportion to the increased frequency with which we were employing this modality. Subsequent review of our experience with more than 350 central venous cannulations disclosed that preventiable complications can be attributed to two primary factors ; a more relaxed attitude toward critical points of catheter placement as an individual or group attains experience with this modality, and delegation of catheter care to nonsurgical personnel after a polyethylene cannula has been inserted. Prolonged central venous eannulation can be accomplished with minimal sequelae, if careful and persistent attention is directed toward certain details of catheter placement and maintenance. Herein we have outlined and emphasized precautions which will preclude occurrence of the most dangerous complications, and minimize the frequency with which the others occur. When employed with proper care, few untoward sequelae will detract from the over-all value of central venous cannulation, a proven clinical adjunct in the management of critically ill patients. Addendum
The prophylactic recommendations outlined in Table I were formulated from experience accumulated through July 1969. Despite the use of these guidelines, during the past twenty months, we have documented eight instances in which the tips of indwelling venous catheters have grown out organisms identical to those cultured from the patients’ blood during septic episodes which
The Amerlcan
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occurred while the catheter was in place. In five of these eight patients, the catheter had been placed during or prior to early sepsis, and unexpected secondary septicemia occurred from eight to fifteen days after the initial infectious process had been treated successfully. Two of the secondary septic episodes closely followed removal of venous catheters, and blood cultures obtained from these and the other three patients who experienced secondary sepsis, yielded the same organisms which were present on the respective catheter tip from these patients. In each of the five patients, the unexpected secondary septicemia introduced morbidity and mortality (two deaths) at a point in the patient’s course when the venous catheter was no longer necessary for or contributing to optimal care. Based on these observations, and realizing that catheter tip fibrin sleeves and thrombi provide lush nidi for bacterial colonization, we now try to avoid use of indwelling central venous catheters in patients who are septic or who have infectious processes in which episodic bacteremia is likely to occur. When use of indwelling central venous catheters is essential for optimal management of such patients, we urge that the catheter be changed every forty-eight to seventy-two hours and discontinued as soon as safely feasible. References 1. Meyers
L: intravenous catheterization. 45: 930, 1945. 2. Brown CA, Kent A: Perforat,ion of right
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Amer ventricle
J Nursing by poly
Central
Venous
Cannulation
ethylene catheter. Southern Med J 49: 466, 1956. 3. Johnson CE: Perforation of right atrium by a polyethylene catheter. JAMA 195: 584, 1966. 4. Friedman BA, Jurgeleit HC: Perforation of atrium by polyethylene CV ‘catheter. JAMA 203: 1141, 1968. 5. Thomas CJ Jr, Carter JW, Lowder SC: Pericardial tamponade from central venous catheters. Arch Surg 98: 217, 1%9. 6. Turner D, Sommers JD: Accidental passage of a polyethylene catheter from the cubital vein to the right atrium. New Eng J Med 251: 744, 1954. 7. Moncrief JA: Femoral catheters. Ann Surg 147: 166, 1958. . 8. Taylor RW, Rutherford CT: Accidental loss of plastic tubing in venous system. Arch Surg 86: 177, 1963. 9. Doering RB, Stemmer EA, Connolly JE: Complications of indwelling venous catheters with particular reference to catheter embolus. Amer J Surg 114: 259, 1967. 10. Wilmore DW, Dudrick SV: Safe longterm venous catheterization. Arch Surg 98: 256, 1969. 11. Duffy BJ Jr: The clinical use of polyethylene tubing for intravenous therapy. Ann Surg 130: 929, 1949. 12. Bonner CD: Experience with plastic tubing in prolonged intravenous therapy. New Eng J Med 245: 97, 1951. 13. Bansmer G, Keith D, Tesluk H: Compkcations following the use of intravenous catheters of the inferior vena cava. JAMA 167: 160, 1958. 14. Bogen JE: Local compkcations in 167 patients with indwelling venous catheters. Surg Gynec Obst 110: 112,
1960. 15. Erwin P, Strickler
JH, Rice CO: Use of polyethylene tubing in intravenous therapy for surgical patients. Arch Sorg 66: 673, 1953. 16. Phillips RW, Wand Eyre JD: Septic thrombophlebitis with septicemia. New Eng J Med 259: 729, 1958. 17. Druskin MA, Siegel PD: Bacterial ‘contamination of indwelling intravenous polyethylene catheters. JAMA 185: 966, 1963. 18. Chaney LW, Lincoln JR: Phlebitis from plastic intravenous catheters. Anesthesiology 25: 92, 1964. 19. Moran JM, Atwood RP, Rowe MI: A clinical and bacteriologic study of infections associated with venous cutdowns. New Eng J Med 272: 554,1965.
605
Recognition,
and Prevention
JOHN
H. HENZEL,
M. S. DeWEESE,
In recent months indwelling venous catheters have gained increasing popularity for purposes of prolonged central venous pressure monitoring and administration of hyperosmolar parenteral alimentation. As experience has accumulated with this modality, various complications associated with its utilization have become apparent. In our own experience with some 350 central venous cannulations over the last four years, we observed more complications during the last twelve months than were encountered during our first three years of vena cava catheter placement. The purpose of this communication, which includes five cases of serious but preventable catheter complications, is to relate factors apparently responsible for the increased number of complications, and to outline and emphasize precautions which should minimize untoward sequelae associated with utilization of indwelling large vein catheters. Case
Reports
CASE I. The patient (CB), a twenty-one year old woman, had a diverting colostomy performed for large bowel necrosis and pericolonic abscess which occurred in association with agranulocytosis. During a postoperative period complicated by wound dehiscence, fecal fistula, and sepsis, a number 240 polyethylene catheter was inserted by external jugular cutdown into what was believed to be superior vena cava, in order to monitor central venous pressure. Forty-eight hours later, unexpected cardiac decompensation and arrest occurred which were resistant to all attempts at resuscitation. During postmortem examination, transmyocardial penetration of the right ventricle was discovered. Approximately 1 inch of the catheter was lying free in a pericardial sac which was taut with some 300 ml of clear fluid.
From the Department of Surgery, University of Missouri Medical Center, Columbia, Missouri.
600
MD, Columbia, Missouri MD, Columbia, Missouri
CASE II. The patient (DS), a fifty-three year old woman, was referred to the University of Missouri Medical Center with renal shutdown seven days after uncomplicated cholecystectomy and common bile duct exploration had been performed. Initial evaluation disclosed a jaundiced, obtunded patient who had a freely draining T tube, and who was anuric with an elevated blood urea nitrogen level and decreased serum sodium. The surgeons were consulted to place a catheter for monitoring central venous pressure, and a number 190 polyethylene catheter was threaded into the superior vena cava via infraclavicular right subclavian puncture, and anchored to the skin with two separate number 3-O silk sutures. Approximately three hours later, the surgical resident was notified that the catheter had “withdrawn beneath the skin surface.” Chest roentgenogram disclosed that the distal end of the radiopaque tubing was in the supracardiac superior vena cava, but technic and superimposition of structures precluded localizing the proximal end of the catheter. While the patient was being returned to the Radiology Department for additional films, cardiopulmonary arrest occurred and although initial resuscitation was successful, she died some nine hours later. Although the follow-up x-ray studies again disclosed that the distal tip of the catheter was in the superior vena cava, the polyethylene tube was found coiled within the right ventricle at autopsy. Since chest films were not obtained after resuscitative efforts, we do not know whether the catheter worked its own way into the heart (case III), or was iatrogenically advanced into the right ventricle during external cardiac message.
CASE III. WT, a twenty-eight year old man, had a SVC catheter inserted via external jugular vein cutdown at the time of celiotomy for multiple gunshot wounds. During the early postoperative period leakage occurred at the adaptor-polyethylene junction, and a 1’7 gauge needle was substituted for the routinely used blunt cannula. Approximately thirty-six hours later, when massive leakage of intravenous fluid recurred, it was discovered that the needle point had completely transected the catheter, and that the distal end had
The American
Journal
of Surgery
Prolonged
withdrawn beneath the skin surface. Chest roentgenogram revealed that the entire length of catheter was coiled within the right ventricle. Shortly thereafter irreversible cardiac arrest occurred in association with septicemia, and postmortem examination confirmed the roentgenographic interpretation. CASE IV. The patient (JR), a twenty-eight year old truck driver, arrived at UMMC after a collision in which his vehicle burst into flames. Because of the extent and location, predominantly in the upper torso, of an estimated 50 per cent deep thermal injury, a central catheter was threaded into the inferior vena cava via percutaneous puncture of the left common femoral vein. During the first seventy-two hours of fluid replacement, at least two surgeons involved in the patient’s care commented about the potential morbidity associated with femoral catheters. Nonetheless, because of the persistent difficulty in recording accurate venous pressure via a separate external jugular catheter, the left femoral site was maintained, although the area was redressed in sterile fashion every third day. On the sixth day after injury, high-output renal failure became evident, and by the ninth day the blood urea nitrogen level had reached 145 mg per cent. During preparations for dialysis, the patient had pleuritic chest pain and hemoptysis, and shortly thereafter an acute terminal episode was characterized by cyanosis, neck vein distention, hypotension, and irreversible cardiac arrest. Although permission for autopsy was denied, edema of the left leg was appreciably greater than that of the right leg. Iliofemoral thrombophlebitis, either precipitated by or related to the indwelling catheter, was considered to be the etiologic factor. CASE v. The patient (LB), a thirty-two year old man, had subclavian catheters placed without incident on five separate occasions during pre and postportacaval shunt management of bleeding esophageal varices. A sixth attempt at catheter insertion via the left subclavian route met with failure, and because numerous peripheral cutdowns had been performed prior to his transfer to the surgical service, a polyethylene catheter was threaded into the inferior vena cava through a cutdown of the proximal left greater saphenous vein. In an effort to preserve venous flow, the catheter was inserted into the greater saphenous vein through a small nick about 1 inch below the fossa ovalis, and the vein was not ligated below this level. The cutdown site had been prepared with alcohol and Betadine@, and bacitratin ointment was spread over the incision and around the catheter before a sterile dressing was taped in place. On the third and the sixth day after cutdown the dressing was removed, and the skin cleansed with alcohol and Betadine prior to new applications of bacitracin ointment and sterile redressing. When sepsis occurred on the seventh day after catheter placement, the femoral catheter was removed. Blood cultures were obtained, as were cultures of the femoral cutdown site
Volume 121. May 1971
Central
Venous
Cannulation
and the tip of the catheter. The culture of the catheter was lost, but the blood cultures revealed Streptococcus fecalis, which was the same organism from the cutdown site.
Comments In the twenty-five years since Meyers [I] first used a plastic catheter for administering intravenous fluids, the over-all merits of indwelling venous cannulation have greatly outweighed the untoward sequelae which occasionally have been associated with this clinical modality. Although a certain incidence of complications is to be anticipated during applicatkon of any contemporary therapeutic modality, the five serious complications which we encountered within the past twelve months were more than we had observed during three preceding years’ experience with vena caval catheters. In reviewing our morbidity and mortality, it became apparent that complications could be directly attributed to two primary factors : a more relaxed attitude toward critical points of catheter placement as we attained experience with this modality, and delegation of catheter care to inexperienced personnel once the polyethylene cannula has been inserted. In this communication we wish to emphasize that complications occur not only during placement but also during maintenance of indwelling central vein catheters. The most serious complication which we encountered, fatal catheter perforation of the right ventricle, was first recorded by Brown and Kent [2] in 1956. Ten years later Johnson [3] reported another instance in which an intravenous catheter penetrated the right atrium and caused the patient’s death, and in 1968 Friedman and Jurgeleit [4] reported a third fatality. Within recent months two additional cases of cardiac penetration have appeared [5], and in one of these patients irreversible cerebral damage occurred during resuscitation from associated pericardial tamponade. Although postmortem examination revealed that catheter tips had been sharpened in the first two reported cases, the fact that cardiac penetration has occurred after percutaneous subclavian puncture (in which the tubing is not beveled) confirms that blunt catheter tips can also penetrate myocardium. Avoidance of cardiac perforation and pericardial tamponade depends upon roentgenographic confirmation that the tip of a radiopaque catheter lies within the su,perior vena cava, and not the right heart. When obesity or other anatomic factors make it difficult to delineate catheter position on routine chest roentgenogram, simple dye injection
601
Henzel and DeWeese
Arrangement for anchoring and stabilizing perFigure 1. cutaneous catheters (ideally number 32-35 monofilament wire sutures). A, suture anchoring catheter at site of cutaneous puncture. f3, second anchoring suture to decrease chance of angulation-obstruction at cutaneous puncture site. C, third suture not only anchors redundant loop, but also attaches catheter to cannula.
will facilitate localization. Since catheters which are initially positioned low in the supracardiac superior vena cava occasionally advance into the right heart, our nursing staff is instructed to assure that respiratory excursion is observable in the manometric column each time that the venous pressure is recorded. The complication described in cases II and III has been well documented ‘in the literature. In 1954 Turner and Sommers [6] recorded the first clinical case of catheter embolus to the right atrium. In Moncrief’s [ 7’1 series of 135 femoral catheter placements, there were three instances of “lost tubing,” and two of these patients died as a result of fatal septic thrombophlebitis at the site where the catheter segments were found in the femoral vein. In the third patient, who was alive and well at the time of Moncrief’s report in 1958, the lost segment was never found, and there had not been any dificulty in the intervening two years since its loss. In 1963 Taylor and Rutherford [S] reported a fatal outcome in seven of nine instances of catheter embolism, and in five patients the catheter was considered instrumental in the patient’s death. In 1967 Doering, Stemmer, and Connolly [9] cited twentysix cases from the literature, and then added twenty-three additional cases of catheter embolism from various Los Angeles hospitals. Of these fortynine cases, fourteen catheter segments ended up in either the right heart or pulmonary artery. Four early deaths were directly attributable to catheter
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embolism, one fatality which ensued a year after catheter embolism was due to shock and atria1 fibrillation, and two deaths occurred because of unrelated causes. Five catheters were successfully removed, and two patients remained asymptomatic without treatment. The potential for catheter embolization can be minimized by adhering to the recently advocated principle that “all catheters should be inserted, maintained, and evaluated exclusively by [personnel experienced in catheter placement]” [IO]. Ideally, whenever leakage, cessation of flow, backbleeding, or any other problem associated with catheter function occurs, the person who placed the catheter should be contacted. Needles are no longer utilized as adapters, and their use is to be condemned since blunt adapter cannulas are now universally available. In our own experience, leakage at the adapter-catheter juncture is usually related to one of three causes. During percutaneous insertion, number 190 catheter is threaded through a 14 gauge thin-wall needle. Since the proximal end of some polyethylene tubing has been flared to permit direct attachment to intravenous tubing when the catheter is inserted by cutdown, the flared portion must be transected before the percutaneous needle can be removed over the tubing. Although usually it is not possible to withdraw the needle back over the tubing if the flare has not been transected at or below its junction with uniform-diameter catheter, this is not always the case. In such instances the appropriate adapter fits loosely into the flared segment. It is important to recognize this cause of leakage since transection of an additional few millimeters of polyethylene will permit a leakproof union. A second source of adapter-catheter leakage is infrequent, but on occasion, after threading the polyethylene into the subclavian vein, one discovers that the catheter does not fit snugly onto the appropriate adapter. This problem is avoided by assuring water-tight adapter-catheter mating prior to venous puncture. In those instances in which a catheter has been placed, and leakage occurs and persists after we have secured the catheter-adapter suture (as illustrated in Figure I), we prefer to substitute the larger PE 240 adapter, rather than place a new catheter. In attempting to position a catheter as far proximal as possible onto any adapter, but particularly with the larger PE 240 cannula, we occasionally encounter a third source of leakage, that is, iatrogenic laceration of the polyethylene. Whenever a crack occurs at the adapter juncture, an additional segment of catheter should be transected
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and the adapter cannula carefully replaced. Although an autopsy was not obtained in case IV, the symptoms preceding the terminal episode and the clinical picture of right heart strain at the time of cardiopulmonary arrest were classical for pulmonary embolism. In addition, edema of the leg was markedly greater on the side of the percutaneous femoral catheter. In all likelihood, insertion of the caval catheter through the femoral route either precipitated local thrombophlebitis at the site of vein puncture, or thrombus developed on the tip of the catheter. As early as 1949 Duffy [11] reported two instances of local phlebitis in twentyeight patients with femoral catheters. Two years later Bonner [12] emphasized the hazards of venous thrombosis in association with long-term femoral vein cannulation, after discovering clot formation about the catheter in five of forty-one patients, one of whom had a nonfatal septic pulmonary embolus. Moncrief identified eighteen instances of venous thromboses proved at autopsy among the ninety-one patients who had 135 femoral vein catheters at the Brooke Army Burn Center, and in four of these patients the thromboses were the direct cause of death [IO]. Bansmer, Keith, and Tesluk [13] recorded a 46 per cent incidence of clinical complications in twenty-four patients who had vena caval catheters. In twenty-two instances the catheters had been placed by percutaneous femoral puncture, and in the other two patients definitive saphenofemoral cutdown had been performed. Seventeen of the patients died, and autopsy revealed mural thrombus within the catheter-containing venous channel in sixteen instances. Although catheters had been in place for periods ranging from one to thirty-six days, in each of the three documented instances of pulmonary embolism, the duration was twelve days or less. Bansmer observed that clinical complications were few when catheters were removed before the seventh day. In Bogen’s [14] series of patients with saphenous vein catheters, there were three fatalities in which a clinical diagnosis of pulmonary infarction had been made shortly before death, and in two of these cases embolization was confirmed at autopsy. Accumulated experience leaves little doubt that with the possible exception of small infants, it is best to avoid placement of indwelling cannulas in veins in the lower extremity. In case v a groin cutdown site became infected and was a proved source of sepsis. Excellent retrospective and prospective studies have demonstrated the importance of managing the catheter site as ‘an open surgical wound. In 1953 Erwin,
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Strickler, and Rice [15] observed that once erythema became evident at a cutaneous puncture site, ascending inflammation would develop if the catheter was allowed to remain in place for another twenty-four hours. In 1958, Phillips and Wand Eyre [16] reported three instances of staphylococcal septicemia which occurred after catheters had been in place for four, five, and seven days, respectively. In each instance the offending organism was cultured from the site of percutaneous puncture. In 1963 Druskin and Siegel [.Z71 removed intravenous catheters in sterile fashion and cultured the distal tips. None of the catheters remaining in place for less than forty-eight hours demonstrated growth, although the incidence of positive cultures after forty-eight hours was 52 per cent. In 1964 Chaney and Lincoln [18] who reported an incidence of culture-positive catheter tips approximating 10 per cent, cleansed catheter puncture sites with Zephiran@ and tested the efficacy of 3 per cent Achromycin@ ointment in lowering the incidence of local reactions. Single applications of the antibiotic failed to reduce either the incidence of phlebitis or the incidence of positive cultures. More recently Moran, Atwood, and Rowe [I91 carried out a prospective double-blind study in which they evaluated the efficacy of repeated applications of broad spectrum antibiotic ointment in decreasing wound infection and catheter sepsis. The number of positive cultures was nearly four times as great in wounds which were not treated with the ointment, and although phlebitis developed in 53 per cent of placebo-treated patients, only 37 per cent of those treated with the antibiotic ointment developed this complication. Two of five patients in whom septicemia developed were in the antibiotic-treated group, whereas the other three had been treated with the placebo. During the past nine months we have employed only broad spectrum antibiotic (Mycitracina, Upjohn) at the catheter skin juncture, after alcoholBetadine cleansing of catheter sites every three days. Since initiating this regimen, we have had no further instances of catheter sepsis, and none of thirteen catheter tips submitted for culture by one of us (JHH) has demonstrated bacterial growth. Case v also exemplifies a good reason for preferring superior vena caval cannulation over the inferior cava in most instances. Since numerous cutdowns and five percutaneous subclavian catheters had exhausted all readily available routes to the superior vena cava, the right femoral vein was cannulated percutaneously when the fifth subclavian catheter became dislodged during an episode
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TABLE
I
Guidelines for Preventing Complications Associated with Central Venous Cannulation
1. Avoid venous 2. 3. 4.
5. 6.
7.
8.
9.
10.
11.
12. 13. -
cannulation in the leg in all patients except infants. Carry out surgical skin preparation for all cannulations, whether percutaneous or by direct cutdown. Assure proper adapter-catheter fit prior to percutaneous venous puncture. (Never use needle for adapter.) Place the patient’s head down when inserting subclavian or jugular catheters to avoid air embolism. When attempted subclavian puncture is unsuccessful, obtain roentgenogram of the chest before attempting puncture on the contralateral side. Utilize specific length of radiopaque tubing; do not bevel catheter tips. Remeasure catheter after removal. Whenever catheter does not advance through needle with ease, remove needle and tubing. Do nut attempt to withdraw catheter through needle. Allow at least 3 inches of catheter length exterior to the skin surface, and assure respiratory excursion of fluid column before anchoring catheter. Obtain chest roentgenogram routinely after catheter insertion to assure supracardiac location of catheter tip and absence of pneumothorax. Use broad spectrum antibiotic at catheter-skin juncture. Redress and culture catheter site every third day. Whenever open wound (such as tracheostomy) is in or near the vicinity of the catheter, apply waterproof tape to assure occlusive sterile dressing. Remove catheter at first suggestion of local inflammation, whenever any unexplained temperature spike occurs, when unable to withdraw blood (suggesting thrombus at catheter tip), and at the earliest date that catheter does not contribute to patient’s care. Measure length of extracted catheter and submit distal tip for culture. Expend every effort to locate and retrieve lost catheters.
of postshunt variceal hemorrhage. In spite of persisting hypotension, tachycardia, and oliguria, inferior vena cava venous pressure levels were repeatedly greater than 20 cm H,O. After reinsertion of a subclavian catheter revealed venous pressures that were consistently below 3 cm HzO, we realized that hepatomegaly, ascites, and shunting of an elevated portal pressure into the inferior vena cava had all combined to produce a grossly elevated inferior vena caval pressure in spite of hypovolemia and diminished return to the right heart. In most instances in which patients are sufficiently ill to require monitoring, the superior vena cava probably provides a more accurate reflection of venous pressures. As evidenced by the recent report of Wilmore and Dudrick [IO] and personal experience since critically reviewing complications in our series, it can be seen that long-term central venous cannulation can be accomplished with minimal sequelae when careful and persistent attention is directed to certain details of catheter placement and
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maintenance. In Table I we have listed guidelines which will prevent occurrence of the most dangerous complications associated with use of indwelling caval catheters, and minimize the frequency with which the others will occur. Central venous cannulation is a proved clinical adjunct in the management of critically ill patients. When employed with the proper care, few complications will detract from its unquestionable value. Summary
During the past few years clinical use of central venous cannulation has increased, principally because of the recognized benefits derived from monitoring central venous pressure and providing hyperosmolar parenteral alimentation. As experience has accumulated with placement and maintenance of vena caval catheters, various associated complications have become apparent. During recent months it seemed that complications were occurring at a rate out of proportion to the increased frequency with which we were employing this modality. Subsequent review of our experience with more than 350 central venous cannulations disclosed that preventiable complications can be attributed to two primary factors ; a more relaxed attitude toward critical points of catheter placement as an individual or group attains experience with this modality, and delegation of catheter care to nonsurgical personnel after a polyethylene cannula has been inserted. Prolonged central venous eannulation can be accomplished with minimal sequelae, if careful and persistent attention is directed toward certain details of catheter placement and maintenance. Herein we have outlined and emphasized precautions which will preclude occurrence of the most dangerous complications, and minimize the frequency with which the others occur. When employed with proper care, few untoward sequelae will detract from the over-all value of central venous cannulation, a proven clinical adjunct in the management of critically ill patients. Addendum
The prophylactic recommendations outlined in Table I were formulated from experience accumulated through July 1969. Despite the use of these guidelines, during the past twenty months, we have documented eight instances in which the tips of indwelling venous catheters have grown out organisms identical to those cultured from the patients’ blood during septic episodes which
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occurred while the catheter was in place. In five of these eight patients, the catheter had been placed during or prior to early sepsis, and unexpected secondary septicemia occurred from eight to fifteen days after the initial infectious process had been treated successfully. Two of the secondary septic episodes closely followed removal of venous catheters, and blood cultures obtained from these and the other three patients who experienced secondary sepsis, yielded the same organisms which were present on the respective catheter tip from these patients. In each of the five patients, the unexpected secondary septicemia introduced morbidity and mortality (two deaths) at a point in the patient’s course when the venous catheter was no longer necessary for or contributing to optimal care. Based on these observations, and realizing that catheter tip fibrin sleeves and thrombi provide lush nidi for bacterial colonization, we now try to avoid use of indwelling central venous catheters in patients who are septic or who have infectious processes in which episodic bacteremia is likely to occur. When use of indwelling central venous catheters is essential for optimal management of such patients, we urge that the catheter be changed every forty-eight to seventy-two hours and discontinued as soon as safely feasible. References 1. Meyers
L: intravenous catheterization. 45: 930, 1945. 2. Brown CA, Kent A: Perforat,ion of right
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Amer ventricle
J Nursing by poly
Central
Venous
Cannulation
ethylene catheter. Southern Med J 49: 466, 1956. 3. Johnson CE: Perforation of right atrium by a polyethylene catheter. JAMA 195: 584, 1966. 4. Friedman BA, Jurgeleit HC: Perforation of atrium by polyethylene CV ‘catheter. JAMA 203: 1141, 1968. 5. Thomas CJ Jr, Carter JW, Lowder SC: Pericardial tamponade from central venous catheters. Arch Surg 98: 217, 1%9. 6. Turner D, Sommers JD: Accidental passage of a polyethylene catheter from the cubital vein to the right atrium. New Eng J Med 251: 744, 1954. 7. Moncrief JA: Femoral catheters. Ann Surg 147: 166, 1958. . 8. Taylor RW, Rutherford CT: Accidental loss of plastic tubing in venous system. Arch Surg 86: 177, 1963. 9. Doering RB, Stemmer EA, Connolly JE: Complications of indwelling venous catheters with particular reference to catheter embolus. Amer J Surg 114: 259, 1967. 10. Wilmore DW, Dudrick SV: Safe longterm venous catheterization. Arch Surg 98: 256, 1969. 11. Duffy BJ Jr: The clinical use of polyethylene tubing for intravenous therapy. Ann Surg 130: 929, 1949. 12. Bonner CD: Experience with plastic tubing in prolonged intravenous therapy. New Eng J Med 245: 97, 1951. 13. Bansmer G, Keith D, Tesluk H: Compkcations following the use of intravenous catheters of the inferior vena cava. JAMA 167: 160, 1958. 14. Bogen JE: Local compkcations in 167 patients with indwelling venous catheters. Surg Gynec Obst 110: 112,
1960. 15. Erwin P, Strickler
JH, Rice CO: Use of polyethylene tubing in intravenous therapy for surgical patients. Arch Sorg 66: 673, 1953. 16. Phillips RW, Wand Eyre JD: Septic thrombophlebitis with septicemia. New Eng J Med 259: 729, 1958. 17. Druskin MA, Siegel PD: Bacterial ‘contamination of indwelling intravenous polyethylene catheters. JAMA 185: 966, 1963. 18. Chaney LW, Lincoln JR: Phlebitis from plastic intravenous catheters. Anesthesiology 25: 92, 1964. 19. Moran JM, Atwood RP, Rowe MI: A clinical and bacteriologic study of infections associated with venous cutdowns. New Eng J Med 272: 554,1965.
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