Article Text
PDF
Statistics from Altmetric.com
Commentary on: Teja B, Bosch NA, Diep C, Pereira TV, Mauricio P, Sklar MC, Sankar A, Wijeysundera HC, Saskin R, Walkey A, Wijeysundera DN, Wunsch H. Complication Rates of Central Venous Catheters: A Systematic Review and Meta-Analysis. JAMA Intern Med 2024;184:474-82.
Implications for practice and research
The use of central venous catheter is associated with serious complications in 3% of cases.
The use of ultrasonography guidance could reduce those risks.
Context
Central venous catheters (CVCs) are widely used for the administration of medications, fluids and parenteral nutrition. It has been estimated that annually 5 million CVCs are inserted in the USA and 27 million worldwide. However, the use of CVC is associated with several risks. This systematic review and meta-analysis by Teja et al provides important findings about some CVC complications globally and at the venous site.1
Methods
The purpose of this systematic review and meta-analysis by Teja et al was to determine the rates of complications from CVC use.1 English-language observational studies and randomised clinical trials of adult patients that reported complication rates of short-term centrally inserted CVCs published between July 2015 and September 2023 are included. Studies that evaluated long-term intravascular devices, dialysis catheters or catheters placed by radiologists were excluded. A total of 15 CVC complications were analysed. Ten complications were related to CVC placement: placement failure, arterial puncture, arterial cannulation, pneumothorax, bleeding events requiring action, nerve injury, arteriovenous fistula, cardiac tamponade, arrhythmia and delay in vasopressor administration. Five complications were related to CVC use: malfunctions, catheter-line-associated bloodstream infection (CLABSI), deep vein thrombosis, thrombophlebitis and venous stenosis.
Findings
In all 130 studies were included. The data on eight CVC-associated complications were insufficient to carry out a meta-analysis on bleeding events requiring action, nerve injury, arteriovenous fistula, cardiac tamponade, arrhythmia, delay in vasopressor administration, thrombophlebitis and venous stenosis.
There data on seven complications were sufficient to carry out a meta-analysis on placement failure, arterial cannulation, arterial puncture, pneumothorax, catheter, CLABSI and deep vein thrombosis. The use of CVC is associated with serious complications (arterial cannulation, pneumothorax, catheter, CLABSI or deep vein thrombosis) in 3% of cases.
Placement failure occurred in 20.4‰ of cases, arterial cannulation in 2.8‰, arterial puncture in 16.2‰ and pneumothorax in 4.4‰ of 1000 CVC placed. Catheter malfunction occurred in 5.5‰ of cases, CLABSI in 4.8‰ of cases and deep vein thrombosis in 2.7‰ of cases per 1000 catheter-days. Use of ultrasonography was associated with lower rates of arterial puncture, pneumothorax and placement failure; over all in jugular site.
In addition, data on four CVC-associated complications were sufficient to describe the venous access procedure. CVC placement failure per 1000 catheters occurred in 11.9‰ of internal jugular access, in 27.7‰ of femoral access and in 35.9‰ of subclavian access. Arterial puncture due to CVC per 1000 catheters occurred in 13.3‰ of internal jugular access, in 12.4‰ of femoral access and in 12.8‰ of subclavian access. Pneumothorax due to CVC per 1000 catheters occurred in 1.9‰ of internal jugular access, and in 7.8‰ of subclavian access. CLABSI due to CVC per 1000 catheter-days occurred in 3.8‰ of internal jugular access, in 2.7‰ of femoral access and in 2.5‰ of subclavian access.
Commentary
This study analysed the incidence of some CVC complications globally and at the catheter site and described very interesting findings that could help decide on the site of CVC. Due to the use of CVC being associated with serious complications, it is necessary to obtain informed consent and to be vigilant with the possible development of complications. Besides, the use of ultrasonography guidance is recommended to reduce those risks. The authors have described very well the limitations of the research. However, there are some important aspects that were not described.
Another risk factor for CLABSI is the type of access of the internal jugular vein canalisation. Our study, that included 684 jugular venous catheters (169 by posterior and 515 by central access), found a higher CLABSI risk in central access than in posterior access of the internal jugular vein.2 Critically ill patients undergoing mechanical ventilation are placed in a semireclined position to decrease the risk of ventilator-associated pneumonia. Thus, in that position the oropharyngeal secretions due to gravity could easily reach the internal jugular vein by central than by posterior access.
Another risk factor for CLABSI is the existence of tracheostomy. Tracheostomy has been found to be a risk factor for CLABSI in a study published by Garnacho-Montero et al that included 1211 subclavian or jugular venous catheters,3 and in one study by our team that included 1392 subclavian or jugular venous catheters.4
Another important complication is the accidental removal of the catheter that could lead to problems caused by the removal itself (such as haemorrhage and vascular damage) and by catheter reinsertion. We found in one study, that included CVC (698 jugular, 432 subclavian and 147 femoral), that the incidence of accidental removal of the catheter was 0.26% in jugular venous access, 0.18% in subclavian access and 0.16% in femoral access per 100 catheter-days.5
Footnotes
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.