| Abstract|| |
Background: Malpositions after central venous cannulation are frequently encountered and may need a change in catheter. The incidence of malpositions are varied according to various studies and depend on the experience of the operator performing the cannulation. Aim: To access the incidence of malpositions and related complications associated with landmark-guided central venous cannulation in a 15-bedded medical surgical ICU over a period of three years. Settings and Design: Retrospective analysis of records of all the central venous cannulation done in a 15- bedded medical- surgical ICU over the period of three years (April 2008 to June 2011) were evaluated for the site and side of insertion, number of attempts of puncture, arterial puncture as well as the malpositions on post procedural chest X-ray. The records were also evaluated for the experience of the operator performing cannulation and relationship between experience of operator to malpositions of catheter. Statistical Analysis: Analysis was done using SPSS v 17.0 for Windows. Chi-square test was applied to evaluate the statistical significance. P > 0.05 was significant. Results: Records of 696 cannulations were evaluated. Malpositions occurred in 40 patients. Subclavian vein cannulation resulted in increased malpositions in relation to internal jugular vein cannulation. More common with left sided cannulation. Experience of operator had positive correlation with malpositions and arterial puncture. Arterial puncture was common in 6%, while more than one attempt for cannulation was taken in 100 patients. Conclusion: Incidence of malpositions was low. We conclude that experience of operator improves successful catheterization with lesser number of complications.
Keywords: Arterial puncture, central venous access, central venous catheter, complications-malpositions
|How to cite this article:|
Agrawal S, Payal YS, Sharma JP. A retrospective clinical audit of 696 central venous catheterizations at a tertiary care teaching hospital in India. J Emerg Trauma Shock 2012;5:304-8
|How to cite this URL:|
Agrawal S, Payal YS, Sharma JP. A retrospective clinical audit of 696 central venous catheterizations at a tertiary care teaching hospital in India. J Emerg Trauma Shock [serial online] 2012 [cited 2020 Jan 26];5:304-8. Available from: http://www.onlinejets.org/text.asp?2012/5/4/304/102369
| Introduction|| |
Central venous catheters (CVC) are commonly used for a number of indications in the pre-operative period as well as in the intensive care. A number of methods are utilized for insertion of CVC commonly being use of surface anatomical landmarks (landmark technique) or direct surgical access to a peripheral vein (cut open technique). Use of ultrasound technology for CVC insertions gained popularity as it provided visualization of desired vein and surrounding structures as well as the relation of tip of needle to these structures. Two techniques utilizing ultrasound are used - 2 D imaging technique and audio-guided doppler ultrasound.  Though a common procedure a number of complications are reported with their usage namely vascular perforation,  risk of thrombosis,  catheter dysfunction, and malpositions of catheter tip.  Studies have reported an incidence of 3.6-14% of catheter malpositions  and its presence is associated with a number of mechanical , complications. Use of post procedural X-rays was a standard practice for diagnosing catheter malpositions but with the advent of bedside ultrasound or TEE questions are being raised as to the utility of chest X-ray for diagnosing catheter malpositions. [8-10] Other modalities utilized for confirmation of catheter tip includes electrocardiography, manometry, pressure waveform analysis, and fluoroscopy. 
We planned this study to evaluate the incidence of malpositions of CVC, its relation to the site and side of insertion, and to assess the rate of complications with the use of such misplaced catheters in our intensive care.
| Materials and Methods|| |
After taking clearance from the Institutional Ethical Committee, the records of all the patients admitted in the 15-bedded medical surgical ICU during the period between April 2008 - June 2010 of our institute were studied for the incidence of CVC cannulation, type of catheter (triple lumen or single lumen IJV/subclavian catheter, peripherally introduced central catheter (PICC), site of insertion, number of attempts during insertion, and complications such as arterial puncture or malpositions of catheter. Post procedural chest X-rays were collected and evaluated by SA our principal investigator for the position of the catheter tip. The catheters were considered to lie at an abnormal position if the tips were not present at the junction of superior vena cava and right atrium. The level of carina was taken as point corresponding to the junction. The patients file were also evaluated for data regarding the experience of the person performing the cannulation, number of attempts for pilot puncture, incidence of carotid puncture, any problem in threading the catheter over the guide wire.
The catheter tip were found to lie at the following sites on the post procedural X-rays:
- Junction of superior vena cava (SVC) and right atrium
- Branchiocephalic veins (right/left)
- Subclavian vein (right/left)
- Internal jugular vein (right/left)
- Any other position
The data were collected and analyzed as to the number of misplacements to the site of insertion. Statistical significance was evaluated utilizing Chi-square test. Yate's correction was applied where necessary. Statistical analysis was performed using SPSS version 17 for Windows.
| Results|| |
A total of 730 CVC were inserted during the study period however the records of 34 insertions were incomplete in terms of inadequate data about the site and complications during insertions and were excluded from the study. Data of 696 catheterisations were evaluated.
Of the 696 catheters inserted, 467 (67%) were in males. Type of catheters inserted included triple lumen (Certofix Trio, B Braun, Melsungen AG, Germany) for IJV and subclavian approach while 45 cm peripheral lines (Cavafix, B Braun, Melsungen AG, Germany) for basilic and femoral catheterizations.
Internal jugular vein (IJV) cannulations were more frequent (452/696) followed by subclavian vein cannulation. Majority of cannulations were done on right side. A total of 40 catheter tip malpositions were seen with the incidence being 5.75% [Table 1].
|Table 1: Total Number of cannulation according to site with malpositions|
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Relationship between site of insertion and catheter tip malpositions is shown in [Table 2].
Of the cannulations performed majority were done by residents of anesthesia managing the intensive care with more than one year experience in the specialty and more than 10 cannulation experience under supervision (90%), while 10% cannulations were performed by specialists with more than 5 years experience in the specialty. Similarly the misplacements were more common in those cannulation done by residents (75%) (P = 0.003, odds ratio 3.37, CI 1.46-7.63).
On comparing right sided cannulation were associated with lesser number of misplacement (5.15%) compared to left (17.64%) (P = 0.008, odds ratio 0.24, CI 0.09-0.71). The incidence of malposition was twice as common after subclavian vein cannulation than internal jugular cannulation 7.74% and 3.69%, respectively (P = 0.04, odds ratio 0.46, CI 0.2-1.05) and two and half times more common by using right subclavian compared to right internal jugular 7.4% vs 2.9%, respectively (P = 0.03, odds ratio 2.57, CI 1.05-6.28). Use of right basilic vein for PICC catheterization resulted in 17.24% misplacement compared to 9% with the use of left basilic vein cannulation (P = 0.29, odds ratio 2.08, CI 0.37-15.17).
Complications such as arterial puncture were found to be in 6%, while more than one attempt for cannulation was seen in 100 patients. Two patients developed pneumothorax, while 10 patients needed recannulation due to arterial cannulation. These 12 cannulations were removed; rest could be utilized for drug / fluid administration as back flow in the lumen were present. The catheters were used for the median duration of 7±4 days. A common cause of removal of catheters was inability to aspirate from the lumen. No vascular perforation from the catheter was noted during the period.
| Discussion|| |
The common complications in closed malpractice claims against anesthesiologists related to central catheters are wire/catheter embolus, cardiac tamponade, carotid artery puncture/ cannulation, hemothorax, and pneumothorax.  Our study illustrates that the overall incidence of catheter malpositions is low, incidence being 5.75% only. The incidence as reported in literature ranges from 3.4% to 14%.
In our study, the major causes associated with malpositions were - experience of the operator, left sided cannulation, subclavian route for cannulation, more than two attempts for cannulation, direction of J tip of the guidewire. In a review about the complications of the central venous catheterization, Kusminsky  have cited following reasons for increase incidence of the mechanical complications namely inexperience of operator,  number of needle passes, BMI greater than 30 or less than 20, large catheter size, previous catheterization, previous surgery, or radiotherapy in anatomical area of insertion and the length of the catheter used. Other factors as quoted by different authors ,,,, relates to the J tip of guide wire, position of head or shoulder during the procedure. All these physical factors have a bearing to the final position taken by catheter as well as the complication associated. ,, Presence of anatomical variation or venous collaterals also provides an alternate low resistance route for the entering catheter tip resulting in malpositions. 
On comparing internal jugular and the subclavian venous cannulation our results were similar to the study of Sibyllee  et al.; however, the incidence of malpositions in our series were lower (3.69% vs 5.3% for internal jugular and 7.74% vs 9.3% for subclavian catheterization). Trerotola et al.  has demonstrated that 10% of all insertions of PICC through basilic vein are associated with malpositions into various locations.
We found that of the 11 left sided IJV and SCV cannulations malpositions was seen in 4 cases (27.27%). We hypothesized that increased incidence of malpositions in our series may have been due to the fact that all our operators were right handed. The space available for cannulation as well as the alignment of needle and J tip of guidewire is easier from right side. When the same was tried from left side angulation of the needle was more and this may have lead to the disparity between the bevel of the needle and the J tip of the guidewire.
Choosing the site of insertion of CVC has a bearing to the number of complications. Though the IJV route is associated with lesser number of complications we used subclavian route in those conditions where presence of or anticipation of early tracheostomy or any other condition preventing the use of IJV as primary site. Another factor influencing malpositions is presence of multiple lines in a single vein. Its use is associated with increased incidence of arrhythmia and malpositions.  In our series, only one single CVC was inserted at a time.
Use of ultrasound  has been recommended for placement of CVC both in the elective and emergency situations. Its use is associated with decrease in the rate of failure and complications and thereby increasing the safety of the patient. A few patients profile have been found to favour ultrasound-guided cannulation to landmark associated catheterization. These include obese patient, swollen neck or upper extremity swelling obscuring anatomical landmarks, patients with coagulopathy, history of surgical or radiotherapy intervention at the site of insertion and especially in children. Use of ultrasonography is increasing for insertion of CVC; few authors , have observed that overall success rate is not influenced by the use of ultrasonography. Ball et al. in their multicentric study concluded that it did not increase the overall success in the first attempt it did decrease the number of punctures per attempt. Limiting factors for the use of ultra-sonography maybe many viz., nonavailibility of machine; insufficient time for set up/use of machine; inadequate training for use of ultrasonography; and lastly, preference of landmark technique for catheterization.
Utility of post procedural chest X-ray lies for assessment of position of catheter tip as well as knowing about complications. Radiologically the carina has been found to correlate to adequate depth.  These landmarks are important as placement into the atrium or higher up in SVC are both associated with complications. Major disadvantage of their use is it is a time consuming procedure, involves exposure to radiation, and high cost. , Use of bedside ultrasound has significantly reduced the time of getting the post procedural scan as well as detection of the complications. ,
We employed the use of post procedure X-ray in our institute as a means to ascertain the catheter position as has been the norm though there is a disadvantage that the procedure is time consuming and is not cost effective.
A few considerations should be borne in mind before embarking upon the procedure. Factors such as experience of operator, site of CVP insertion, type and length of the catheter, orientation of the head during internal jugular cannulation while shoulder position during subclavian cannulation, position of J tip during insertion, number of attempts during needle puncture all have a bearing on mechanical complications of catheterization. Incidence of pneumothorax is directly related to increase in number of attempts and insertion of large bore cannula especially dialysis catheters. The angle of incidence of the catheter tip to the wall of vena cava plays an important role in vessel perforation. Correct position of the catheter should be parallel to the wall of the superior vena cava as well as the junction of superior vena cava and right atrium judged to be at-least 2.9 cm above the pericardial reflection and at the junction of right tracheobronchial angle on X-ray. Another important aspect to be kept in mind is that guidewire and catheters should not be pulled out of the needle as chances of shearing are high.
Few limitations of our study are it being a single institute study and our results may not be generalized. We are also not sure as to the number of underreporting of the complications as well as the missed malpositions.
| Conclusion|| |
Although the incidence of malpositions of CVC insertions is low in our cohort, left internal jugular lines, subclavian lines and operator experience are significantly associated with catheter malpositions. A further study is required to reassess if routine use of ultrasound guidance decreases the incidence of malpositions in our setup, as well as to ascertain our hypothesis of handedness of operator to the incidence of malpositions.
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Department of Anaesthesiology Intensive Care and Pain Management, Himalayan Institute of Medical Sciences, HIHT University, Dehradun
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2]