Complications of Central Venous Catheters and Their Prevention

9/4/2018 Complications of central venous catheters and their prevention - UpToDate
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Complications of central venous catheters and their prevention
Author: Michael P Young, MD

Section Editors: David L Cull, MD, Scott Manaker, MD, PhD
Deputy Editor: Kathryn A Collins, MD, PhD, FACS
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Mar 2018. | This topic last updated: Jan 23, 2018.
INTRODUCTION — Insertion of a central venous catheter in a human was first reported by Werner Forssman, a
surgical intern, who described canalizing his own right atrium via the cephalic vein in 1929. A technique that
facilitates catheter placement into lumens and body cavities was subsequently introduced by Sven-Ivar Seldinger
in 1953 [1]. Insertion of a central venous catheter using the Seldinger technique has revolutionized medicine by
allowing the central venous system to be accessed safely and easily [2].
Central venous catheters are now common among critically ill patients. In the United States, over 15 million
catheter-days/year are recorded in the intensive care unit alone [3]. Multilumen central venous catheters have
become ubiquitous in the intensive care unit. New catheter designs, standardization of insertion techniques, use
of ultrasound guidance, and subsequent central line management have reduced complication rates.
Mechanical complications associated with central venous catheter placement and removal and strategies to
prevent these complications are discussed here. The placement of central venous catheters and infectious and
thrombotic complications are discussed separately. (See "Overview of central venous access", section on
'Indications' and "Diagnosis of intravascular catheter-related infections" and "Catheter-related upper extremity
venous thrombosis" and "Epidemiology, pathogenesis, and microbiology of intravascular catheter infections".)
COMPLICATIONS — Numerous complications are associated with central venous catheter placement. The most
common are listed in the table (table 1).
Published rates of cannulation success and complications vary according to the anatomic site, the use of
ultrasound guidance, and operator experience. As an example, one review described an overall complication
rate of 15 percent [4], while an observational cohort study of 385 consecutive central venous catheter attempts
over a six-month period found that mechanical complications occurred in 33 percent of attempts [5].
Complications included failure to place the catheter (22 percent), arterial puncture (5 percent), catheter
malposition (4 percent), pneumothorax (1 percent), subcutaneous hematoma (1 percent), hemothorax (less than
1 percent), and asystolic cardiac arrest (less than 1 percent). In the past decade, the mechanical complication
rate and failure rate have significantly decreased with the use of ultrasound-guided cannulation, especially for
catheter insertion using the internal jugular site. The advantage of using ultrasound guidance is less well
established when using the femoral or subclavian vein approach [6]. (See "Principles of ultrasound-guided
venous access".)
Most mechanical complications (eg, pneumothorax) are detected at the time of catheter insertion. Mechanical
complications at the time of catheter insertion are more common after attempted insertion in the subclavian vein
compared with the internal jugular approach and least common for the femoral vein [5,7]. Despite this,
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subclavian insertion may be preferred in experienced hands since the rate of mechanical complications is largely
operator dependent [4], and the subclavian approach is associated with fewer bloodstream infections and
symptomatic thrombosis [7]. Infectious and thrombotic complications usually occur later than mechanical
complications. (See "Overview of central venous access", section on 'Site selection'.)
Catheter-related infection — Infection is a common complication of indwelling central venous catheters. The
diagnosis, microbiology, and treatment of catheter-related infection is discussed in detail elsewhere. (See
"Epidemiology, pathogenesis, and microbiology of intravascular catheter infections" and "Diagnosis of
intravascular catheter-related infections" and "Treatment of intravascular catheter-related infections".)
Catheter-induced thrombosis — Thrombosis is another common complication of indwelling central venous

catheters. The diagnosis and treatment of upper extremity catheter-related thrombosis and, for patients with
femoral catheters, lower extremity deep vein thrombosis are discussed elsewhere. (See "Catheter-related upper
extremity venous thrombosis" and "Clinical presentation and diagnosis of the nonpregnant adult with suspected
deep vein thrombosis of the lower extremity" and "Overview of the treatment of lower extremity deep vein
thrombosis (DVT)".)
Catheter-related vein stenosis — Significant rates of central vein stenosis are associated with the use of
peripherally inserted central catheter (PICC) lines and central lines placed in both the internal jugular and
subclavian veins. The true incidence of subclavian vein stenosis remains unclear, but a 50 percent vein stenosis
rate has been cited for subclavian vein dialysis catheters. The risk for central vein stenosis appears increased
with placement in the left internal jugular or subclavian vein versus the right internal jugular or femoral vein,
longer catheter dwell time, and the use of dialysis catheters versus smaller, more flexible catheters [8]. (See
"Central vein stenosis associated with hemodialysis access".)
Arrhythmia — Ventricular dysrhythmias and bundle branch block are well-recognized complications during
central venous access procedures. Periprocedural arrhythmias are universally the result of guidewire or catheter
placement into the right heart. Limiting the depth of guidewire insertion to fewer than 16 cm avoids this
complication [9-11]. Catheter migration up to 3 cm is common with patient movement, and repositioning may
cause delayed symptoms. Nontunneled central venous catheters positioned deep into the right atrium or
catheters placed in the right ventricle increase the risk for dysrhythmias and cardiac perforation, although cardiac
perforation appears to be a rare event [12].
Vascular injury — Arterial puncture is noted in 3 to 15 percent of central venous access procedures [4]. The use
of ultrasound during central catheter placement can help decrease inadvertent arterial puncture. (See
'Ultrasound guidance' below and "Principles of ultrasound-guided venous access".)
Immediate recognition and management of arterial puncture usually prevents subsequent complications. Once
an arterial stick is suspected, the needle is immediately withdrawn and direct but nonocclusive pressure applied
to the site continuously for 15 minutes to prevent hematoma formation. Unrecognized arterial cannulation with
subsequent dilation and catheter placement is associated with life-threatening hemorrhage and neurologic
complications [13]. Late recognition of arterial cannulation increases the risk of hemorrhagic complications that
may require surgical intervention.
If location of the catheter in the vein versus the artery is unclear, measuring intraluminal pressure with a
transducer prior to dilation aids in recognizing arterial puncture [4,14]. Simple catheter removal, also known as
the "pull-and-pressure" approach, may be considered for inadvertent femoral artery cannulation [14]. Accidental
cannulations of the carotid or subclavian artery by a large-bore catheter (>7 F) can cause hemorrhage, stroke,
pseudoaneurysm, or death. When the carotid or subclavian artery is cannulated by a large-bore catheter, before
catheter removal, clinicians should consult immediately with a vascular surgeon for possible emergent vascular
repair of the damaged artery [15,16].
Pulmonary complications — Free aspiration of air into the syringe may occur with pleural puncture but is often
the result of incomplete seal of the syringe and needle. Suspected pleural puncture should prompt close
attention for signs or symptoms of cardiopulmonary distress due to pneumothorax. Pleural puncture can quickly
evolve into tension pneumothorax with hemodynamic collapse, especially in patients receiving positive pressure
ventilation. The need for emergency intravenous access may require continued attempts at the same or
alternative locations. Avoid contralateral supradiaphragmatic access attempts in close succession due to the
potential for bilateral pneumothoraces. Hemothorax, hydrothorax, and chylothorax occur in a small fraction of
torso cannulations.
Venous air embolism — Central venous access procedures create a risk for venous air embolism [17]. Venous
air embolism is a serious and poorly recognized complication that can occur at the time of central venous
catheter insertion, while the catheter is in place, or at the time of catheter removal [18-20]. Air is easily entrained
into the vascular space when a needle or catheter is left open to the atmosphere. The effect of venous air
embolization depends upon the rate and volume of air introduced into the venous circulation. Although the
minimum volume of air that is lethal to humans has not been established, fatal doses of air measuring as little as
200 mL have been reported [21,22]. The lethal dose for humans has been theorized to be 3 to 5 mL/kg [23].
Upright positioning, hypovolemia, spontaneous inhalation during instrumentation, and inattention to catheter
seals increase the risk for entraining air. Affected patients can suffer cardiovascular and pulmonary symptoms
including tachyarrhythmias, chest pain, cardiovascular collapse, dyspnea, coughing, hypoxemia, and respiratory
distress. Symptoms such as these in association with central line insertion or manipulation are highly suspicious
for venous air embolism. Left lateral decubitus and Trendelenburg positioning to trap the air in the right
ventricular apex are often recommended but have not been rigorously studied. Supportive measures including
fluid resuscitation and adrenergic agents should be used as needed. One hundred percent inspired oxygen may
speed air resorption. (See "Air embolism".)
Bleeding — Serious blood loss associated with central venous catheter placement is uncommon. Hematomas
that form in the neck after inadvertent cannulation of the carotid artery may obstruct the airway and be life-
threatening [24]. It remains uncertain when and if coagulation defects should be corrected prior to nonemergent
central venous catheter placement [25]. (See "Overview of central venous access", section on 'Coagulopathy
and/or thrombocytopenia'.)
PREVENTING COMPLICATIONS — Central venous catheterization should be performed with the patient
carefully positioned, using sterile conditions and topical analgesia. An experienced operator, ultrasound
guidance, and nursing supervision are preferable, if available.
Infection — In a large, prospective cohort study, the following five steps (sometimes called the Pronovost
checklist) reduced central venous catheter-related bloodstream infections when instituted together [26]. (See
"Prevention of intravascular catheter-related infections", section on 'Catheter teams and use of checklist'.)
● Hand hygiene – An alcohol sanitizer or antimicrobial soap should be used immediately prior to donning
sterile gloves.
● Chlorhexidine skin antisepsis – A chlorhexidine solution should be applied by back-and-forth rubbing for at
least 30 seconds. The solution should be allowed to air dry for at least two minutes and should not be wiped
or blotted. Chlorhexidine appears preferable to a povidone-iodine solution [27].
● Maximal barrier precautions – All operators should wear a mask, cap, sterile gown, and sterile gloves. In
addition, a sterile full-body drape should be placed on the patient.
● Avoid insertion into the femoral vein – Insertion of a central venous catheter into the subclavian vein is
associated with the lowest risk of infection compared with insertion into the internal jugular or femoral vein
(1.3 per 1000 catheter-days compared with 2.7 per catheter-days) [28].
● Remove unnecessary central venous catheters – A daily review of central venous catheter necessity should
be performed, with prompt removal of unnecessary central venous catheters.
Additional interventions that may reduce central venous catheter-associated bloodstream infections include
antibiotic-impregnated central venous catheters, nursing supervision during insertion, and increased attention to
ongoing catheter care after insertion:
● Antibiotic-impregnated central venous catheters – A meta-analysis of 11 randomized controlled trials (2603

catheters) found that central venous catheters impregnated with chlorhexidine-silver sulfadiazine were less
likely to cause bloodstream infection (odds ratio [OR] 0.56, 95% CI 0.37-0.84) [29]. However, this finding has
not been universal [30,31].
● Nursing supervision – In a prospective cohort study, the patient's nurse used a checklist defining best
practice to monitor the procedure and was empowered to stop the procedure if best practice was violated
[32]. Over a six-month period, the central venous catheter-related bloodstream infection rate decreased from
11 to 0 infections per 1000 catheter-days.
● Vigilant catheter care – A prospective audit of postinsertion catheter care was conducted over a 28-day
period (721 catheter-days) [33]. There were 323 breaches in catheter care and four catheter-related
bloodstream infections (5.5 infections per 1000 catheter-days). The major breaches included dressings that
were not intact (158 breaches per 1000 catheter-days) and incorrectly placed caps (156 breaches per 1000
catheter-days). This study suggests that there is substantial opportunity to better standardize and improve
the maintenance of central venous catheters. Such care should also target earlier recognition of potentially
infected catheter sites.
Mechanical problems — Factors associated with fewer mechanical complications (eg, bleeding, blood vessel
injury, pneumothorax, failure to cannulate the vein) include increased operator experience, site of insertion, fewer
insertion attempts, patient body habitus, and ultrasound guidance.
Appropriate operator experience — It is unknown how many central venous catheters should be inserted by
an operator each year to maintain his or her skills. However, experience is clearly important. In one prospective
cohort study, operators who had previously inserted more than 50 central venous catheters were more likely to
be successful at inserting subsequent central venous catheters with fewer complications.
Recognition of the importance of operator experience has prompted many hospitals to require that a certain
number of successful central venous catheter insertions be performed before an operator can place central
venous catheters without supervision. In addition, some centers use simulation labs with mannequins or have
rotations through their cardiac catheterization lab to allow operators to receive highly supervised practice
inserting central venous catheters [34,35].
Limiting attempts — The number of attempts is also related to the likelihood of a mechanical complication. In
a prospective cohort study, the incidence of mechanical complications was sixfold higher when insertion was
attempted more than three times, compared with successful insertion on the first attempt. It is, therefore,
reasonable for an operator to seek assistance if a central venous catheter cannot be successfully inserted after
three attempts to cannulate the vein or to insert the catheter [36]. We define an attempt as each time the hollow
needle is inserted in search of the vein or each attempt to dilate the vein or thread the catheter over the
guidewire.
Ultrasound guidance — Real-time two-dimensional ultrasound guidance is superior to blind, landmark-

guided techniques, particularly when used during central venous catheter insertion into the internal jugular vein.
The use of real-time ultrasound to guide cannulation of either the subclavian vein or femoral vein is less well
studied. Limited data suggest that real-time ultrasound may increase femoral vein cannulation success but does
not decrease the risk of arterial puncture or hematoma [37]. (See "Overview of central venous access", section
on 'Use of ultrasound' and "Principles of ultrasound-guided venous access".)
Confirm catheter positioning — A newly placed central venous catheter is frequently used before it has
been confirmed by a chest radiograph that it is correctly positioned. This is most common in the operating room
and in emergency situations. Failure to confirm the position can be problematic since clinician judgment does not
consistently predict catheter malposition or other mechanical complications, especially with less experienced
operators [38]. There is evidence that a chest radiograph may not be mandated after uncomplicated ultrasound-
guided right internal jugular vein cannulation [39]. (See "Overview of central venous access", section on
'Confirmation of catheter tip positioning'.)
Preventing air embolism — Venous air embolism is a serious and poorly recognized complication of central
venous catheterization. Venous air embolism can occur at the time of central venous catheter insertion, while the
catheter is in place, or at the time of catheter removal [18-20]. (See 'Venous air embolism' above.)
Trendelenburg positioning, Valsalva maneuver, prompt needle/catheter occlusion, and tight intravenous
connections help to avoid this complication during central venous catheter placement [17,40]. Prior to central
venous catheter removal, patients should be placed in the supine position. The central venous catheter should
be removed during exhalation, when intrathoracic pressure is greater than atmospheric pressure. Firm pressure
should be applied for at least one minute following removal. (See "Overview of central venous access", section
on 'Positioning'.)
SUMMARY AND RECOMMENDATIONS
● We recommend that a protocol be used in all patients who require a central venous catheter (Grade 1B).
One protocol proven to reduce central venous catheter-associated blood stream infections includes hand
hygiene, chlorhexidine skin antisepsis, maximal barrier precautions, avoiding femoral vein insertion, and
prompt removal of unnecessary catheters. (See 'Infection' above.)
● Increased operator experience, fewer insertion attempts, and ultrasound guidance are associated with fewer
mechanical complications. (See 'Mechanical problems' above.)
● Central venous catheters can be inserted into the internal jugular, external jugular, subclavian, femoral, or
brachial vein (table 2). The optimal site is determined by operator preference, operator experience, patient
anatomy, and clinical circumstances. (See "Overview of central venous access", section on 'Site selection'.)
● Numerous complications are associated with central venous catheter placement (table 1). Mechanical
complications (eg, pneumothorax) tend to be detected at the time of catheter insertion, whereas infectious
and thrombotic complications usually occur later. Venous air embolism and bleeding are the complications
most likely to occur when the central venous catheter is removed. (See 'Complications' above and
'Preventing air embolism' above.)
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REFERENCES
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view/cdc/5916/ (Accessed on February 06, 2014).
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10. Tripathi M, Dubey PK, Ambesh SP. Direction of the J-tip of the guidewire, in seldinger technique, is a
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11. Lefrant JY, Muller L, De La Coussaye JE, et al. Risk factors of failure and immediate complication of
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urban legend? A systematic review of the literature. J Cardiothorac Vasc Anesth 2015; 29:491.
13. Oliver WC Jr, Nuttall GA, Beynen FM, et al. The incidence of artery puncture with central venous
cannulation using a modified technique for detection and prevention of arterial cannulation. J Cardiothorac
Vasc Anesth 1997; 11:851.
14. Bowdle A. Vascular complications of central venous catheter placement: evidence-based methods for
prevention and treatment. J Cardiothorac Vasc Anesth 2014; 28:358.
15. Shah PM, Babu SC, Goyal A, et al. Arterial misplacement of large-caliber cannulas during jugular vein
catheterization: case for surgical management. J Am Coll Surg 2004; 198:939.
16. Guilbert MC, Elkouri S, Bracco D, et al. Arterial trauma during central venous catheter insertion: Case
series, review and proposed algorithm. J Vasc Surg 2008; 48:918.
17. Mirski MA, Lele AV, Fitzsimmons L, Toung TJ. Diagnosis and treatment of vascular air embolism.
Anesthesiology 2007; 106:164.
18. Roberts S, Johnson M, Davies S. Near-fatal air embolism: fibrin sheath as the portal of air entry. South Med
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19. Laskey AL, Dyer C, Tobias JD. Venous air embolism during home infusion therapy. Pediatrics 2002;
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20. Heckmann JG, Lang CJ, Kindler K, et al. Neurologic manifestations of cerebral air embolism as a
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21. Flanagan JP, Gradisar IA, Gross RJ, Kelly TR. Air embolus--a lethal complication of subclavian
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30. Kalfon P, de Vaumas C, Samba D, et al. Comparison of silver-impregnated with standard multi-lumen
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31. Lai NM, Chaiyakunapruk N, Lai NA, et al. Catheter impregnation, coating or bonding for reducing central
venous catheter-related infections in adults. Cochrane Database Syst Rev 2013; :CD007878.
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intensive care unit. Crit Care Med 2004; 32:2014.
33. Shapey IM, Foster MA, Whitehouse T, et al. Central venous catheter-related bloodstream infections:
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34. Ramakrishna G, Higano ST, McDonald FS, Schultz HJ. A curricular initiative for internal medicine residents
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Guided Right Internal Jugular Vein Catheterization. Crit Care Med 2016; 44:e804.
40. Ely EW, Hite RD, Baker AM, et al. Venous air embolism from central venous catheterization: a need for
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Topic 8180 Version 13.0
GRAPHICS
Complications of central venous catheterization
Immediate
Bleeding
Arterial puncture
Arrhythmia
Air embolism
Thoracic duct injury (with left SC or left IJ approach)
Catheter malposition
Pneumothorax or hemothorax
Delayed
Infection
Venous thrombosis, pulmonary emboli
Venous stenosis
Catheter migration
Catheter embolization
Myocardial perforation
Nerve injury
SC: subclavian; IJ: internal jugular.
Graphic 77376 Version 4.0
Advantages and disadvantages of central vein approaches
Approach Advantages Disadvantages
External Superficial vessel that is often visible Not ideal for prolonged venous access
jugular Coagulopathy not prohibitive Poor landmarks in obese patients
Minimal risk of pneumothorax (especially with High rate of malposition
US guidance) Catheter may be difficult to thread
Head-of-table access
Prominent in elderly patients
Rapid venous access
Internal Minimal risk of pneumothorax (especially with Not ideal for prolonged access
jugular US guidance) Risk of carotid artery puncture
Head-of-table access Uncomfortable
Procedure-related bleeding amenable to Dressings and catheter difficult to maintain
direct pressure
Thoracic duct injury possible on left
Lower failure rate with novice operator
Poor landmarks in obese/edematous patients
Excellent target using US guidance
Potential access and maintenance issues with
concomitant tracheostomy
Vein prone to collapse with hypovolemia
Difficult access during emergencies when airway control
being established
Subclavian Easier to maintain dressings Increased risk of pneumothorax

More comfortable for patient Procedure-related bleeding less amenable to direct
Better landmarks in obese patients pressure
Accessible when airway control is being Decreased success rate with inexperience
established Longer path from skin to vessel
Catheter malposition more common (especially right
SCV)
Interference with chest compressions
Femoral Rapid access with high success rate Delayed circulation of drugs during CPR
Does not interfere with CPR Prevents patient mobilization
Does not interfere with intubation Difficult to keep site sterile
No risk of pneumothorax Difficult for PA catheter insertion
Trendelenburg position not necessary during Increased risk of iliofemoral thrombosis
insertion
US: ultrasound; SCV: subclavian vein; CPR: cardiopulmonary resuscitation; PA: pulmonary artery.
With permission from: Factor P, Sznajder JI. Vascular cannulation. In: Principles of Critical Care, Hall JB, Schmidt GA, Wood
LDH (Eds), McGraw-Hill, New York, 1992. Copyright 1992 McGraw-Hill.
Graphic 71716 Version 6.0
Contributor Disclosures
Michael P Young, MD Nothing to disclose David L Cull, MD Nothing to disclose Scott Manaker, MD,
PhD Consultant/Advisory boards: Expert witness in workers' compensation and in medical negligence matters
[General pulmonary and critical care medicine]. Equity Ownership/Stock Options (Spouse): Johnson & Johnson;
Pfizer (Numerous medications and devices). Other Financial Interest: Director of ACCP Enterprises, a wholly
owned for-profit subsidiary of ACCP [General pulmonary and critical care medicine (Providing pulmonary and
critical care medicine education to non-members of ACCP)]. Kathryn A Collins, MD, PhD, FACS Nothing to
disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform to
UpToDate standards of evidence.
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9/4/2018 Complications of central venous catheters and their prevention - UpToDate

Official reprint from UpToDate®

Author: Michael P Young, MD

Catheter-induced thrombosis — Thrombosis is another common complication of indwelling central venous

● Antibiotic-impregnated central venous catheters – A meta-analysis of 11 randomized controlled trials (2603

Ultrasound guidance — Real-time two-dimensional ultrasound guidance is superior to blind, landmark-

SUMMARY AND RECOMMENDATIONS

Use of UpToDate is subject to the Subscription and License Agreement.

Topic 8180 Version 13.0

Complications of central venous catheterization

Thoracic duct injury (with left SC or left IJ approach)

Venous thrombosis, pulmonary emboli

SC: subclavian; IJ: internal jugular.

Graphic 77376 Version 4.0

Advantages and disadvantages of central vein approaches

Approach Advantages Disadvantages

Subclavian Easier to maintain dressings Increased risk of pneumothorax

Graphic 71716 Version 6.0

Conflict of interest policy

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