Central Venous Access in the Emergency Department: Recommendations for Reducing Complications

Gregory P. Garra, DO, FACEP, Clinical Assistant Professor of Emergency Medicine, Residecny Program Director, Director of Medical Education, Stony Brook University Hospital, Stony Brook, NY

Central venous access is often necessary for the care of critically ill patients. Central venous catheters (CVC) are utilized for rapid volume replacement, administration of critical care medications such as vasopressors and inotropes, hemodynamic monitoring and cardiac pacing. The three most common sites for CVC placement are the femoral, subclavian and internal jugular veins. Each site has associated advantages and disadvantages. Regardless of the site of cannulation, CVC’s have associated infectious and mechanical complications. Infectious complications include catheter-related local infections (CRLIs) and catheter-related bloodstream infections (CR-BSIs). Mechanical complications include pneumothorax, hemothorax, chylothorax, local hematoma formation, arterial puncture or line malposition.

Infectious complications can range from mild, catheter related local infections (CRLI) or more serious catheter-related bloodstream infections (CR-BSIs). CRLI are limited to the insertion site and manifest as pericatheter skin inflammation with or without purulent drainage. CR-BSI’s are defined as a positive blood culture with clinical or microbiological evidence that strongly implicates the catheter as the source of infection.1 The Center for Disease Control and Prevention estimates the rate of CR-BSI’s to be 2.8 to 12.8 per 1,000 catheter days.2 CR-BSI’s are reported to be associated with increased hospital length of stay, healthcare costs and mortality.3 Lorente et al4 reported on the incidence of catheter related local infection (CRLI) and CR-BSI’s from an Intensive Care Unit. In their cohort of patients, no difference was found in the rates of CR-BSI’s based upon the insertion site (overall incidence of 1.4 infections per 1,000 catheter days). However, there is a documented difference in CRLI when stratified by insertion site. Femoral vein access is associated with an incidence of 13 infections per 1,000 catheter days. Internal jugular and subclavian venous access have an associated incidence of 6.3 and 1.8 infections per 1,000 catheter days, respectively. There is no literature pertaining to the incidence of CRLI’s and CR-BSIs in emergency department placed central venous catheters. Regardless, recent recommendations from both the Agency for Healthcare Research and Quality (AHRQ) and the Institute for Healthcare Improvement may provide a substantial impact in reducing the incidence of catheter-related infections. These recommendations include: use of maximal barrier precautions during CVC insertion, use of CVC’s coated with antibacterial or antiseptic agents, use of chlorohexidine gluconate skin antisepsis prior to CVC insertion, optimal catheter site selection (subclavian as the preferred site for non-tunneled catheters) and daily review of line necessity with prompt removal of unnecessary lines.

Mechanical complications impose another threat to patient morbidity and mortality. Successful insertion is largely attributed to an intimate knowledge of the anatomy combined with operator skill. CVC insertion is traditionally performed using anatomical landmarks as a guide to vessel location. However, aberrant anatomy is documented in up to 8.5% of patients requiring internal jugular cannulation.5 Failure to cannulate the vessel is estimated to be as high as 30%.6

Ultrasound has been emerging as a technique to improve first stick success rates and reduce complications. CVC insertion under real-time ultrasound guidance permits visualization of the desired vein and surrounding anatomic structures. Evidence-based recommendations issued by the AHRQ include central line insertion with real-time ultrasound guidance as one of 79 patient safety practices that might prove effective in reducing the 44,000 to 98,00 hospital-related deaths resulting from medical errors.7 Ultrasound-guided central venous catheter placement is well documented in anesthesiology and radiology literature. Miller et al8 documented a statistically significant reduction in the time to blood flash and fewer attempts when compared to the traditional landmark guidance technique of internal jugular cannulation in the emergency department. An ultrasound device suited for CVC insertion typically costs $11,000 to $16,000.

In summary, there are many ways to reduce morbidity and mortality associated with central venous catheters. Recommendations provided by AHRQ and IHI for reducing CVC complications are simple to employ and relatively inexpensive. Each hospital should institute mechanisms that can be easily instituted and uniformly adopted. n

References
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5 Denys BG, Uretsky BF. Anatomy variations of internal jugular vein location: impact of central venous access. Crit Care Med 1991;19:1516-19.
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7 Agency for Healthcare Research and Quality. Making health care safer: a critical analysis of patient safety practice. Evid R ep Technol Assess 2001;38:i-x, 1-668.
8 Miller AH, Roth BA, Mills TJ, et al. Ultrasound guidance versus the landmark technique for the placement of central venous catheters in the emergency department. Aca Emerg Med 2002;9:800-805.