Central venous catheterization
In health care, a central venous catheter (CVC or central venous line) is a catheter placed into a large vein in the neck, chest or groin, this is inserted by a physician when the patient needs more intensive cardiovascular monitoring, for assessment of fluid status, and for increased viability of intravenous drugs/fluids. The most commonly used veins are the internal jugular vein, the subclavian vein and the femoral vein. This is in contrast to a peripheral line which is usually placed in the arms or hands.
How to insert
If after the insertion the chest radiography shows that the vertical distance from the CVC tip to the carina is more than 55 mm, the line may have been inserted too far.[1]
Complications
Thrombosis
27% to 67% of patients may have catheter-associated deep vein thrombosis.[2] A meta-analysis found that "anticoagulant prophylaxis is effective for preventing all catheter-associated deep vein thrombosis in patients with central venous catheters. The effectiveness for preventing symptomatic venous thromboembolism, including pulmonary embolism, remains uncertain."[2]
Infection
All catheters can introduce bacteria into the bloodstream, but CVCs are known for occasionally causing Staphylococcus aureus and Staphylococcus epidermidis sepsis.
Diagnosis
A patient with a central line, fever, and no obvious cause of the fever may have catheter-related sepsis. A meta-analysis found "Paired quantitative blood culture is the most accurate test for diagnosis of IVD-related bloodstream infection. The cultures are compared for number of colonies with line infection indicated by 5:1 ratio (CVC versus peripheral). However, most other methods studied showed acceptable sensitivity and specificity (both >0.75) and negative predictive value (>99%)".[3]
Quantitative cultures are not commonly available. Alternatively, paired qualitative cultures in which time to positivity is assessed with line infection indicated by cultures that are positive 2 hours before peripheral cultures.[3]
This analysis did not include gram stain and acridine-orange leucocyte cytospin test (AOLC) of 100 microliters of catheter blood (treated with edetic acid) which one group of investigators proposes. [4]
The American Centers for Disease Control and Prevention recommends again routine culturing of central venous lines upon their removal.[5] However, the three cited studies do not directly address the validity of this practice.[6][7][8]
Treatment
Generally, antibiotics are used, and occasionally the catheter will have to be removed. In the case of bacteremia from staphylococcus aureus, removing the catheter without administering antibiotics is not adequate as 38% of such patients may still develop bacterial endocarditis.[9]
Prevention
To prevent infection, some central lines are now coated or impregnated with antibiotics, silver (specifically silver sulfadiazine) and or chlorahexadine.
Using chlorhexidine-based solutions to wash the insertion site[10], or the whole patient[11], may prevent bacteremia according to randomized controlled trials.
Routine replacement of a new central line catheter did not help in a randomized controlled trial.[12]
Clinical practice guidelines from the American Centers for Disease Control and Prevention make a number of recommendations.[5]
References
- ↑ Wirsing M, Schummer C, Neumann R, Steenbeck J, Schmidt P, Schummer W (September 2008). "Is traditional reading of the bedside chest radiograph appropriate to detect intraatrial central venous catheter position?". Chest 134 (3): 527–33. DOI:10.1378/chest.07-2687. PMID 18641117. Research Blogging.
- ↑ 2.0 2.1 Kirkpatrick A, Rathbun S, Whitsett T, Raskob G (2007). "Prevention of central venous catheter-associated thrombosis: a meta-analysis". Am. J. Med. 120 (10): 901.e1–13. DOI:10.1016/j.amjmed.2007.05.010. PMID 17904462. Research Blogging.
- ↑ 3.0 3.1 Safdar N, Fine JP, Maki DG (2005). "Meta-analysis: methods for diagnosing intravascular device-related bloodstream infection". Ann. Intern. Med. 142 (6): 451-66. PMID 15767623. [e]
- ↑ Kite P, Dobbins BM, Wilcox MH, McMahon MJ (1999). "Rapid diagnosis of central-venous-catheter-related bloodstream infection without catheter removal". Lancet 354 (9189): 1504-7. PMID 10551496. [e]
- ↑ 5.0 5.1 O'Grady NP, Alexander M, Dellinger EP, et al (2002). "Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention". MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control 51 (RR-10): 1-29. PMID 12233868. [e]
Cite error: Invalid
<ref>tag; name "pmid12233868" defined multiple times with different content - ↑ Widmer AF, Nettleman M, Flint K, Wenzel RP (1992). "The clinical impact of culturing central venous catheters. A prospective study". Arch. Intern. Med. 152 (6): 1299-302. PMID 1599360. [e]
- ↑ Pittet D, Tarara D, Wenzel RP (1994). "Nosocomial bloodstream infection in critically ill patients. Excess length of stay, extra costs, and attributable mortality". JAMA 271 (20): 1598-601. PMID 8182812. [e]
- ↑ Raad II, Baba M, Bodey GP (1995). "Diagnosis of catheter-related infections: the role of surveillance and targeted quantitative skin cultures". Clin. Infect. Dis. 20 (3): 593-7. PMID 7756481. [e]
- ↑ Watanakunakorn C, Baird IM (1977). "Staphylococcus aureus bacteremia and endocarditis associated with a removable infected intravenous device". Am. J. Med. 63 (2): 253-6. PMID 888847. [e]
- ↑ Mimoz O, Villeminey S, Ragot S, et al (2007). "Chlorhexidine-based antiseptic solution vs alcohol-based povidone-iodine for central venous catheter care". Arch. Intern. Med. 167 (19): 2066–72. DOI:10.1001/archinte.167.19.2066. PMID 17954800. Research Blogging.
- ↑ Bleasdale SC, Trick WE, Gonzalez IM, Lyles RD, Hayden MK, Weinstein RA (2007). "Effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients". Arch. Intern. Med. 167 (19): 2073–9. DOI:10.1001/archinte.167.19.2073. PMID 17954801. Research Blogging.
- ↑ Cobb DK, High KP, Sawyer RG, et al (1992). "A controlled trial of scheduled replacement of central venous and pulmonary-artery catheters". N. Engl. J. Med. 327 (15): 1062-8. PMID 1522842. [e]