Central venous catheter (CVC) insertion carries a risk of complications which clinicians must be prepared to manage. This article outlines common complications, their causes, methods of prevention, and appropriate clinical responses to ensure safe and effective practice.
Complications can be divided into three categories: acute, semi-acute and delayed. These can include acute or technical complications directly related to the procedure, these are:
- Infection (discussed in article 3)
- Arterial puncture (discussed in article 5)
- Arterial cannulation
- Air embolism
- Nerve damage
- Malposition and failure to place catheter.
These complications can occur despite training and experience, making them a recognised risk when inserting these catheters[1]. Additionally, quality of care issues, such as repeated insertion attempts, can cause significant patient anxiety and discomfort. It is essential that practitioners are aware of potential complications and understand how to prevent and manage them effectively[2].
Inadvertent arterial puncture
The differing anatomy of veins and arteries is vital to help identify them. An artery will appear rounder than a vein and when compressed an artery will pulsate, which will be seen on ultrasound.
Inadvertent arterial puncture involving a small needle (22G or 25G) is often without significant consequences[3]. However, the same injury with a large-bore catheter, can have serious consequences if not recognised, including haemotoma3.
Identification
If an artery is punctured accidentally, it will be identifiable by bright red pulsating / spurting arterial blood. Blood can also fill the syringe on puncture.
Management
If this occurs, the needle should be removed and pressure applied for at least ten minutes to prevent haematoma formation. Pressure may need to be applied for up to 20 minutes.
Prevention
As previously mentioned, the use of ultrasound has been shown to greatly reduce the incidence of complications including inadvertent arterial puncture, as you can identify the artery with ultrasound.
Symptoms
Bright red, pulsating blood on removal of wire and dilator.
Action
- If the arterial puncture is by a needle – remove and apply pressure for at least 10 minutes, even up to 20 minutes where required3.
- If a central line is inserted into an artery and is a large-bore CVC (7Fr or larger)3:
- Leave the CVC in situ
- Then, depending on the site of the injury, seek endovascular or surgical repair.
Air embolism
Air can enter the venous system during or following the vascular access insertion procedure, with increased risk when using dilators which may rapidly draw air in large amounts into central circulations. This risk increases when the patient is hypovolemic, vulnerable, critically ill or breathless and gasping for air. While small volumes of air are often reabsorbed, larger volumes (3–8 ml/kg) can result in acute right ventricular dysfunction and pulmonary injury, leading to cardiogenic shock and circulatory arrest. Air entry at rates of 75–105 mL/sec is usually fatal, and symptoms may appear with 20 mL[4],[5].
Symptoms
Symptoms occur rapidly, and you will normally hear the air entering the system as a sucking sound. The patient will experience some or all of these signs and symptoms:
- Dyspnea
- Chest pain
- Tachycardia
- Hypotension
- Confusion
- Anxiety
- Lowered level of consciousness
- Neurological deficits
- Circulatory shock or sudden death.
Prevention
Valsalva Manoeuvre
This increases the pressure in the thoracic cavity. Attempting to breathe out against a closed epiglottis increases pressure in the thoracic cavity and hinders the return of venous blood into the heart. Ensure your patient is adequately hydrated where possible, as if the patient is hypovolemic this can generate an increased ‘sucking’ force. Use a closed CVC system and ensure vigilance during manipulation. Consider the use of luer lock connectors. Remember that air embolism can also occur following CVC catheter removal, therefore, ensure the use of an occlusive dressing following removal4.
Management
If this occurs:
- Do not sit patient up
- Lie patient in the left lateral Trendelenburg position
- Administer 100% oxygen
- Consider intubation if respiratory distress evident
- Terminate procedure unless access is needed urgently
- Ensure help is sought early
- Continuous monitoring and documentation.
Pneumothorax and haemothorax
This in one of the most common complications of CVC insertion and is more likely to occur in emergency situations or when the device is being inserted by an inexperienced operator[6].
Symptoms
- Chest pain
- Hypotension/hypertension
- Respiratory effort (unilateral)
- Tracheal deviation.
Action
- Chest x-ray
- Administer 100% oxygen via trauma mask
- Maintain, or establish, venous access
- Monitor (Sao2, BP, Pulse, Respirations)
- Depending on patient condition – contact your emergency response team
- Call Cardiothoracic surgeons.
Cardiac tamponade
This is usually a result of damage to cardiac wall during dilator insertion. Cardiac tamponade can also occur if a catheter tip is left abutting the wall of a vessel.
Signs and symptoms
- Falling blood pressure
- Tachycardia or bradycardia
- Cold/clammy
- Feeling of dizziness
- Nausea
- Temporary loss of consciousness
- Chest pain radiating to back, shoulders and abdomen
- Anxiety
- Dyspnea/cyanosis.
Action
- Contact the emergency response team
- Monitor (Sao2, BP, Pulse, Respirations)
- Oxygen 100% via trauma mask
- Maintain or obtain venous access
- Administer fluids
- Arrange for a chest x-ray
- Arrange for an ECG/Echocardiogram
Prevention of cardiac tamponade
Never force a dilator, there should be no resistance. Keep the wire moving during dilator introduction. The wire should continue to move freely.
Catheter misplacement during insertion
The tip of the catheter should ideally rest in the superior vena cava or upper right atrium[7],[8],1. Without fluoroscopy there are many methods for estimating the ideal catheter length before device insertion. Fluoroscopy screening should be used whenever available as this is the gold standard method of ensuring a device is in the correct position. It is also important to remember that the tip position should be confirmed and documented as being in the correct position prior to use.
Complications in relation to tip positioning
An incorrectly positioned catheter tip can potentially increase the risk of complications such as thrombosis or in extreme cases cardiac tamponade1. More commonly an incorrectly placed tip disrupts the drug infusion flow rate and can lead to Persistent Withdrawal Occlusion (PWO) which is the ability to freely deliver medication but an inability to aspirate from the catheter. PWO can also be a feature of a catheter abutting a vein wall[9].
Conclusion
In summary, while central venous catheter insertion is a routine and often life-saving procedure, it is not without risk. The range of complications, from arterial puncture and air embolism to cardiac tamponade and catheter misplacement, highlights the need for meticulous technique and clinical vigilance. Preventative strategies, such as ultrasound guidance and adherence to best practice, are essential but not infallible. Ultimately, recognising and managing complications promptly is critical to safeguarding patient outcomes and maintaining high standards of care.
Continue Reading
- Article 1: Understanding CVCs: Roles, Anatomy, and Device Selection
- Article 2: Preparing for CVC Insertion – Patient Assessment, Consent and Pain Management
- Article 3: Infection Prevention and Aseptic Techniques
- Article 4: Foundations of Ultrasound Physics and Applications
- Article 5: Central Venous Lines – Insertion Techniques and Pain Management
- Article 6: Navigating Complications in Central Venous Access
- Article 7: Post-Insertion Care, Maintenance and Safe Removal
References
[1] Bodenham, A. Babu, J. Bennett, J. Binks, R. Fee, P. Fox, B. Johnston, AJ. Klein, AA. Langton, JA. Mclure, H. Tighe, SQM (2016) Safe vascular assess guidelines. Anaesthesia. Available online: doi:10.111/anae.13360
[2] Bodenham and Simcock in Hamilton, H and Bodenham, AR (2009) Central Venous Catheters. Wiley-Blackwell. UK
[3]Shiu WHL. Inadvertent cannulation of subclavian artery in central venous catheter insertion: A case report and review of prevention and management. J Clin Imaging Sci 2022;12:34.
[4] Earhart, A (2013) Recognizing, preventing and troubleshooting central – line complications. American Nurse Today. Vol 8 (11) 18 – 24
[5] Nayeemuddin, M. Pherwani, AD. Asquith, JR (2013) Imaging and management of complications of central venous catheters. Clinical Radiology: 68, 529 – 544
[6] Tsotsolis N, Tsirgogianni K, Kioumis I, Pitsiou G, Baka S, Papaiwannou A, et al. Pneumothorax as a complication of central venous catheter insertion. Ann Transl Med. 2015;3(3):40.
[7] Royal College of Nursing (2010) standards for infusion therapy. RCN Intravenous Therapy Forum, London
[8] Vesley TM (2003) Central Venous Catheter Tip Position: a continuing controversy Journal of Vascular Interventional Radiology 14(5): 527– 534
[9] Santilli, J (2002) Fibrin Sheaths and central venous catheter occlusions: diagnosis and management. Techniques in Vascular and Interventional radiology: 5(2)89 – 94
