Retrospective analysis of incidence of complications of central venous catheterization at an intensive care unit

Objectives: To compare mechanical, infectious, and thrombotic complications of internal jugular; subclavian and femoral venous catheterization at an post surgical and medical intensive care units Methods: It is a retrospective study in which the data from the medical records was evaluated and analyzed. Data, such as sex, date of insertion and removal, failure to place, malposition, complications and site of central venous catheterization were recorded. Landmark-based central venous catheterization using seldinger technique was performed under all aseptic precautions in 597 patients in postsurgical and medicine intensive care units. Central venous catheterization by three different routes i.e. IJV, SV and femoral vein were performed in critically ill patients. Results: Incidence of mechanical, infectious, and thromboembolic complications of central venous catheterization was 8.71%, 7.37 %, and 2.68% respectively. Incidences of different mechanical complications are as follows, arterial puncture4.18%, hematoma 3.18%, pneumothorax 1 %, haemothorax 0.33% .Incidence of central venous catheter with failure to place at various sites were 11.72 %. Incidences of central venous catheter with malposition at various sites were 6.36%. Conclusion: We found that complication rates of CVC insertion at our hospital are similar to those reported previously. Based on our experience, internal jugular venous access is associated with a low rate of mechanical complications like arterial punctures, hematoma, pneumothorax, thrombosis. Incidence with infection was least with subclavian cannulation.


1.Introduction
Central venous catheters (CVC) are widely used in critically ill patients throughout the world. They permit hemodynamic monitoring and allow reliable access for the administration of fluids, blood products, medications and total parenteral nutrition (TPN) [1,2]. First venous catheterization was subclavian vein; it was first described in 1952 by Aubaniac. It was popularized in the United States by Wilson and his associates in 1962 as a method of monitoring central venous pressure [3,4]. These percutaneous techniques left the operating physician exclusively reliant upon the relationships between surface anatomic landmarks and the underlying deep anatomic structures [5]. Despite their utility, placement of central venous catheters is often associated with mechanical, infectious and thromboembolic complications [6]. CVC -related thrombosis and infections are frequently occurring complications [7][8][9][10][11]. The purpose of the study was to compare the incidence of mechanical, infectious, and thrombotic complications of internal jugular; subclavian and femoral venous catheterization at post surgical and medical intensive care unit.

Study design
This study was designed as a retrospective observational study.

Study period
The study was conducted during July 2013 to June 2014.

Study size
Landmark-based central venous catheterization using seldinger technique was performed under all aseptic precautions in 597 patients in postsurgical and medicine intensive care unit.

Exclusion criteria
central venous catheterization in bleeding disorder, on anticoagulation therapy, with distorted anatomy, burns at insertion site, severe dermatitis at insertion site, performed in operation theater, casualty and by inexperienced residents were excluded from study.

Statistical analysis
Data was recorded using a predesigned semi structured proforma and entered into Microsoft Excel worksheet. Appropriate tests were applied for analysis.
During cannulation if red bright colored blood gushed into the syringe, arterial puncture was suspected. If patient developed unexplained tachypnea and/or tachycardia during cannulation, procedure was abandoned and chest radiograph was taken to check for pneumothorax and air embolism. If patient had symptoms of catheter related blood stream infection (CRBSI) and/or local infection, blood culture/ site swab was sent for culture and sensitivity.
Catheter-associated infections were defined as follows: 1) Exit site infectionerythema, tenderness, induration, purulent discharge and growth on culture.
(2) Catheter tip colonizationgrowth on culture of the distal segment of the CVC with clinical signs of infection. (3)CRBSI -isolation of the same organism from the catheter tip culture and from at least one of the two blood cultures, along with signs and symptoms of infection [12].
Mechanical complication:-This retrospective study found that incidence of mechanical complications of central venous catheterization was 8.71%. Incidence of mechanical complication in internal jugular, subclavian and femoral venous cannulation were 8.30%, 8.85% and 12.5 % respectively The incidence of mechanical complication has been studied and our results are consistent with other studies. David et al [12] reported mechanical complications were occurred in between 5 to 19 % of patient. This study also found that internal jugular and subclavian venous catheterization carry similar risks of mechanical complications. Kusminsky et al [13] reported that complication associate with central venous catheterization varies between 5 to 19%. In this study, incidences of different mechanical complications are as follows, arterial puncture 4.18% (25/597), hematoma 3.18% (19/597), pneumothorax 1.0% (6/597), haemothorax 0.33% (2/597). These findings were consistent with other studies.

Failure to place CVC
Total numbers of central venous catheter (CVC) with failure to place at various sites were 11.72 % (70/597). Out of this, 11.41% (33/289) internal jugular vein (IJV), 13.43% (36/268) subclavian vein (SV) and 2.5% (1/40) femoral vein (FV) catheters were fails to place. Lewis et al [7] found that the most common complication was failure to place, occurring in 22% of all attempts by intern, residents, fellows and attending. He also found that Subclavian, internal jugular and femoral catheterization attempts were unsuccessful 26%, 25%, and 15% respectively. He also observed that incidence of failure to place CVC by only fellow and attending was 10%. This finding was consistent with our study.

Conclusions
Central venous lines, although effective in establishing vascular access, were time-consuming to insert and are associated with high complication rates, with accompanying patient morbidity and mortality .We found that complication rates of CVC insertion at our hospital are similar to those reported previously. Based on our experience, internal jugular venous access is associated with a low rate of mechanical complications like arterial punctures, hematoma, pneumothorax, thrombosis. Incidence with infection was least with subclavian cannulation.
Ultrasonography guided CVC are best performed to prevent mechanical complications and improve patient safety.