While generally considered safe, complications may arise in 5-33% of the cases. Central line removal is also associated with significant morbidity.
This necessitates the need for early assessment of patient conditions and comorbidities. HPC tells you what to expect with our central line course.
Potential Complications of Central Line Placement
Let’s take a look at the complications associated with central line removal.
Arterial Puncture
Arterial puncture happens when the needle punctures an artery instead of a vein during insertion. It occurs in 4.2% to 9.3% of central line placements and can lead to serious complications like pseudoaneurysm or hematoma.
These post-surgical complications can make the patient vulnerable to another set of illnesses.
Localized hematomas, for instance, have been linked with vocal cord paralysis in patients with distorted anatomy of the neck. Literature also reports an association between airway obstruction and phrenic nerve injury.
Infection
Central line-associated bloodstream infection (CLABSI) occurs when germs enter the patient’s bloodstream through a central line. It is a common problem, with an incidence between 0.5 and 5 per 1,000 catheter days.
CLABSI is not only a significant cause of morbidity and mortality but it is associated with a high-cost burden. It could cost approximately $46,000 per case.
Pneumothorax
Pneumothorax occurs due to an inadvertent puncture of the lung during central venous catheterization. It represents up to 30% of all mechanical adverse events, with the likelihood reported in the following cases:
- Congenital anomalies
- Restless/uncooperative patient
- Nature of the underlying disease
- Previous operations in the treatment site
- Previous catheterizations (or number of attempts)
It can also be motivated by catheter type and site chosen for insertion.
Thrombosis
Thrombosis or sudden onset blood clot formation in a blood vessel can occur with central venous catheters (CVCs). It’s a serious condition that restricts or blocks blood flow and thus requires immediate medical attention.
There’s also the Risk of Air Embolism During Central Line Removal
Literature provides insights into complications after central line removal, which is known to lead to life-threatening problems.
Air embolism can occur when air enters the vascular system during CVC access, insertion, or removal. A majority of these air embolism events are cases of pulmonary air embolism, likely because normal venous circulation is eventually pumped into the pulmonary vasculature.
It is a rare but catastrophic complication with a reported incidence rate of 0.03% to 2% and an overall one-year mortality in the region of 21%.
The odds get worse for patients who are in a sitting or upright position during inspiration when there is a notable increase in the pressure gradient. An analysis of over 7 years, submitted to the Patient Safety Authority, has identified it as one of the most frequently reported contributing factors for CVC-associated air embolism.
Moreover, there’s a risk of a venous air embolism becoming an arterial air embolism — both in the presence and absence of a shunt.
In patients with a shunt, the embolization of air moves through a patent foramen ovale, with a prevalence of about 1 in 4 cases. It can raise right heart pressures and permit paradoxical emboli. In those without a shunt, it could overwhelm the pulmonary filter and spill into the arterial circulation.
This can produce organ ischemia from insufficient collateral circulation, which can invoke inflammatory responses, leading to tissue injury and death.
CVC-associated air embolism has mortality rates from 23% to 50%.
This is because if the embolism is introduced closer to the heart, it only takes a small volume — 200 to 300mL — in the bloodstream to prove lethal. It could happen in mere seconds during a central line placement.
Prevention Should be the Only Cure
Central venous catheters are routinely used in the critically ill, but they carry a tangible risk. With procedural-related complications now being considered ‘never events’, healthcare providers must drive better outcomes with the development and implementation of the following measures:
- All central lines should be removed in the Trendelenberg position during central line removal if possible
- If the patient is unable to lie in the Trendelenberg position, they should at minimum lie in the supine position during central line removal
- The patient should perform a valsalva maneuver, hold their breath or hum during central line removal
- The operator should place gauze immediately over the puncture site and cover the gauze with an impermeable dressing (to not allow air to enter the puncture site)
- The patient should continue to lie flat for at least 5 minutes after dressing is applied before sitting up
Hyperbaric Oxygen Therapy (HBOT)
HBOT uses 100% oxygen at a high atmospheric pressure to maintain vital functions. It can decrease the size of air bubbles, decrease reperfusion injury, and provide an adequate supply of oxygen to the ischemic tissue.
Early therapy, administered within 6 hours, can lead to the best prognosis.
Maximum Sterile Barrier (MSB) Precautions
Most of the time, CLABSI can be prevented with the use of maximal sterile barrier precautions. It calls for using a full-body drape, wearing a mask, cap, and sterile gown and gloves, and using chlorhexidine for skin antisepsis.
Ultrasound Guidance
Real-time ultrasound guidance could reduce risk and improve insertion success by improving visualization. It’s a cost-effective method available everywhere, with economic modeling reports suggesting it was likely to save £2000 ($3249; €2840) of NHS resources for every 1000 procedures.
The Importance of Developing Physician Knowledge
A 1998 case report suggested that healthcare workers who are expected to perform CVC must be aware of any adverse events associated with it, and how to adopt techniques that prevent their occurrence.
A recent retrospective cohort study has shed light on its efficacy.
It showed that a focused education program can significantly reduce the rate of catheter-related infections. Since approximately 3% of CVCs were found to be associated with major complications, theoretical-practical training has become non-negotiable for reducing the rate of incidents.
Why Learn with HPC
Simulation-trained interns have better odds of reducing CVC-related complications as they exhibit better adherence to prescribed protocols.
That’s why, our courses come complete with hands-on training and simulators to familiarize you with CVC insertion and its associated challenges. It helps you respond appropriately to complications after central line removal, which can decrease the length of hospital stay and ensure a speedy recovery.
Resources
Choi, J. C.; Kim, M.; Kim, S. W.; Lee, J.; Myeong Seong, G. Massive air embolism while removing a central venous catheter. Int J Crit Illn Inj Sci. 2018 Jul-Sep; 8(3): 176–178.doi: 10.4103/IJCIIS.IJCIIS_14_18: 10.4103
Feil, M. CVC Removal: A Procedure Like Any Other. MSN, RN | June 1, 2014
Eisen, L. A.; Narasimhan, M.; Berger, J. S.; Mayo, P. H.; Rosen, M. J.; Schneider, R. F. Mechanical complications of central venous catheters. J Intensive Care Med. 2006 Jan-Feb;21(1):40-6. doi: 10.1177
Silva, F. Neck haematoma and airway obstruction in a patient with goitre: complication of internal jugular vein cannulation. Case Reports Acta Anaesthesiol Scand. 2003 May;47(5):626-9. doi: 10.1034
Drachler, D. H.; Koepke, G. H.; Weg, J. G. Phrenic nerve injury from subclavian vein catheterization. Diagnosis by electromyography, Case Reports JAMA. 1976 Dec 20;236(25):2880-1.
Lal, S. M.; Twardowski, Z. J.; Van Stone, J.; Keniston, D.; Scott, W. J.; Berg, G. G.; Nichols, W. K.Benign intracranial hypertension: a complication of subclavian vein catheterization and arteriovenous fistula. Case Reports Am J Kidney Dis. 1986 Oct;8(4):262-4. doi: 10.1016
Bell, J.; Goyal, M.; Long, S.; Kumar, A.; Friedrich, J.; Garfinkel, J.; Chung, S.; Fitzgibbons, S. Anatomic Site-Specific Complication Rates for Central Venous Catheter Insertions. Multicenter Study J Intensive Care Med. 2020 Sep;35(9):869-874. doi: 10.1177/0885066618795126
Bessereau, J.; Genotelle, N.; Chabbaut, C.; Huon, A.; Tabah, A.; Aboab, J.; Chevret, S.; Annane, D. Long-term outcome of iatrogenic gas embolism. Intensive Care Med. 2010 Jul;36(7):1180-7. doi: 10.1007/s00134-010-1821-9. Epub 2010 Mar 11
Calvert, N.; Hind, D.; McWilliams, R. G.; Thomas, S. M.; Beverley, C.; Davidson, A. The effectiveness and cost-effectiveness of ultrasound locating devices for central venous access: a systematic review and economic evaluation. Health Technol Assess. 2003;7(12):1-84. doi: 10.3310
Eum, D. H.; Lee, S. H.; Kim, H. W.; Jung, M. J.; Lee, J. G. Cerebral air embolism following the removal of a central venous catheter in the absence of intracardiac right-to-left shunting: a case report. Case Reports Medicine (Baltimore). 2015 Apr;94(13):e630. doi: 10.1097