CVAD recommendations for practice

Insertion of a central venous access device (CVAD) is a common hospital procedure and an estimated 15,000 devices are inserted in NSW ICUs every year (1). It is unclear how many CVADs are inserted in patients presenting to acute care facilities. Most commonly CVADs are inserted into the internal jugular, subclavian or femoral vein. A peripherally inserted device may be inserted via the cephalic or basilic vein. Insertion of a CVAD is not risk free for patients. Factors such as the inexperience of proceduralists, multiple needle passes, high or low body mass index, previous catheterisations, and severe dehydration or hypovolaemia increase the risks of complications associated with the procedure. Additionally, uncorrected coagulopathy and insertion of large bore devices place the patient at further risk for complications. Other major risks associated with CVAD insertion include infection, malposition, pneumothorax, thrombosis, vascular injury and air embolus (2).

The most frequent complication of post insertion care is infection and a large project to standardise aseptic insertion found the NSW ICU incidence reported at 1.2/1000 patient line days (1). Most infections are attributed to contamination from the insertion site or the catheter hub. Infection risk increases the longer a device is left in situ (3) and is perpetuated by biofilm formation, therefore many of the suggested management strategies in this document are in place to reduce infective risk.

Thrombosis is also a frequent occurrence with minimal clinical symptoms. There are many reasons for thrombosed CVADs including, but not limited to, endothelial injury, turbulence of the venous circulation, the catheter itself and the composition of the infusions delivered (2). A fibrin sheath usually develops soon after CVAD insertion, which contributes to catheter occlusion and may lead to vessel stenosis. For this reason there are a number of recommendations relating to maintaining lumen patency and while there is increasing interest in restoring patency through infusion of fibrinolytic agents, this guideline includes no specific recommendations related to that practice. Removal of CVADs has been highlighted due to the number of occurrences of air embolus in patients in NSW. This is a severe complication with an associated high morbidity and mortality. Air embolism may also occur with accidental hub disconnection or through a residual catheter track. For this reason there are a number of recommendations specific to CVAD removal.

References

  1. Burrell T, Mc Laws ML, Murgo M, Calabria E, Pantle AC, Herkes R. Aseptic insertion of central venous lines to reduce bacteraemia: The Central Line Associated Bacteraemia in NSW Intensive Care Units (CLAB ICU) Collaborative. MJA. 2011 6 June 2011;194(11):583-7.
  2. Kusminsky RE. Complications of central venous catheterization. Journal of the American College of Surgeons. 2007;204(4):681-96. PubMed PMID: 17382229.
  3. McLaws M-L, Burrell AR. Zero risk for central line-associated bloodstream infection: are we there yet? Critical Care Medicine. 2012;40(2):388-93. PubMed PMID: 22020239.

Disclaimer

The information on this page is general in nature and cannot reflect individual patient variation. It reflects Australian intensive care practice, which may differ from that in other countries. It is intended as a supplement to the more specific information provided by the doctors and nurses caring for your loved one. ICNSW attests to the accuracy of the information contained here but takes no responsibility for how it may apply to an individual patient. Please refer to the full disclaimer.