A Reevaluation of the Radiographically Detectable Complications of Percutaneous Venous Access Lines Inserted by Four Subcutaneous Approaches (1999)

As a result of prior studies elucidating the potential complications associated with the use of central venous access lines, the Food and Drug Administration and the manufacturers themselves have published guidelines and warnings outlining these dangers and describing the safest insertion techniques. We will attempt to determine whether this improved education has altered the number and type of complications, comparing the results from different types of hospitals, among the various medical services and among operators with varying degrees of experience. This is a prospective analysis of all central venous pressure (CVP) and Swanz-Ganz catheters (SGCs) inserted between July 1, 1995, and February 30, 1996, at a regional Veteran's Affairs hospital and an inner city university medical center. Three hundred seventy-five inpatients underwent 417 new percutaneous venous catheter placements while in the medical or surgical intensive care units or in the general care wards. A portable chest radiograph was obtained immediately after each procedure, and the position of the catheter and any associated complications were recorded, initially by the radiology resident in the emergency suite and subsequently as confirmed by a chest radiology attending. CVP lines were considered malpositioned when the tip was not located in the superior vena cava, and SGCs were recorded as misplaced when the tip was not found within the main, left main, right main, or either lower lobe pulmonary artery within 2 cm of the cardiac border. For patients undergoing CVP line placement, the right atrium was the most frequent site of tip malposition with 38 of 69 total misplacements (55%), whereas for SGCs, 22 of 55 malplacements (40%) were too distal in a lower lobe pulmonary artery. Only 1 of 248 CVP lines resulted in a pneumothorax (PTX; 0.4%), whereas 6 of 169 SGC insertions caused a PTX (3.5%), a significant difference (P=0.019). Five of 192 catheters (2.6%) placed via an internal jugular approach resulted in PTX, whereas only 2 of 150 subclavian cannulations (1.3%) caused this complication, revealing a trend, but not reaching statistical significance (P=0.473). However, there was a significant decrease in the rate of catheter misplacements in the third part of the month compared with the first 20 days (35% versus 24%; P=0.031), and the Veteran's Affairs hospital displayed a trend toward more complications for SGC insertions than the university hospital (47% versus 32%), but not for CVP lines. In general, individual medical and surgical services displayed a similar frequency of complications (29-38%), except for CVP lines inserted in the medical intensive care unit. Venous access catheter tip malpositions are very common in all settings, but easily recognized by radiography, whereas PTXs are unusual. In contrast to most older studies, PTXs are more frequently observed with internal jugular as opposed to subclavian cannulations and with SGCs rather than CVP lines. However, our data support prior studies that the right atrium and distal right lower lobe pulmonary artery are the most common sites for CVP and SGC misplacement, respectively, and that there is an improvement in success rates with increasing operator experience.