Arterial and Central Venous Catheters

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Chapter 11 Arterial and Central Venous Catheters

Hovig V. Chitilian, MD

1 What are the indications for intraarterial blood pressure monitoring?

image Inability to obtain noninvasive blood pressure measurements (i.e., burn or multitrauma patient with all extremities affected; during cardiopulmonary bypass; in patients with left ventricular assist devices)

image Need for beat-to-beat monitoring of blood pressure because of patient’s underlying condition

image Need for multiple blood drawings for laboratory testing

2 Which are the common sites for intraarterial catheter placement? What is the effect of the catheter site on the measured blood pressure?

The common sites are the radial, brachial, axillary, femoral, and dorsalis pedis arteries. As the monitoring site is moved further distally in the arterial tree, systolic pressures increase and diastolic pressures decrease when compared with central arterial pressure. The mean arterial pressure, however, remains the same between peripheral and central arterial waveforms.

3 What additional data can be determined from the intraarterial pressure waveform?

In addition to direct pressure measurements, the arterial pressure waveform can be used to determine a patient’s fluid responsiveness, as well as cardiac output. Changes in the arterial pressure waveform with mechanical ventilation have been shown to predict fluid responsiveness (a measurable increase in stroke volume with the administration of fluid). Goal-directed intraoperative fluid management based on arterial waveform changes has been shown to improve outcome in patients undergoing high-risk surgery. In addition, a number of commercially available devices exist that allow the continuous measurement of cardiac output with use of arterial pressure waveform analysis.

4 What are the most common complications of arterial catheterization?

Vascular insufficiency (3%-5%), bleeding (1.5%-2.5%), and infection (< 1%)

5 What are the risk factors for vascular complications in patients with intraarterial catheters?

Concomitant use of vasopressors, prior arterial injury, duration of cannulation longer than 48 or 72 hours, hematoma formation, presence of disseminated intravascular coagulation, reduced cardiac output, and female sex

6 What is the risk of permanent distal ischemic damage?

Studies have suggested that the rate of arterial occlusion is lower in axillary and femoral catheters compared with radial artery catheters; however, the rate of permanent distal ischemic damage is comparable at 0.1% to 0.2%. The incidence of permanent ischemic damage to the hand after radial artery catheterization has been reported to be 0.09%.

7 Is the modified Allen’s test useful?

There is no evidence that the modified Allen’s test (a test of circulatory supply to the hand based on alternating occlusion of the radial and ulnar arteries) can predict hand ischemia with radial artery cannulation.

8 What is the risk of arterial catheter–related bloodstream infection (BSI)?

The incidence of BSIs associated with arterial catheters is 0.8% or 1.7 per 1000 catheter days. Data are conflicting regarding the association of the site of catheterization with risk of infection with some studies suggesting that radial or dorsalis pedis arterial sites are associated with a decreased incidence of BSI when compared with the femoral artery.

9 What measures can be taken to reduce the risk of BSI associated with intraarterial catheters?

The Centers for Disease Control and Prevention do not recommend routine replacement of peripheral arterial catheters at fixed time intervals as a method for preventing catheter-related BSIs. The use of full-barrier sterile precautions (chlorhexidine skin preparation, mask, hat, sterile gloves, gown, and sheet) has not been shown to reduce the risk of bacterial colonization or BSI when compared with the use of hand washing, chlorhexidine preparation, and sterile gloves for the placement of radial or dorsalis pedis arterial catheters.

10 What are the indications for central venous cannulation?

image Monitoring cardiac filling pressures

image Rapid administration of fluid

image Intravenous administration of drugs or fluids that are potentially damaging to peripheral veins or tissues (vasoactive medications, parenteral nutrition)

image Insertion of pulmonary artery catheter or transvenous pacing wires

image Aspiration of air embolus

image Access for hemodialysis or hemofiltration

image Venous access in the instance of difficult peripheral venous access

11 Which veins are commonly used, and how are they accessed?

The most commonly accessed central veins are the internal jugular, the subclavian, and the femoral veins. With use of either anatomic landmarks or ultrasound guidance, the vein is accessed percutaneously with a finder needle of a gauge smaller than the catheter. A guidewire is then passed through the needle and into the vein. The needle is removed, and a dilator is passed over the wire and into the vein to dilate the tissues and venous entry point. The dilator is removed, and the catheter is then passed over the wire and into the vein.

12 What are the complications associated with central venous catheterization?

It is estimated that more than 15% of patients who receive central venous catheters have complications. Significant complications include arterial puncture, hematoma, pneumothorax, hemothorax, air embolus, and bloodstream infections. The risk of each complication varies with the location of the vein that is cannulated. The most common mechanical complications are arterial puncture, hematoma, and pneumothorax. Internal jugular venous catheterization and subclavian venous catheterization carry similar risks of mechanical complications. Subclavian venous cannulation carries the highest risk of pneumothorax (1.5%-3%). Femoral venous cannulation carries the highest risk of arterial puncture (9%-15%) followed by internal jugular venous cannulation (6%-9.5%).

13 Is there any benefit to the use of ultrasound guidance?

The use of ultrasound guidance for central venous catheterization has been shown to reduce the number of cannulation attempts, as well as the incidence of a number of mechanical complications, including arterial puncture, hematoma, pneumothorax, brachial plexus injury, and infection. The data showing the benefit of ultrasound guidance of central venous catheterization has prompted regulatory agencies in both the United States and Europe to recommend the routine use of ultrasound guidance for establishing central venous access.

14 How can ultrasound be used to establish central venous access?

Ultrasound-guided vascular access should be conducted with a linear probe using a 7- to 12-MHz frequency range. In general, imaging with higher ultrasound frequencies yields greater resolution but lower penetration. The use of lower ultrasound frequencies yields greater penetration but reduced resolution. Blood vessels can be visualized in the long axis (ultrasound beam parallel to the vessel) or in the short axis (ultrasound beam perpendicular to the vessel). Likewise, the needle can be visualized in the plane of the ultrasound beam and parallel to it (in-plane visualization) or perpendicular to the plane of the ultrasound beam (out of plane). During imaging, the ultrasound probe should always be held perpendicular to the skin. The relevant ultrasound anatomy should be identified in the short axis, and the vein of interest should be examined for evidence of thrombosis or aberrant anatomy. The vessel of interest should be centered on the screen, and its depth should be noted. Veins should be distinguished from arteries on the basis of their thinner walls, compressibility, and nonpulsatile flow.

15 What is the risk of central venous catheter–related bloodstream infection (CRBSI)?

It is estimated that approximately 80,000 central venous CRBSIs occur in intensive care units in the United States each year. The total associated cost has been estimated to be $0.67 to $2.7 billion.

16 What are the risk factors for CRBSI in patients with central venous catheters?

image Prolonged hospitalization before catheterization

image Prolonged duration of catheterization

image Heavy microbial colonization at the insertion site

image Heavy microbial colonization of the catheter hub

image Internal jugular venous catheterization

image Neutropenia

image Total parenteral nutrition through the catheter

image Substandard care of the catheter

The subclavian site of insertion is associated with the lowest risk of CRBSI.

17 What is the pathogenesis of CRBSI?

CRBSI arises from bacterial colonization of the central venous catheter. The two methods of colonization are:

image Migration of bacteria along the skin-catheter interface

image Contamination of a catheter access port

Common bacterial pathogens in hospital-acquired CRBSI include coagulase-negative Staphylococcus aureus, S. aureus, Enterococcus species, Candida species, Escherichia coli, and Klebsiella species.

18 How is a CRBSI diagnosed?

CRBSI should be suspected in patients who have evidence of a BSI (such as fever) and an indwelling central venous catheter. The Infectious Diseases Society of America (IDSA) guidelines recommend that the diagnosis be confirmed with simultaneous quantitative blood cultures drawn through the central venous catheter and a peripheral vein with at least a threefold greater colony count from the central line sample. Alternatively, the diagnosis can be made if the blood culture drawn from the catheter becomes positive over a 2-hour period before the simultaneously drawn peripheral culture.

19 How is a CRBSI treated?

Once cultures are obtained, treatment of CRBSI involves removal of the catheter and initiation of systemic antibiotics. Because gram-positive cocci are the most common pathogens, empiric therapy with vancomycin is recommended until culture results and sensitivities are obtained. In patients who receive total parenteral nutrition, are taking a prolonged course of broad-spectrum antibiotics, have a hematologic malignancy, have had stem cell or solid organ transplantation, or have femoral catheterization, empiric coverage should include antibiotics with activity against gram-negative bacilli and Candida species.

20 What steps are recommended to prevent CRBSI?

Recommendations by the IDSA to prevent CRBSI include

image Performance of hand hygiene before catheter insertion

image Centralization of central line insertion supplies in a line cart or kit

image Use of maximal sterile barrier precautions

image Skin preparation with 2% chlorhexidine-based antiseptic

image Preferential use of the subclavian vein and avoidance of the femoral vein

image Disinfection of catheter ports before access

image Evaluation of the need for continued central catheter use on a daily basis

The use of ultrasound guidance for central venous catheter insertion has also been shown to reduce the risk of CRBSI.

Key Points Arterial and Central Venous Cathetersimage

1. Indications for intraarterial blood pressure monitoring: inability to obtain noninvasive blood pressure measurements, need for beat-to-beat monitoring of blood pressure, need for multiple blood drawings for laboratory testing.

2. Common complications of intraarterial catheter placement: vascular insufficiency, hematoma, and infection.

3. Common indications for central venous cannulation: monitoring of cardiac filling pressures, central administration of drugs, rapid administration of fluid, and insertion of pulmonary artery catheter.

4. Prevention of central venous CRBSIs includes performance of hand hygiene before catheter insertion, use of maximal sterile barrier precautions, preferential use of the subclavian vein, and skin preparation with 2% chlorhexidine-based antiseptic.

Bibliography

1 Brzezinski M., Luisetti T., London M.J. Radial artery cannulation: a comprehensive review of recent anatomic and physiologic investigations. Anesth Analg. 2009;109:1763–1781.

2 de Waal E.E.C., Wappler F., Buhre W.F. Cardiac output monitoring. Curr Opin Anesthesiol. 2009;22:71–77.

3 Fragou M., Grawanis A., Dimitriou V., et al. Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: a prospective randomized study. Crit Care Med. 2011;39:1607–1612.

4 Frezza E.E., Mezghebe H. Indications and complications of arterial catheter use in surgical or medical intensive care units: analysis of 4932 patients. Am Surg. 1998;64:127–131.

5 Karakitsos D., Labropoulos N., De Groot E., et al. Real-time ultrasound-guided catheterisation of the internal jugular vein: a prospective comparison with the landmark technique in critical care patients. Crit Care. 2006;10:R162.

6 Lipira A.B., Mackinnon S.E., Fox I.K. Axillary arterial catheter use associated with hand ischemia in a multi-trauma patient: case report and literature review. J Clin Anesth. 2011;23:325–328.

7 Maki D.G., Kluger D.M., Crnich C.J. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc. 2006;81:1159–1171.

8 Making health care safer. a critical analysis of patient safety practices. In Agency for Healthcare Research and Quality publication 01-E058. Rockville: Maryland;; Jul 20, 2001.

9 Mark J.B., Barbeito A. Arterial and central venous pressure monitoring. Anesthesiol Clin. 2006;24:717–735.

10 McGee D.C., Gould M.K. Preventing complications of central venous catheterization. N Engl J Med. 2003;348:1123–1133.

11 Michard F. Stroke volume variation: from applied physiology to improved outcomes. Crit Care Med. 2011;39:402–403.

12 O’Grady N.P., Alexander M., Dellinger E.P., et al. Guidelines for the prevention of intravascular catheter–related infections. Am J Infect Control. 2002;30:476–489.

13 Rijnders B.J.A., Wijngaerden E.V., Wilmer A., et al. Use of full sterile barrier precautions during insertion of arterial catheters: a randomized trial. Clin Infect Dis. 2003;36:743–748.

14 Scheer B., Perel A., Pfeiffer U.J. Clinical review: complications and risk factors of peripheral arterial catheters used for hemodynamic monitoring in anaesthesia and intensive care medicine. Crit Care. 2002;6:199–204.

15 Weber D.J., Rutala W.A. Central line–associated bloodstream infections: prevention and management. Infect Dis Clin North Am. 2011;25:77–102.

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Chapter 11 Arterial and Central Venous Catheters

Hovig V. Chitilian, MD

1 What are the indications for intraarterial blood pressure monitoring?

image Inability to obtain noninvasive blood pressure measurements (i.e., burn or multitrauma patient with all extremities affected; during cardiopulmonary bypass; in patients with left ventricular assist devices)

image Need for beat-to-beat monitoring of blood pressure because of patient’s underlying condition

image Need for multiple blood drawings for laboratory testing

2 Which are the common sites for intraarterial catheter placement? What is the effect of the catheter site on the measured blood pressure?

The common sites are the radial, brachial, axillary, femoral, and dorsalis pedis arteries. As the monitoring site is moved further distally in the arterial tree, systolic pressures increase and diastolic pressures decrease when compared with central arterial pressure. The mean arterial pressure, however, remains the same between peripheral and central arterial waveforms.

3 What additional data can be determined from the intraarterial pressure waveform?

In addition to direct pressure measurements, the arterial pressure waveform can be used to determine a patient’s fluid responsiveness, as well as cardiac output. Changes in the arterial pressure waveform with mechanical ventilation have been shown to predict fluid responsiveness (a measurable increase in stroke volume with the administration of fluid). Goal-directed intraoperative fluid management based on arterial waveform changes has been shown to improve outcome in patients undergoing high-risk surgery. In addition, a number of commercially available devices exist that allow the continuous measurement of cardiac output with use of arterial pressure waveform analysis.

4 What are the most common complications of arterial catheterization?

Vascular insufficiency (3%-5%), bleeding (1.5%-2.5%), and infection (< 1%)

5 What are the risk factors for vascular complications in patients with intraarterial catheters?

Concomitant use of vasopressors, prior arterial injury, duration of cannulation longer than 48 or 72 hours, hematoma formation, presence of disseminated intravascular coagulation, reduced cardiac output, and female sex

6 What is the risk of permanent distal ischemic damage?

Studies have suggested that the rate of arterial occlusion is lower in axillary and femoral catheters compared with radial artery catheters; however, the rate of permanent distal ischemic damage is comparable at 0.1% to 0.2%. The incidence of permanent ischemic damage to the hand after radial artery catheterization has been reported to be 0.09%.

7 Is the modified Allen’s test useful?

There is no evidence that the modified Allen’s test (a test of circulatory supply to the hand based on alternating occlusion of the radial and ulnar arteries) can predict hand ischemia with radial artery cannulation.

8 What is the risk of arterial catheter–related bloodstream infection (BSI)?

The incidence of BSIs associated with arterial catheters is 0.8% or 1.7 per 1000 catheter days. Data are conflicting regarding the association of the site of catheterization with risk of infection with some studies suggesting that radial or dorsalis pedis arterial sites are associated with a decreased incidence of BSI when compared with the femoral artery.

9 What measures can be taken to reduce the risk of BSI associated with intraarterial catheters?

The Centers for Disease Control and Prevention do not recommend routine replacement of peripheral arterial catheters at fixed time intervals as a method for preventing catheter-related BSIs. The use of full-barrier sterile precautions (chlorhexidine skin preparation, mask, hat, sterile gloves, gown, and sheet) has not been shown to reduce the risk of bacterial colonization or BSI when compared with the use of hand washing, chlorhexidine preparation, and sterile gloves for the placement of radial or dorsalis pedis arterial catheters.

10 What are the indications for central venous cannulation?

image Monitoring cardiac filling pressures

image Rapid administration of fluid

image Intravenous administration of drugs or fluids that are potentially damaging to peripheral veins or tissues (vasoactive medications, parenteral nutrition)

image Insertion of pulmonary artery catheter or transvenous pacing wires

image Aspiration of air embolus

image Access for hemodialysis or hemofiltration

image Venous access in the instance of difficult peripheral venous access

11 Which veins are commonly used, and how are they accessed?

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