Effect of ultrasound-guided central venous catheter insertion on the incidence of catheter-related bloodstream infections and mechanical complications

How to improve the efficiency and the safety of real-time ultrasound-guided central venous catheterization in 2023: a narrative review

Central venous catheterization (CVC) is a frequent procedure, practiced by intensivists, anesthesiologists and advanced practice nurses in intensive care units and operative rooms. To reduce CVC-associated morbidity, it is essential to strive for best practices, based on the latest evidence. This narrative review aims to synthesize current knowledge on evidence-based best practices for CVC that improve the use and feasibility of real-time ultrasound-guided insertion procedures. Optimization of the vein puncture technique and the development of new technologies are discussed to reinforce the use of the subclavian vein catheterization as first choice. The search for alternative site of insertions, without increasing infectious and thrombotic risks, deserves further research.

Incidence of catheter-related bloodstream infections following ultrasound-guided central venous catheterization: a systematic review and meta-analysis

Background

Ultrasonographic guidance is widely used for central venous catheterization. Several studies have revealed that ultrasound-guided central venous catheterization increases the rate of success during the first attempt and reduces the procedural duration when compared to the anatomical landmark-guided insertion technique, which could result in protection from infectious complications. However, the effect of ultrasound-guided central venous catheterization on catheter-related bloodstream infections remains unclear. We aimed to conduct a systematic review and meta-analysis to evaluate the value of ultrasound guidance in preventing catheter-related bloodstream infections and catheter colonization associated with central venous catheterization.

Methods

The Cochrane Central Register of Controlled Trials (CENTRAL) and MEDLINE (via PubMed) were searched up to May 9, 2022 for randomized controlled trials (RCTs) comparing ultrasound-guided and anatomical landmark-guided insertion techniques for central venous catheterization. Risk of bias was assessed using the Cochrane Risk of Bias 2 (RoB 2) tool for RCTs. A meta-analysis was performed for catheter-related bloodstream infections and catheter colonization, as primary and secondary outcomes, respectively.

Results

Four RCTs involving 1268 patients met the inclusion criteria and were analyzed. Ultrasound-guided central venous catheterization was associated with a slightly lower incidence of catheter-related bloodstream infections (risk ratio, 0.46; 95% confidence interval [CI], 0.16–1.32) and was not associated with a lower incidence of catheter colonization (risk ratio, 1.36; 95% CI, 0.57–3.26).

Conclusion

Ultrasound-guided central venous catheterization might reduce the incidence of catheter-related bloodstream infections. Additional RCTs are necessary to further evaluate the value of ultrasound guidance in preventing catheter-related bloodstream infections with central venous catheterization.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07760-1.

Management of a malpositioned central venous catheter in the accessory hemiazygos vein

Malposition of a central venous catheter (CVC) in the accessory hemiazygos vein is an uncommon but potentially fatal complication; however, there is limited information regarding the preferred removal technique. We report a patient, a 57-year-old woman, who presented with overdose of her prescribed sedatives, who experienced this catheter complication after CVC insertion in the left internal jugular vein. The CVC was placed without resistance but routine postplacement chest X-ray showed abnormal coursing of the catheter close to the descending aorta. We used non-enhanced CT as an adjunct to safely identify the catheter position and assess for any bleeding during removal. CT images taken after retraction of the catheter tip by 10 cm showed no bleeding and we were able to remove the catheter safely. We recommend using CT as an adjunct to safely remove malpositioned catheters and reduce the risk of further complication.

Incidence of central line associated bloodstream infection following central venous catheter placement in the emergency department

INTRODUCTION

Central line-associated bloodstream infections (CLABSI) are costly and can be lifethreatening. Many efforts have been taken to minimize the rates of infection, including sterile technique, pre-packaged sterile kits, site selection, and replacing infected or potentially infected lines. This study aims to identify the incidence of CLABSI following catheter placement in the ED, and to compare rates of CLABSI among ED and ICU placed catheters.

METHODS

This retrospective chart review was conducted at a Level 1 Trauma Center. Eligibility criteria included patients who had CVC placed in the ED or ICU from January 1st, 2018, through July 31st, 2019 who were 18 years or older.

RESULTS

Among 1810 patients with central lines, 1254 met eligibility criteria. There was no significant difference in infection rates when comparing lines placed in the ED (2.5 per 1000 catheter days, 95% confidence interval [CI] 0.8 to 5.8) compared to those placed in the ICU (4.6 per 1000 catheter days, 95% CI 3.0 to 6.8). The odds of CLABSI was not associated with age, sex, indication, site, location nor which type of health care professional (HCP) placed the line.

CONCLUSIONS

In this study, the incidence of infection was no different between lines placed in the ED compared to the ICU.

What is new in catheter use and catheter infection prevention in the ICU

PURPOSE OF REVIEW

Short-term intravascular catheters are instrumental in the care of critically ill patients. Despite their benefits, they also are potential entries for systemic infections. There is a growing body of literature on catheter use and the prevention of intravascular catheter infections in intensive care. This review highlights major recent contributions to the topic and put them into perspective to recommendations on best practice procedures.

RECENT FINDINGS

Many studies published in the last years have evaluated prevention strategies applying technology and addressing behavior change. Skin disinfection with 2% alcoholic chlorhexidine-gluconate (CHG) and CHG-impregnated dressings are increasingly used in clinical practice. However, the role of universal CHG bathing remains controversial. A number of new and innovative technologies are in development. Recent qualitative research offers new perspectives about behavior change interventions to improve implementation.

SUMMARY

Many options for effective intravascular catheter infection prevention are currently available. A number of recent systematic reviews and meta-analyses not only confirmed measures targeting best practice and technology at catheter insertion and catheter care but also challenged interventions, such as CHG bathing. More focus should be put to implementation strategies.

Changes in Central Venous Catheter Use in the Hematology Unit with the Introduction of Ultrasound Guidance and a Peripherally Inserted Central Venous Catheter

Objective A central venous catheter (CVC) is often needed to treat hematologic diseases, but it is accompanied by many complications. Ultrasound guidance (USG) or a peripherally inserted central venous catheter (PICC) can reduce such complications. Meterials We collected data of patients with attempted CVC placement in our hematology unit in 2012 (before introduction of USG and PICC) and 2018 (after introduction) and compared both periods. Results In total, 187 CVC insertions were attempted in 2018 and 198 in 2012. USG was used 154 times (82%) in 2018 and 4 times (2%) in 2012 (p<0.001). The success rates of insertion were 95% in 2018 and 89% in 2012 (p=0.063). The incidence of acute complications was 4.3% in 2018 and 9.1% in 2012 (p=0.069). The incidence of CVC removal owing to delayed complications was 26% in 2018 and 21% in 2012 (p=0.327). The sites of approach in 2018 and 2012 were the internal jugular in 42 (22%) and 54 (27%), subclavian in 52 (28%) and 128 (65%), brachial (PICC) in 89 (48%) and 14 (7%), and femoral in 4 (2%) and 2 (1%), respectively (p<0.001). Conclusion USG has become commonplace since its introduction. The landmark-based subclavian approach was largely replaced by PICC with USG in 2018. USG and PICC can help improve success rates and safety profiles.

Central venous catheter-related infections in hematology and oncology: 2020 updated guidelines on diagnosis, management, and prevention by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO)

Cancer patients frequently require central venous catheters for therapy and parenteral nutrition and are at high risk of central venous catheter-related infections (CRIs). Moreover, CRIs prolong hospitalization, cause an excess in resource utilization and treatment cost, often delay anti-cancer treatment, and are associated with a significant increase in mortality in cancer patients. We therefore summoned a panel of experts by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) and updated our previous guideline on CRIs in cancer patients. After conducting systematic literature searches on PubMed, Medline, and Cochrane databases, video- and meeting-based consensus discussions were held. In the presented guideline, we summarize recommendations on definition, diagnosis, management, and prevention of CRIs in cancer patients including the grading of strength of recommendations and the respective levels of evidence. This guideline supports clinicians and researchers alike in the evidence-based decision-making in the management of CRIs in cancer patients.

Ultrasound Guidance and Risk for Central Venous Catheter-Related Infections in the Intensive Care Unit: A Post Hoc Analysis of Individual Data of 3 Multicenter Randomized Trials

BACKGROUND

Ultrasound (US) guidance is frequently used in critically ill patients for central venous catheter (CVC) insertion. The effect of US on infectious risk remains controversial, and randomized controlled trials (RCTs) have assessed mainly noninfectious complications. This study assessed infectious risk associated with catheters inserted with US guidance vs use of anatomical landmarks.

METHODS

We used individual data from 3 large RCTs for which a prospective, high-quality data collection was performed. Adult patients were recruited in various intensive care units (ICUs) in France as soon as they required short-term CVC insertion. We applied marginal Cox models with inverse probability weighting to estimate the effect of US-guided insertion on catheter-related bloodstream infections (CRBSIs, primary outcome) and major catheter-related infections (MCRIs, secondary outcome).We also evaluated insertion site colonization at catheter removal.

RESULTS

Our post hoc analysis included 4636 patients and 5502 catheters inserted in 2088 jugular, 1733 femoral, and 1681 subclavian veins, in 19 ICUs. US guidance was used for 2147 catheter insertions. Among jugular and femoral CVCs and after weighting, we found an association between US and CRBSI (hazard ratio [HR], 2.21 [95% confidence interval {CI}, 1.17-4.16]; P = .014) and between US and MCRI (HR, 1.55 [95% CI, 1.01-2.38]; P = .045). Catheter insertion site colonization at removal was more common in the US-guided group (P = .0045) among jugular and femoral CVCs in situ for ≤7 days (n = 606).

CONCLUSIONS

In prospectively collected data in which catheters were not randomized to insertion by US or anatomical landmarks, US guidance was associated with increased risk of infection.

Reducing central vein catheterization complications with a focused educational program: a retrospective cohort study

Central venous catheters (CVCs) are frequently used, but the rate of complications is high. This study evaluates the effects of a short training program for CVC insertion in a university-based teaching hospital. A sample of adults with CVCs inserted outside the intensive care unit was selected from two academic years: 2015, year without structured training, and 2016, year with structured training. Clinical and laboratory information, as well as the procedure’s characteristics and complications (mechanical and infectious) were collected. The incidence of complications before and after the training was compared. A total of 1502 punctures were evaluated. Comparing the pre- and post-training period, there was an increase in the choice for jugular veins and the use of ultrasound. A numerical reduction in the rate of complications was identified (RR 0.732; 95% CI 0.48–1.12; P = 0.166). This difference was driven by a statistically significant lower rate of catheter-related infections (RR 0.78; 95% CI 0.64–0.95; P = 0.047). In the multivariate analysis, aspects regarding technique (ultrasound use, multiple punctures) and year of training were associated with outcomes. Structured training reduces the rate of complications related to CVC insertion, especially regarding infections.