To the Editor: The review by McGee and Gould entitled "PreventingComplications of Central Venous Catheterization" (March 20 issue)1convincingly shows that there are substantial data from clinicalstudies to guide the performance of this important procedure.For example, the authors advocate the use of full sterile-barrierprecautions because they have been proven to reduce the incidenceof catheter-related infections.2 A recent consensus statementfrom the Centers for Disease Control and Prevention and 13 professionalmedical societies also mandates the use of full sterile-barrierprecautions.3 Unfortunately, in the instructional video thataccompanies the review, the physicians do not wear sterile gowns.The prevalence of physicians' noncompliance with guidelinesfor the use of full sterile-barrier precautions is unknown,but it may be high, given the frequency of catheter-relatedinfections.4 The medical community should create incentivesfor adherence to the best-practice guidelines stated in thereview.
David A. Berlin, M.D. Weill Medical College of Cornell University New York, NY 10021 berlind-d{at}lycos.com
References
McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123-1133. [Free Full Text]
Raad II, Hohn DC, Gilbreath BJ, et al. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiol 1994;15:231-238. [ISI][Medline]
O'Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the prevention of intravascular catheter-related infections. MMWR Morb Mortal Wkly Rep 2002;51:1-29. [Medline]
Singh S. Prevention of intravascular catheter-associated infections. In: Shojania KG, Duncan BW, McDonald KM, et al., eds. Making health care safer: a critical analysis of patient safety practices. Evidence report/technology assessment no. 43. Rockville, Md.: Agency for Healthcare Research and Quality, July 2001:163-84. (AHRQ publication no. 01-E058.)
To the Editor: In Table 1 of their article, McGee and Gouldsuggest that the use of maximal sterile-barrier precautionsduring catheter insertion may decrease the risk of infectiouscomplications. However, the accompanying video shows the operatorwearing only gloves. Clearly visible in the video is the operator'sidentification badge, which has the potential to contaminatethe wire. Our institution requires a surgical scrub, removalof rings and watches, and the use of sterile gowns and gloves.Some institutions now use full-body draping. In addition, ademonstration of ultrasound guidance would have made the videomore educational. Although the video may provide a good demonstrationof the mechanical aspects of placing a central venous catheter,it fails to show how to minimize the complications that arethe subject of the article.
Lee S. Perrin, M.D. Caritas St. Elizabeth's Medical Center Boston, MA 02135
To the Editor: McGee and Gould state that "subclavian venouscatheterization carries the lowest risk of catheter-relatedthrombosis" and advocate this route rather than the internaljugular vein for central venous access. This recommendationis based on a single study1 in which bedside Doppler ultrasoundexamination of the accessed vein was performed at the time ofcatheter removal. Images of central venous outflow (throughthe innominate vein and superior vena cava) was not imaged.None of the patients with positive findings had symptoms, andnone received a diagnosis of pulmonary embolism. However, multiplestudies have shown the opposite — that subclavian venouscatheterization results in a much higher incidence of venousstenosis and thrombosis than does catheterization with internaljugular venous access.2,3,4 These studies used contrast venography,allowing complete evaluation of central venous outflow. Moreover,the incidence of symptomatic lesions has been shown to be significantlyhigher with subclavian access than with internal jugular access.2,3These findings are certainly echoed at our institution, wheremembers of our interventional radiology service insert morethan 1500 venous-access devices each year and where we routinelydeal with complications of venous access.
George D. Soltes, M.D. Merle H. Barth, M.D. John O. Roehm,M.D. Methodist Hospital Houston, TX 77030 gsoltes{at}tmh.tmc.edu
References
Timsit JF, Farkas JC, Boyer JM, et al. Central vein catheter-related thrombosis in intensive care patients: incidence, risk factors, and relationship with catheter-related sepsis. Chest 1998;114:207-213. [Free Full Text]
Trerotola SO, Kuhn-Fulton J, Johnson MS, Shah H, Ambrosius WT, Kneebone PH. Tunneled infusion catheters: increased incidence of symptomatic venous thrombosis after subclavian versus internal jugular venous access. Radiology 2000;217:89-93. [Free Full Text]
Macdonald S, Watt AJ, McNally D, Edwards RD, Moss JG. Comparison of technical success and outcome of tunneled catheters inserted via the jugular and subclavian approaches. J Vasc Interv Radiol 2000;11:225-231. [ISI][Medline]
Cimochowski GE, Worley E, Rutherford WE, Sartain J, Blondin J, Harter H. Superiority of the internal jugular over the subclavian access for temporary dialysis. Nephron 1990;54:154-161. [ISI][Medline]
To the Editor: McGee and Gould's article on preventing complicationsduring central venous catheterization is informative and wellillustrated. However, the authors do not adequately addressthe complication of pneumothorax after internal jugular venouscannulation. Instead of inserting the needle between the headsof the sternocleidomastoid muscle low in the neck, as they suggest,a more cranial and lateral approach is advantageous. The puncturesite is posterolateral to the sternocleidomastoid muscle, halfwaybetween the mandible and the clavicle. Inadvertent carotid punctureis still possible, but initially aiming superficially and then"walking" the needle down until venous blood is returned willresult in a high rate of successful cannulation and virtuallyeliminate the risk of inadvertent pleural entry. This pointis of great importance in patients receiving positive-pressureventilation, in whom puncture of the lung may result in thedevelopment of a tension pneumothorax.
Kenneth Ouriel, M.D. Cleveland Clinic Foundation Cleveland, OH 44195
To the Editor: McGee and Gould recommend the use of chlorhexidine-basedrather than povidone–iodine solutions for skin preparation.However, the occurrence of immediate, life-threatening hypersensitivityreactions has been described after the insertion of centralvenous catheters impregnated with chlorhexidine, after the intraurethraluse of chlorhexidine, and after the topical application of chlorhexidine.1,2,3Indeed, in more than 60 published cases the diagnosis of anaphylaxisdue to chlorhexidine was confirmed. The severity of these casesprompted the Food and Drug Administration (FDA), in 1998, toissue an alert to the medical community about the potentialfor serious hypersensitivity reactions to chlorhexidine-impregnatedmedical devices.4
Pascale Dewachter, M.D., Ph.D. Claudie Mouton-Faivre, M.D. Paul-Michel Mertes, M.D., Ph.D. Hôpital Central 54035 Nancy, France pascale.dewachter{at}wanadoo.fr
References
Terazawa E, Shimonaka H, Nagase K, Masue T, Dohi S. Severe anaphylactic reaction due to a chlorhexidine-impregnated central venous catheter. Anesthesiology 1998;89:1296-1298. [Medline]
Garvey LH, Roed-Petersen J, Husum B. Anaphylactic reactions in anaesthetised patients -- four cases of chlorhexidine allergy. Acta Anaesthesiol Scand 2001;45:1290-1294. [CrossRef][ISI][Medline]
Chisholm DG, Calder I, Peterson D, Powell M, Moult P. Intranasal chlorhexidine resulting in anaphylactic circulatory arrest. BMJ 1997;315:785-785. [Erratum, BMJ 1998;316:441.] [Free Full Text]
Center for Devices and Radiological Health. FDA public health notice: potential hypersensitivity reactions to chlorhexidine-impregnated medical devices. Rockville, Md.: Food and Drug Administration, March 1998. (Accessed June 6, 2003, at http://www.fda.gov/cdrh/chlorhex.html.)
To the Editor: McGee and Gould do not mention the routine useof chest films to identify malpositioning of catheters. Whenblind-access procedures are used, catheter malpositioning isfrequently an unavoidable but correctable error, and complicationsare therefore usually preventable by immediate repositioning.
It is essential to ensure that the catheter tip is in the distalportion of the superior vena cava, just above the right atrium,in the longitudinal plane. Preventable complications includetachyarrhythmias or delayed pericardial tamponade, delayed contralateralhydrothorax, ipsilateral internal jugular or contralateral subclavianintubation with early thrombosis, and late progression of smallpneumothoraxes.1
Francis A. Beer, M.D. Waltham Hospital Waltham, MA 02452 fbeermd{at}msn.com
References
Bowdle TA. Central line complications from the ASA Closed Claims Project: an update. Vol. 66. No. 6. ASA Newsletter. June 2002:11-2, 25. (Washington, D.C.: American Society of Anesthesiology.)
To the Editor: In their excellent review, McGee and Gould correctlyemphasize knowledge of the venous anatomy of the neck. I suggestthat similar knowledge of thoracic venous anatomy and its variationsis also essential for anyone who inserts these catheters.1 Radiologistsoccasionally see the tips of central venous catheters in azygosveins, internal thoracic veins, and anomalies such as a leftsuperior vena cava. Few residents who insert catheters recognizethese venous structures.
Mark J. Towers, F.R.C.R. Our Lady's Hospital Navan, County Meath, Ireland mark.towers{at}nehb.ie
References
Godwin JD, Chen JT. Thoracic venous anatomy. AJR Am J Roentgenol 1986;147:674-684. [Free Full Text]
The authors reply: We thank Drs. Berlin and Perrin for reemphasizingthat full sterile-barrier precautions should be used when insertinga central venous catheter. Because it is difficult to changephysicians' behavior, we agree with Dr. Berlin that appropriateincentives should be devised to encourage this practice.
Dr. Soltes and colleagues argue that the rate of catheter-relatedthrombosis or stenosis is higher with catheters that are placedat the subclavian site than with those placed at the internaljugular site, in contrast to the findings of Timsit et al.1To support their argument, they cite studies of variable qualitythat enrolled patients with dialysis catheters or tunneled infusioncatheters, which were not the focus of our review. If Dr. Soltesand his group have collected data on the risk of thrombosisassociated with the use of standard, nontunneled catheters thatcontradict the findings of Timsit et al., we encourage themto publish their findings.
Dr. Ouriel is concerned that we did not address the risk ofpneumothorax after internal jugular catheterization. However,in Table 2 of our article, we cite data showing that pneumothoraxoccurs infrequently during catheterization at this site. Toour knowledge, no one has shown that the risk of pneumothoraxis lower when internal jugular catheterization is performedthrough the posterior approach, although this seems plausibleon the basis of anatomical considerations. We agree that itis useful to be familiar with multiple approaches for placingcentral venous catheters, and we thank Dr. Ouriel for describingthe technique of posterolateral insertion.
Dr. Dewachter and colleagues warn that cases of anaphylaxishave been linked to the use of chlorhexidine-impregnated catheters.For reasons that are not known, most cases have occurred inJapan, prompting voluntary withdrawal of these catheters fromthe Japanese market in August 1997.2 Fortunately, since theFDA issued its public health notice on this matter in March1998, only one additional case of immediate hypersensitivityto a chlorhexidine-impregnated catheter has been reported inthe United States (Yoder DL, FDA: personal communication). Therisk of this very rare but potentially life-threatening complicationmust be weighed against the much greater risk of catheter-relatedbloodstream infection, which is also potentially life-threatening.
Finally, we agree with Drs. Beer and Towers that radiographsof the chest should be obtained and knowledge of thoracic venousanatomy should be applied to confirm that a newly placed catheteris positioned correctly.
Michael K. Gould, M.D. Stanford University School of Medicine Stanford, CA 94305
David C. McGee, M.D. East Bay Pulmonary Medical Group SanPablo, CA 94806
References
Timsit JF, Farkas JC, Boyer JM, et al. Central vein catheter-related thrombosis in intensive care patients: incidence, risk factors, and relationship with catheter-related sepsis. Chest 1998;114:207-213. [Free Full Text]
Center for Devices and Radiological Health. Potential hypersensitivity reactions to chlorhexidine-impregnated medical devices. Rockville, Md.: Food and Drug Administration, March 1998. (Accessed June 6, 2003, at http://www.fda.gov/cdrh/chlorhex.html.)
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