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January 19, 2021

Safe Central Venous Access in an Overburdened Health System

Author Affiliations
  • 1Division of Vascular Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
JAMA. 2021;325(3):299-300. doi:10.1001/jama.2020.20361

Case Summary

A previously healthy man, intubated in the intensive care unit (ICU) for respiratory failure due to coronavirus disease 2019 (COVID-19), required central venous access for vasopressor infusion. The intensivists were occupied managing other critically ill patients, so an available intern attempted to place a triple-lumen catheter in the right internal jugular vein using only anatomic landmarks for guidance. When the access needle was inserted, pulsatile return of blood was noted.

What Should Be Done Next?

  • Remove the needle and hold pressure.

  • Place a small single-lumen catheter to prevent bleeding.

  • Use a percutaneous closure device to close the puncture site.

  • Surgically expose the artery to remove the needle and repair the artery.

Consider the Options

With immediate recognition of the arterial puncture and only the access needle in place, the needle can safely be removed and prolonged pressure held over the site for 10 to 30 minutes.1 The risk of hematoma or pseudoaneurysm formation is low and can be further reduced by using a small 22-gauge or 25-gauge micropuncture needle for the access.1 The tract should not be dilated by placement of a single-lumen catheter. Percutaneous arterial closure devices have been effectively used off label for repair of iatrogenic carotid artery injuries associated with central venous access when a large-bore catheter has been placed.2 However, given that the artery was not dilated and the catheter was not yet placed, neither percutaneous closure nor surgical repair is indicated. In the unlikely event that despite prolonged pressure a hematoma or pseudoaneurysm results, surgical repair may be required.

Root Cause Analysis

This iatrogenic arterial injury associated with a central venous access procedure may have resulted from several factors, including failure to use ultrasound guidance, which is the contemporary standard practice, and central line placement attempt by an inexperienced and likely inadequately trained operator.3

Correct the Errors

Placement of central venous access, a routine occurrence in critical care units and emergency departments, poses a unique challenge during health care crises when experienced clinicians are overburdened with acutely ill patients. To better utilize the specialized skills of the available workforce and maximize patient safety during the COVID-19 pandemic, central venous access line teams have been developed to address the venous access needs of hospitalized patients.4,5 The teams typically include vascular surgeons, general surgeons, interventional radiologists, and anesthesiologists, all specialists with training and experience in central venous access. During the height of the COVID-19 pandemic and other health care emergencies, elective operations and procedures were deferred, freeing up personnel and resources that could serve on line insertion teams. These specialists also have experience identifying and managing the complications associated with these procedures. Some line insertion teams also placed arterial lines, orogastric and nasogastric tubes, and Foley catheters to further assist other overburdened clinicians.5

To evaluate the implementation and outcomes of these central venous access line teams, a cross-sectional, self-reported multi-institutional study was performed.5 Sixty hospitals in 13 countries and 37 US states contributed data regarding their experiences of creating and implementing line insertion teams. They also reported on technical aspects of the central venous access procedures in the pandemic setting and the management of associated iatrogenic complications. Of the 60 hospitals, 58 had designated teams of clinicians available for central line placement. Most of these hospitals did not have line insertion teams prior to the pandemic. Line insertion team protocols were rapidly developed to address urgent and unique venous access requirements during the pandemic. Most of the participating hospitals were urban, academic, university-affiliated hospitals with more than 400 beds. Data were collected between April 22 and May 4, 2020. Most line insertion teams provided services for ICU patients with positive or pending COVID-19 test results. Some teams also placed lines in COVID-19–negative patients to assist the overburdened ICU teams, and some also placed lines for patients in the medical/surgical units or in the emergency department. All centers continued to adhere to standard practice and use ultrasound guidance for central venous access procedures whenever possible, including confirming wire position in the long-axis ultrasound view.

There were 2657 lines placed in patients with positive, pending, and negative COVID-19 test results in the 20 participating sites that were able to report the total number of lines placed. Of these, 11 (0.41%) line placements were associated with iatrogenic complications, less than the expected complication rate of 4% to 9%.6-9 There were 2 inadvertent arterial catheter placements, 7 puncture-site bleeding episodes (hematoma or active bleeding), 1 pneumothorax, and 1 air embolism. The air embolism was in a patient with COVID-19 who was not intubated, and the patient died shortly thereafter. This was the only death reported from these sites that was directly related to an iatrogenic venous access complication. The lower-than-expected complication rate might have been attributable to the greater level of experience and expertise of the vascular access teams.

Line insertion teams managed a total of 48 iatrogenic complications in COVID-19–positive patients at 23 of the 60 participating sites. Most (39/48) complications were associated with line placement procedures performed by clinicians who were not part of the line insertion team. In 20 of the 48 complications, the participating site reported that the complications were attributable to insufficient operator experience and inadequate use of ultrasound or wire control during the procedures. Every line insertion team reported using ultrasound guidance for all procedures, but this was not the case for lines placed by clinicians who were not associated with the line insertion teams.

When initiating a central venous access line team, an appropriate schedule for the team’s activation should be established based on available resources and institutional needs. Ideally, the team should be available at all times and be able to provide service throughout the hospital; any limitations of hours or sites served should be communicated clearly to all relevant hospital personnel. The activation and conclusion of line insertion team services should be tailored to the needs of the institution and the requirement of the line insertion team members’ expertise in other clinical areas. Understanding variations in individual institutional resource allocation and having open communication between relevant stakeholders is key to providing appropriate, high-quality service to all hospitalized patients at the optimal time and place. In preparation for future surges of the COVID-19 pandemic and other health care emergencies, protocols should be developed that include central venous access line teams composed of physicians with percutaneous vascular access expertise, development of standardized protocols, and a method to track procedural outcomes.

An adequately stocked line cart increases the efficiency of line placements. This cart should have all the supplies and personal protective equipment (PPE) necessary to safely perform the procedures. An appropriately stocked cart minimizes potential clinician exposure to infectious agents and allows for a more streamlined performance. Further increases in the efficiency of clinician utilization can be realized by limiting the number of clinicians in the room performing the procedure to 2, with a runner outside the room to retrieve additional supplies as needed. This likewise can preserve PPE and minimize personnel exposed to infectious agents.

The internal jugular vein was the preferred anatomic location for central venous access used in this study of 60 hospitals during the COVID-19 pandemic due to ease of accessibility by ultrasound. Subclavian lines were discouraged, given the known increased incidence of pneumothorax compared with internal jugular lines. Due to the frequent use of prone positioning in patients with COVID-19, study participants reported successfully placing a triple-lumen catheter in the popliteal vein under ultrasound guidance with techniques commonly used in the lysis of iliofemoral deep vein thrombosis (Video).10 This demonstrates the ability of clinicians with appropriate specialized technical expertise to adapt to unusual challenges that may be imposed by a health care crisis. A caveat of placing central lines in the popliteal vein is a potential increase in the risk of deep vein thrombosis. Thus, each case should be carefully considered and executed with caution.

Video. Ultrasound-Guided Popliteal Vein Access in Prone Patients

Outcome

The needle was removed and pressure was held for 20 minutes. The patient did not develop any clinical signs of a hematoma or pseudoaneurysm during the hospitalization, which was confirmed by ultrasound.

Box Section Ref ID

Bottom Line

  • Even during a health care emergency, standard practices including use of ultrasound guidance for central venous access and prioritization of standard anatomic locations should be maintained to minimize procedural complications.

  • Dedicated central venous access line teams composed of physicians trained in percutaneous central venous access can ease a stressed health care system during a health care crisis.

  • Appropriately staffed dedicated central venous access line teams can perform high volumes of procedures with low procedural complication rates.

  • Planning for future health care emergencies should include protocols for central venous access line teams that describe staffing, a dedicated line cart, recommendations on the optimal anatomic site and technique, and a method to evaluate outcomes.

Section Editor: Edward H. Livingston, MD, Deputy Editor, JAMA.
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Article Information

Corresponding Author: Karen Woo, MD, MS, Division of Vascular Surgery, Department of Surgery, University of California, Los Angeles, 200 UCLA Medical Plaza, Ste 526, Los Angeles, CA 90095 (kwoo@mednet.ucla.edu).

Conflict of Interest Disclosures: None reported.

References
1.
Guilbert  MC, Elkouri  S, Bracco  D,  et al.  Arterial trauma during central venous catheter insertion.   J Vasc Surg. 2008;48(4):918-925. doi:10.1016/j.jvs.2008.04.046PubMedGoogle ScholarCrossref
2.
Bechara  CF, Barshes  NR, Pisimisis  G,  et al.  Management of inadvertent carotid artery sheath insertion during central venous catheter placement.   JAMA Surg. 2013;148(11):1063-1066. doi:10.1001/jamasurg.2013.3770PubMedGoogle ScholarCrossref
3.
Franco-Sadud  R, Schnobrich  D, Mathews  BK,  et al.  Recommendations on the use of ultrasound guidance for central and peripheral vascular access in adults.   J Hosp Med. 2019;14:E1-E22. doi:10.12788/jhm.3287PubMedGoogle ScholarCrossref
4.
Ilonzo  N, Rao  A, Soundararajan  K,  et al.  The importance of a centralized line service during the COVID-19 pandemic.   J Vasc Surg. 2020;72(2):403-404. doi:10.1016/j.jvs.2020.05.016PubMedGoogle ScholarCrossref
5.
Chun  TT, Judelson  DR, Rigberg  D,  et al.  Managing central venous access during a health care crisis.   J Vasc Surg. 2020;72(4):1184-1195. doi:10.1016/j.jvs.2020.06.112PubMedGoogle ScholarCrossref
6.
Kornbau  C, Lee  KC, Hughes  GD, Firstenberg  MS.  Central line complications.   Int J Crit Illn Inj Sci. 2015;5(3):170-178. doi:10.4103/2229-5151.164940PubMedGoogle ScholarCrossref
7.
Hameeteman  M, Bode  AS, Peppelenbosch  AG,  et al.  Ultrasound-guided central venous catheter placement by surgical trainees.   J Vasc Access. 2010;11(4):288-292. doi:10.5301/JVA.2010.2372PubMedGoogle ScholarCrossref
8.
McGee  DC, Gould  MK.  Preventing complications of central venous catheterization.   N Engl J Med. 2003;348(12):1123-1133. doi:10.1056/NEJMra011883PubMedGoogle ScholarCrossref
9.
Merrer  J, De Jonghe  B, Golliot  F,  et al.  Complications of femoral and subclavian venous catheterization in critically ill patients.   JAMA. 2001;286(6):700-707. doi:10.1001/jama.286.6.700PubMedGoogle ScholarCrossref
10.
Koksoy  C, Cetinkaya  OA.  Popliteal access in the supine position for endovenous management of deep vein thrombosis.   EJVES Short Rep. 2019;46:5-8. doi:10.1016/j.ejvssr.2019.05.004PubMedGoogle ScholarCrossref
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    3 Comments for this article
    EXPAND ALL
    "Popliteal Midline" Access
    Benjamin Galen, MD | Albert Einstein College of Medicine
    I would like to thank the authors for their thorough discussion of "central venous access" during this crisis. I would like to point out that a 20 cm catheter placed in the popliteal vein would terminate in the femoral vein, which is not considered "central." I presume the suitability of this deep vein for agents typically reserved for "central" administration has not been extensively studied. Nevertheless, the safety of infusing, e.g., vasopressors into veins of this caliber (and smaller) has been studied in the upper extremity veins. To allow for this nuance and perhaps guide further study on the safety of catheters placed in the popliteal vein, might the better name be "popliteal midline?" I do not believe that a "popliteal midline" catheter would meet the definition of a "central line" for purposes of delineating central line associated bloodstream infection (CLABSI) events.
    CONFLICT OF INTEREST: None Reported
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    Regarding "Safe Central Venous Access in an Overburdened Health System"
    Patrick Cleary, MD,PhD. | Surgeon IU Health Ball Memorial Hospital-Affiliate Staff Muncie, IN
    I read with great interest your article by Dr. Woo and colleagues highlighting the development, implementation, and outcomes of a cohort of central venous access teams during the COVID-19 pandemic. Cannulation of the right internal jugular vein under ultrasound guidance was by far the most common technique followed by the subclavian approach. Reported complications were well below expected and (not surprisingly) inversely proportional to operator experience. In that educational vein (pun intended) I would direct new learners to review the cited reference by Drs. McGee and Gould (NEJM. 2003; 348) describing both prevention and management of central line complications. They also identify those scenarios in which non-internal jugular central access may be preferable, thus emphasizing the importance of acquiring those skillsets as well. The accompanying video of popliteal vein cannulation also provided by Dr. Koo was most instructive and impressive.
    CONFLICT OF INTEREST: None Reported
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    Safe Central Venous Access in an Overburdened Health System
    Timothy Spencer, BHSc, ICCert, APRN, VA-BC | Director, Global Vascular Access, LLC
    I recently read the publication by Woo et al, noting central venous catheterization was performed using only anatomical landmarks in a critically ill, ventilated COVID-19 patient. A blind technique is now frequently avoided and ultrasound (US)-guided vascular assessment should always be considered when attempting vascular access to central venous and arterial vessels, as well as in difficult peripheral venous cannulation situations. [1]

    While a commonplace procedure in critical care, there are risks when performed by a novice clinician without an experienced clinician on hand to supervise or perform the procedure themselves. A decade of strong clinical evidence supports the
    use of US in today's practices, and published guidelines now state the benefits of ultrasound in all patients, not just the critically ill. [2-6]

    A recent study [7] evaluated pre- and post-procedural skills acquisition and clinician confidence, demonstrating significant improvement in clinician skillsets and ultrasound use. Both groups resulted in statistically significant results in both procedural confidence (P<.001) and ultrasound skills (P<.001). This research also demonstrated higher-than-published, self-disclosed complication rates related to CVC insertion. These results point to the need for continued competency assessment, with a focus on improving patient safety and reducing patient harm [7].

    Even with experienced inserters the reported rate of complications reinforces the need for a standardized approach to clinician education and training, including procedural supervision, appropriate use of ultrasound in patient assessment and needling techniques, along with complication management and risk reduction strategies to help prevent patient harm.

    References

    1. Spencer TR, Pittiruti M. Rapid Central Vein Assessment (RaCeVA): a systematic, standardized approach for ultrasound assessment before central venous catheterization. Journal of Vascular Access. 2019 May;20(3):239-49.
    2. Schmidt GA, Blaivas M, Conrad SA, Corradi F, Koenig S, Lamperti M, Saugel B, Schummer W, Slama M. Ultrasound-guided vascular access in critical illness. Intensive care medicine. 2019 Apr;45(4):434-46.
    3. Lamperti M, Bodenham AR, Pittiruti M, Blaivas M, Augoustides JG, Elbarbary M, Pirotte T, Karakitsos D, LeDonne J, Doniger S, Scoppettuolo G. International evidence-based recommendations on ultrasound-guided vascular access. Intensive Care Medicine. 2012 Jul;38(7):1105-17.
    4.Leibowitz A, Oren-Grinberg A, Matyal R. Ultrasound guidance for central venous access: Current evidence and clinical recommendations. Journal of Intensive Care Medicine. 2020 Mar;35(3):303-21.
    5. Lamperti M, Biasucci DG, Disma N, Pittiruti M, Breschan C, Vailati D, Subert M, Traškaite V, Macas A, Estebe JP, Fuzier R. European Society of Anaesthesiology guidelines on peri-operative use of ultrasound-guided for vascular access (PERSEUS vascular access). European Journal of Anaesthesiology| EJA. 2020 May 1;37(5):344-76.
    6. Apfelbaum JL, Rupp SM, Tung A, Connis RT, Domino KB, Grant MD, Mark JB. Practice guidelines for central venous access 2020: An updated report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology. 2020; 132:8–43
    7. Spencer TR, Bardin-Spencer AJ. Pre-and post-review of a standardized ultrasound-guided central venous catheterization curriculum evaluating procedural skills acquisition and clinician confidence. Journal of Vascular Access. 2020 Jul;21(4):440-8.

    CONFLICT OF INTEREST: Consultant for Teleflex Inc, FUJIFILM Sonosite Inc., Butterfly Network Inc.
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