https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2815818
Key Points
Question What are the rates of complications from central venous catheter (CVC) use?
Findings This systematic review and meta-analysis of literature from 2015 to 2023 found that rates of complications varied substantially across studies, but on average, the rate of serious complications (arterial cannulation, pneumothorax, infection, or deep vein thrombosis) from a CVC placed for 3 days was estimated to be 30 events per 1000 catheters placed (3%). Use of ultrasonography was associated with lower rates of immediate insertion-related complications.
Meaning This study found that approximately 3% of CVC placements were associated with major complications, with ultrasonography guidance reducing some of the specific risks.
Review by PulmCCM
A new paper in JAMA Internal Medicine overstates the risks of central venous catheter placements, asserting that 3% of CVC placements result in either arterial puncture, pneumothorax, bloodstream infection, or deep venous thrombosis, within 3 days.
Let’s take a look at the methods they used to arrive at this surprising finding.
Authors included 130 studies published 2015-2023, “to ensure that included studies were representative of current medical practices, including ultrasonography guidance.” But less than half of the included studies used ultrasound guidance during central line placements. Ultrasound guidance during CVC placement has been a recommended practice since 2001 by the Agency for Healthcare Research and Quality, with multiple professional societies echoing that recommendation in the following decade. In a 2018 survey [substack.com] of 136 ED and ICU attendings and trainees in the state of Maryland (limited by its small size and response bias), 96% reported using ultrasound for internal jugular central line placements.
(For central line placements in the subclavian vein, the use of ultrasound is more technically difficult and less strongly indicated.)
The inclusion of so many ultrasound-agnostic sites muddies the data and makes useful conclusions impossible. As an example, for internal jugular CVC placement, authors report the rate of pneumothorax using ultrasound was 0.4 per 1000 catheters, vs 18 per 1000 without ultrasound–a 45-fold difference in risk. These two cohorts shouldn’t be combined; their pooled rate is meaningless.
Authors also had no information on operators’ experience levels. Such studies are usually conducted at academic medical centers, where a large proportion of CVC placements are done by comparatively inexperienced residents and fellows (with experienced non-physician providers performing many as well). As with any other procedure, less-experienced operators as a group are expected to have more complications after CVC placement.
Lumping together central line placements done with ultrasound and without, and by trainees and experienced operators, winds up providing no useful information about either.
In skilled hands using ultrasound, CVC complications are much lower than 3%. How low? In a series of 1262 consecutive central lines [substack.com] placed at the internal jugular site by experienced interventional radiologists at UMass, the incidence of pneumothorax was zero.