Anatomical variation in the internal jugular vein:potential risk factors for central venous catheterization-a case report

Central venous catheterization(CVC)is an invasive medical procedure used to measure central venous pressure and provides a stable route for continuous drug administration.CVC is widely used in the emergency department and intensive care units.It is typically performed by inserting a catheter through the internal jugular vein(IJV)into the superior vena cava near the right atrium.[1,2]While catheterization is a fundamental skill proficiently performed by healthcare professionals,lethal complications may occasionally occur because of undesirable positioning,depth and diameter.

Comparison of intraosseous access and central venous catheterization in Chinese adult emergency patients: A prospective, multicenter, and randomized study

BACKGROUND: It is challenging to establish peripheral intravenous access in adult critically patients. This study aims to compare the success rate of the first attempt, procedure time, operator satisfaction with the used devices, pain score, and complications between intraosseous(IO) access and central venous catheterization(CVC) in critically ill Chinese patients.METHODS: In this prospective clustered randomized controlled trial, eight hospitals were randomly divided into either the IO group or the CVC group. Patients who needed emergency vascular access were included. From April 1, 2017 to December 31, 2018, each center included 12 patients. We recorded the data mentioned above.RESULTS: A total of 96 patients were enrolled in the study. There were no statistically significant differences between the two groups regarding sex, age, body mass index, or operator satisfaction with the used devices. The success rates of the first attempt and the procedure time were statistically significant between the IO group and the CVC group(91.7% vs. 50.0%, P<0.001;52.0 seconds vs. 900.0 seconds, P<0.001). During the study, 32 patients were conscious. There was no statistically significant difference between the two groups regarding the pain score associated with insertion. There were statistically significant differences between the two groups regarding the pain score associated with IO or CVC infusion(1.5 vs. 0.0, P=0.044). Complications were not observed in the two groups.CONCLUSIONS: IO access is a safe, rapid, and effective technique for gaining vascular access in critically ill adults with inaccessible peripheral veins in the emergency departments.

Ultrasound-Guided Central Venous Catheterization: A Protocol to Be Followed in Pediatrics?

Objective: To investigate the effectiveness of ultrasound-guided central venous catheterization when compared to the conventional procedure. Method: A prospective cohort study was carried out over a 9-month period from February to October 2016 involving 144 inpatients at PICU of Irmandade da Santa Casa de Sao Paulo Hospital, undergoing central venous catheterization. The patients were matched in pairs of identical patients according to the levels of potentially intervening variables (age, nutritional status, puncture site, professional experience), differing only as to the CVC technique: ultrasound-guided (USG-CVC) or conventional (C-CVC). Discarding data from non-paired patients, the remaining did forming 47 pairs, matched as two related samples: USG-CVC and C-CVC groups. Success parameters: number of puncture attempts;time spent at CVC;success rate and complications. Results: In the USG-CVC group, the number of attempts (mean = 2.04) and the time spent at catheterization (mean = 11.89 minutes) were lower (t = 2.34, df = 46, t 0.95 = 2.02, p t = 3.07, df = 46, t 0.95 = 2.02, p < 0.05), respectively, when compared to the results obtained for the control group (C-GVC), (mean = 3.21) and (mean = 28.26 minutes), respectively. As to success, there was observed a significant difference (F (1, 46) = 16.6;Q (1) = 12.5, p < 005) when considering only one trial (USG -CVC = 27/47;C-CVC = 9/47), but no significant difference (F (1, 46) = 3.76;Q (1) = 3.56, p > 0.05) when considering several attempts. Complications were found less frequently in the USG-CVC group (3/47) than in the CVC-C (13/47), (F (1, 46) = 8.24;Q (1) = 7.14, p < 0.05). Conclusion: USG-CVC was found to be more effective than the conventional technique, especially regarding success at the first puncture attempt.

Current Research Progress of Central Venous Catheter-Associated Fibrin Sheath Prevention and Nursing Care

With the popularization of central venous catheterization in recent years,the problems arising from intravenous therapy have gradually increased.Fibrin sheath is the complication with the highest incidence rate in central venous catheterization,which has always been a major problem in intravenous therapy.So the prevention and treatment of fibrin sheath has become a hot spot of research in recent years.Hence,this paper summarizes the research on fibrin sheath in recent years.

Clues for diagnosing misplaced central venous catheter in the right ascending lumbar vein during right femoral venous access

The right ascending lumbar vein is difficult to detect on anteroposterior abdominalradiographs because it overlaps with the inferior vena cava on anteroposteriorradiographs.Intensive observation by medical providers may be a cue fordiagnosis.However,knowledge of catheter misplacement of the right ascendinglumbar vein is also necessary,because misplacement cannot be suspected withoutthat awareness.

Multiple paradoxical embolisms caused by central venous catheter thrombus passing through a patent foramen ovale: A case report

BACKGROUND To date,this is the first case of a paradoxical embolism(PDE)that concurrently manifested in the coronary and lower limb arteries and was secondary to a central venous catheter(CVC)thrombus via a patent foramen ovale(PFO).CASE SUMMARY Here,we report a case of simultaneous coronary and lower limb artery embolism in a PFO patient carrier of a CVC.The patient presented to the hospital with acute chest pain and lower limb fatigue.Doppler ultrasound showed a large thrombus in the right internal jugular vein,precisely at the tip of the CVC.Transthoracic and transesophageal echocardiography confirmed the existence of a PFO,with inducible right-to-left shunting by the Valsalva maneuver.The patient was administered an extended course of anticoagulation therapy,and then the CVC was successfully removed.Percutaneous PFO closure was not undertaken.There was no recurrence during follow-up.CONCLUSION Thus,CVC-associated thrombosis is a potential source for multiple PDE in PFO patients.

Ultrasound based estimate of central venous pressure:Are we any closer?

Central venous pressure(CVP)serves as a direct approximation of right atrial pressure and is influenced by factors like total blood volume,venous compliance,cardiac output,and orthostasis.Normal CVP falls within 8-12 mmHg but varies with volume status and venous compliance.Monitoring and managing disturbances in CVP are vital in patients with circulatory shock or fluid disturbances.Elevated CVP can lead to fluid accumulation in the interstitial space,impairing venous return and reducing cardiac preload.While pulmonary artery catheterization and central venous catheter obtained measurements are considered to be more accurate,they carry risk of complications and their usage has not shown clinical improvement.Ultrasound-based assessment of the internal jugular vein(IJV)offers real-time,non-invasive measurement of static and dynamic parameters for estimating CVP.IJV parameters,including diameter and ratio,has demonstrated good correlation with CVP.Despite significant advancements in non-invasive CVP measurement,a reliable tool is yet to be found.Present methods can offer reasonable guidance in assessing CVP,provided their limitations are acknowledged.

Central venous catheterization-related complications in a cohort of 100 hospitalized patients:An observational study

Objective:To evaluate the complications of central venous catheterization(CVC).Methods:A prospective,observational study was conducted at a tertiary care center in India from December 2018 to September 2020.Critically ill patients(aged≥18 years)in the intensive care unit undergoing CVC procedures were included in the study.Baseline demographics and detailed medical history were recorded.Chest X-rays and electrocardiography were performed on all the patients.Complications associated with CVC were recorded.Results:A total of 100 patients with the indication for central venous catheter insertion were included.The majority(81%)of the patients were inserted with CVC at the right internal jugular vein.Complications such as arterial puncture(2%),hematoma(4%),blood clot formation(4%),catheter kinking(3%),thoracic injury(1%),thrombophlebitis(6%),sepsis(9%)and nerve injury(1%)were reported.Conclusions:Though central venous access is preferred in management of critically ill patients,it has its risks.However,early recognition and prompt management of complications may reduce mortality and morbidity.Physicians and intensive care unit intensivists should be vigilant for central venous catheter-related complications.Suitable site selection,operator experience,and proper catheter maintenance are associated with optimal outcomes.

Controlled low central venous pressure reduces blood loss and transfusion requirements in hepatectomy

AIM: To evaluate the effect of low central venous pressure (LCVP) on blood loss and blood transfusion in patients undergoing hepatectomy.

Effect of controlled low central venous pressure on renal function in major liver resection

Objective： To investigate the effects of low central venous pressure （LVCP） on blood loss and evaluate its influence on renal function in patients undergoing hepatectomy. Methods： Forty-six patients, ASA classification Ⅰ-Ⅲ, undergoing liver resection were randomized into LCVP group （n = 23） and control group （n = 23）. In LCVP group, CVP was maintained at 2-4 mmHg and MBP above 60 mmHg during hepatectomy, while in control group hepatectomy was performed routinely without lowering CVP. Volume of blood loss during hepatectomy, volume of blood transfusion, and changes of renal functions were compared between the two groups. Results： There were no significant differences in demographics, ASA score, type of hepatectomy, duration of inflow occlusion, operation time, weight of resected liver tissues, and renal functions between the two groups. LCVP group had a significantly lower volume of total intraoperative blood loss （P 〈 0.01） and RBC transfusion （P 〈 0.05）. Conclusion： Lowering the CVP to less than 5 mmHg is a simple and effective technique to reduce blood loss and blood infusion during liver resection, and has no detrimental effects on renal functions.

Factors influencing the optimal selection of central venous access devices:A qualitative study of health care team members’perspectives

Objective:This study aimed to explore health care team members’understanding of the factors influencing the optimal selection of central venous access devices(CVADs).Methods:The data of the study was collected using semi-structured interviews.Twenty-six hospital medical staff(four hospital manager,15 head nurses,7 nurse)with experience in peripheral or central catheterization from four regions(Northern China,Southern China,Northwest China,and Qinghai-Tibet China)in China were interviewed between June and October 2021.Content analysis was used to analyze the data.Results:The results revealed five themes and 14 sub-themes.Patients:concerns,resources,requirements,and evaluation(security concerns,support resources,life requirements,evaluation among patients);nurses:awareness,knowledge,and popularizing methods(awareness of intravenous therapy,understanding of professional knowledge,forms of popularizing methods);doctors:support and involvement(support for decision-making,involvement in intravenous work);hospital managers:authority,quality control and continuing education(management of catheterization authority,quality control of intravenous infusion,investment in continuing education)and environment:differences and commonalities(differences in social support,and current commonalities).Conclusion:Nurses and other healthcare team members’understanding,selection,use,and recommendation of CVADs have an indirect effect on patients’decision-making.Therefore,hospital managers and government departments can indirectly strengthen medical team cooperation and improve learning education in order to improve the safety of patients receiving intravenous infusions.

Correlation of Inferior Vena Cava Respiratory Variability Index with Central Venous Pressure and Hemodynamic Parameters in Ventilated Pigs with Septic Shock

Septic shock is a common critical condition, for which effective early fluid resuscitation is the therapeutic focus. According to the 2008 international guidelines for management of severe sepsis and septic shock, resuscitation should achieve a central venous pressure （CVP） of 8-12 mmHg within the first 6 h. However, it is still uncertain about the sensitivity and specificity of CVP in reflecting the cardiac preload. Ultrasonography is a simple, rapid, non-invasive, and repeatable method for the measurement of sensitivity and specificity of CVP and has thus gradually attracted the increasing attention of physicians. It was reported that ultrasonography can show the inferior vena cava diameter, respiratory variability index, and blood volume in patients with sepsis or heart failure.

Sonographic guidance for tunneled central venous catheters insertion in pediatric oncologic patients: guided punctures and guide wire localization

Objective Totally implantable devices (TIDs) and external tunneled catheters (ETCs) became a basic requirement in the treatment of pediatric oncologic patients. Techniques for implantation and confirmation of proper position vary among different centers. The article presented different techniques for sonographic guided puncture of the target central vein and confirmation of the proper position of tunneled catheters.

Clinical Course of Lung Cancer Patients with Subcutaneously Implanted Central Venous Access Device Ports from the Time of Receiving Chemotherapy to the Endpoint of Cancer

Background: As the prognosis of lung cancer (LC) patients improves, subcutaneously implanted central venous access device ports (CV-ports) have frequently been used for continuing chemotherapy (CC) or palliative care (PC). In this study, we examined the clinical course of LC patients with subcutaneously implanted CV-ports from the time of receiving chemotherapy to the endpoint of cancer. Materials and Methods: We retrospectively reviewed the clinical data and treatment history of LC patients with subcutaneously implanted CV-ports between June 2008 and November 2013 using clinical records and a pharmacy database. Results: Of the 132 LC patients with subcutaneously implanted CV-ports, 79 (59.8%) had CV-ports for CC (the CC group) and 53 (40.2%) had CV-ports for PC (the PC group). After CV-port implantation, LC patients in the CC group received a median of two regimens with a median of 6 cycles. The median survival time of patients in the CC and PC groups was 457 and 44 days, respectively. In the CC group, the median survival time of small cell and non-small cell LC patients was 342 (95% confidence interval, 235 - 627) and 563 (95% confidence interval, 368 - 728) days, respectively. Nine patients (6.8%) had their CV-ports removed due to complications. Forty (30.3%) of the 132 enrolled patients were referred for at-home PC. The at-home death rate observed among these 40 patients was 30.0% (N = 12). Conclusion: CV-ports may contribute to seamless oncological care.

A review in emergency central venous catheterization

Central venous catheterization is widely used in the emergency setting. This review aims to assess central venous catheterization from the perspectives of types of catheters, sites of insertion, and tech- niques. In emergency conditions, non-tunneled catheters are preferred because the technique for its insertion is not complicated and less time-consuming. The size of catheter depends on the purpose of catheterization. For example, a large bore catheter is needed for rapid infusion. The ideal catheterization site should bear fewer thromboses, lower infectious rate, and fewer mechanical complications. Thus the femoral vein should be avoided due to a high rate of colonization and thrombosis while the subclavian vein seems to exhibit fewer infectious complications compared with other sites. The ultrasound-guided technique increases the success rate of insertion while decreases the mechanical complications rate,

Optimal central venous pressure during partial hepatectomy for hepatocellular carcinoma

BACKGROUND:Low central venous pressure(CVP) affects hemodynamic stability and tissue perfusion.This prospective study aimed to evaluate the optimal CVP during partial hepatectomy for hepatocellular carcinoma(HCC).METHODS:Ninety-seven patients who underwent partial hepatectomy for HCC had their CVP controlled at a level of 0 to 5 mmHg during hepatic parenchymal transection.The systolic blood pressure(SBP) was maintained,if possible,at 90 mmHg or higher.Hepatitis B surface antigen was positive in 90 patients(92.8%) and cirrhosis in 84 patients(86.6%).Pringle maneuver was used routinely in these patients with clamp/unclamp cycles of 15/5 minutes.The average clamp time was 21.4±8.0 minutes.These patients were divided into 5 groups based on the CVP:group A:0-1 mmHg;B:1.1-2 mmHg;C:2.1-3 mmHg;D:3.1-4 mmHg and E:4.1-5 mmHg.The blood loss per transection area during hepatic parenchymal transection and the arterial blood gas before and after liver transection were analyzed.RESULTS:With active fluid load,a constant SBP ≥90 mmHg which was considered as optimal was maintained in 18.6% in group A(95% CI:10.8%-26.3%);39.2% in group B(95% CI:29.5%-48.9%);72.2% in group C(95% CI:63.2%-81.1%);89.7% in group D(95% CI:83.6%-95.7%);and 100% in group E(95% CI:100%-100%).The blood loss per transection area during hepatic parenchymal transection decreased with a decrease in CVP.Compared to groups D and E,blood loss in groups A,B and C was significantly less(analysis of variance test,P【0.05).Compared with the baseline,the blood oxygenation decreased significantly when the CVP was reduced.Base excess and HCO 3-in groups A and B were significantly decreased compared with those in groups C,D and E(P【0.05).CONCLUSION:In consideration of blood loss,SBP,base excess and HCO 3-,a CVP of 2.1-3 mmHg was optimal in patients undergoing partial hepatectomy for HCC.

Low central venous pressure reduces blood loss in hepatectomy

AIM： To investigate the effect of low central venous pressure （LCVP） on blood loss during hepatectomy for hepatocellular carcinoma （HCC）. METHODS： By the method of sealed envelope, 50 HCC patients were randomized into LCVP group （n=25） and control group （n=25）. In LCVP group, CVP was maintained at 2-4 mmHg and systolic blood pressure （SBP） above 90 mmHg by manipulation of the patient＇s posture and administration of drugs during hepatectomy, while in control group hepatectomy was performed routinely without lowering CVP. The patients＇ preoperative conditions, volume of blood loss during hepatectomy, volume of blood transfusion, length of hospital stay, changes in hepatic and renal functions were compared between the two groups. RESULTS： There were no significant differences in patients＇ preoperative conditions, maximal tumor dimension, pattern of hepatectomy, duration of vascular occlusion, operation time, weight of resected liver tissues, incidence of post-operative complications, hepatic and renal functions between the two groups. LCVP group had a markedly lower volume of total intraoperative blood loss and blood loss during hepatectomy than the control group, being 903.9 ± 180.8 mL vs 2 329.4 ±2 538.4 （W=495.5, P〈0.01） and 672.4±429.9 mL vs 1 662.6±1 932.1 （W=543.5, P〈0.01）. There were no remarkable differences in the pre-resection and post-resection blood losses between the two groups. The length of hospital stay was significantly shortened in LCVP group as compared with the control group, being 16.3±6.8 d vs 21.5 ± 8.6 d （W= 532.5, P〈0.05）.CONCLUSION： LCVP is easily achievable in technique. Maintenance of CVP ≤4 mmHg can help reduce blood loss during hepatectomy, shorten the length of hospital stay, and has no detrimental effects on hepatic or renal function.

Hemodynamics and oxygen transport dynamics during hepatic resection at different central venous pressures in a pig model

BACKGROUND: Although low central venous pressure (CVP) has been used to minimize blood loss during hepatectomy the impact of variations of CVP on the rate of blood loss and on the perfusion of end-organs has not been evaluated This animal study aimed to evaluate the hemodynamics and oxygen transport changes during hepatic resection at different CVP levels. METHODS: Forty-eight anesthetized Bama miniature pigs were divided into 8 groups with CVP during hepatic resection controlled at 0 to <1, 1 to <2, 2 to <3, 3 to <4, 4 to <5, 5 to <6, 6 to <7, and 7 to <8 cmH 2 O. Intergroup comparisons were made for hemodynamic parameters, oxygen transport dynamics, and the rate of blood loss. RESULTS: The rate of blood loss and the hepatic venous pressure during hepatic resection were almost linearly related to the CVP. A significant drop in the mean arterial pressure cardiac output, and cardiac index occurred between CVP ≥2 and <2 cmH 2 O. Oxygen delivery (DO 2 ), oxygen consumption (VO 2 ) and oxygen extraction ratio (ERO 2 ) remained relatively constant between CVPs of 2 to <8 cmH 2 O. There was a significant drop in DO 2 when the CVP was <2 cmH 2 O. There was also a significant drop in VO 2 and ExO 2 when the CVP was <1 cmH 2 O.CONCLUSION: The optimal CVP for hepatic resection is 2to 3 cmH2O.

Analysis of risk factors for central venous port failure in cancer patients

AIM: To analyze the risk factors for central port failure in cancer patients administered chemotherapy, using univariate and multivariate analyses. METHODS: A total of 1348 totally implantable venous access devices (TIVADs) were implanted into 1280 cancer patients in this cohort study. A Cox proportional hazard model was applied to analyze risk factors for failure of TIVADs. Log-rank test was used to compare actuarial survival rates. Infection, thrombosis, and surgical complication rates (χ2 test or Fisher's exact test) were compared in relation to the risk factors. RESULTS: Increasing age, male gender and openended catheter use were signifi cant risk factors reducing survival of TIVADs as determined by univariate and multivariate analyses. Hematogenous malignancy decreased the survival time of TIVADs; this reduction was not statistically signifi cant by univariate analysis [hazard ratio (HR) = 1.336, 95% CI: 0.966-1.849, P = 0.080)]. However, it became a signifi cant risk factor by multivariate analysis (HR = 1.499, 95% CI: 1.079-2.083, P = 0.016) when correlated with variables of age, sex and catheter type. Close-ended (Groshong) catheters had a lower thrombosis rate than open-ended catheters (2.5% vs 5%, P = 0.015). Hematogenous malignancy had higher infection rates than solid malignancy (10.5% vs 2.5%, P < 0.001). CONCLUSION: Increasing age, male gender, openended catheters and hematogenous malignancy were risk factors for TIVAD failure. Close-ended catheters had lower thrombosis rates and hematogenous malignancy had higher infection rates.

Clinical analysis of central venous catheter-related infections in patients in the emergency ICU

BACKGROUND:Catheter-related infection(CRI)of the central vein is a common cause of nosocomial infection.This study was undertaken to investigate the pathogen culturing and risk factors of CRI in emergency intensive care unit(EICU)in order to provide the beneficial reference.METHODS:From January 2008 to December 2010,a total of 1 363 patients were subjected to catheterization.In these patients,the peak CRI rate of the patients was determined by bacterial cultivation and blood bacterial cultivation.RESULTS:CRI happened in 147 of the 1 363 patients using the central venous catheter.The peak rate of CRI was 10.79%,with an incidence of 3.05 episodes per 1 000 catheter days.Of the147 patients,46.94%had gram-negative bacilli,40.14%had gram-positive cocci,and 12.92%had fungi.Unconditional logistic regression analysis suggests that multiple catheterization,femoral vein catheterization,the application of multicavity catheter,and the duration of catheterization were the independent risk factors for CRI.CONCLUSION:The risk factors for catheter-related infections should be controlled to prevent the occurrence of nosocomial infection.