<unk>  line insertion may cause several complications. The benefit expected from their use should outweigh the risk of those complications. Pneumothorax The incidence of pneumothorax is highest with subclavian vein catheterization due to its anatomic proximity to the apex of the lung. In the case of catheterization of the internal jugular vein, the risk of pneumothorax is minimized by the use of ultrasound guidance. For experienced clinicians, the incidence of pneumothorax is about 1.5–3.1%. The National Institute for Health and Clinical Excellence (UK) and other medical organizations recommend the routine use of ultrasonography to minimize complications. If a pneumothorax is suspected, an upright chest x-ray should be obtained. An upright chest x-ray is preferred because free air will migrate to the apex of the lung, where it is easily visualized. Of course, this is not always possible, particularly in critically ill patients in the intensive care unit. Radiographs obtained in the supine position fail to detect 25–50% of pneumothoraces. Instead, bedside ultrasound is a superior method of detection in those too ill to obtain upright imaging. Vascular perforation Perforation of vasculature by a catheter is a feared and potentially life-threatening complication of<unk>  lines. Fortunately, the incidence of these events is exceedingly rare, especially when lines are placed with ultrasound guidance. Accidental cannulation of the carotid artery is a potential complication of placing a<unk>  line in the internal jugular vein. This occurs at a rate of approximately 1% when ultrasound guidance is used. However, it has a reported incidence of 0.5–11% when an anatomical approach is used. If the carotid is accidentally cannulated and a catheter is inserted into the artery, the catheter should be left in place and a vascular surgeon should be notified because removing it can be fatal. Catheter-related bloodstream infections All catheters can introduce bacteria into the bloodstream. This can result in serious infections that can be fatal in up to 25% of cases. The problem of<unk>  line-associated bloodstream infections (CLABSI) has gained increasing attention in recent years. They cause a great deal of morbidity (harm) and deaths, and increase health care costs. Microbes can gain access to the bloodstream via a<unk>  catheter a number of ways. Rarely, they are introduced by contaminated infusions. They might also gain access to the lumen of the catheter through break points such as hubs. However, the method by which most organisms gain access is by migrating along the portion of the catheter tracking through subcutaneous tissue until they reach the portion of the catheter in the vein. Additionally, bacteria present in the blood may attach to the surface of the catheter, transforming it into a focus of infection. If a<unk>  line infection is suspected in a person, blood cultures are taken from both the catheter and a vein elsewhere in the body. If the culture from the<unk>  line grows bacteria much earlier (>2 hours) than the other vein site, the line is likely infected. Quantitative blood culture is even more accurate, but this method is not widely available. Antibiotics are nearly always given as soon as a patient is suspected to have a catheter-related bloodstream infection. However, this must occur after blood cultures are drawn, otherwise the culprit organism may not be identified. The most common organisms causing these infections are coagulase negative staphylococci such as staphylococcus epidermidis. Infections resulting in bacteremia from Staphylococcus aureus require removal of the catheter and antibiotics. If the catheter is removed without giving antibiotics, 38% of people may still develop endocarditis. Evidence suggests that there may not be any benefit associated with giving antibiotics before a long-term<unk>  is inserted in cancer patients and this practice may not prevent gram positive catheter-related infections. However, for people who require long-term<unk> s who are at a higher risk of infection, for example, people with cancer who at are risk of neutropenia due to their chemotherapy treatment or due to the disease, flushing the catheter with a solution containing an antibiotic and heparin may reduce catheter-related infections. In a clinical practice guideline, the American Centers for Disease Control and Prevention recommends against routine culturing of<unk><unk>  lines upon their removal. The guideline makes several other recommendations to prevent line infections. To prevent infection, stringent cleaning of the catheter insertion site is advised. Povidone-iodine solution is often used for such cleaning, but chlorhexidine appears to be twice as effective as iodine. Routine replacement of lines makes no difference in preventing infection. The CDC makes a myriad of recommendations regarding risk reduction for infection of<unk> s, including: * The preferred site of insertion (including for non-tunneled catheter placement), from an infection prevention point of view, is in the subclavian vein, and to generally avoid the femoral vein if possible. * There is no clear recommendation for a tunneled catheter site in the guidelines. * Selection of catheters should include those with minimal ports to accomplish the clinical goal. * Sterile gloves are required for<unk>  * Full body sterile drapes, cap, mask, gloves are required for placement of<unk> s * The catheter site should be monitored visually and with palpation (through dressing) on a regular basis to assess for infection. * It is, however, acceptable to use clean, non-sterile, gloves for changing the dressing of intravascular catheters. * Both chlorhexidine and povidone-iodine are acceptable skin cleansers, though chlorhexidine is preferred. * For short-term<unk>  sites, dressings must be changed at least every 7 days for transparent dressings, and every 2 days for gauze dressings. * For long-term implanted or tunneled catheters, dressings are to be changed no more than once weekly unless soiled or loose. *Routine removal and replacement of a<unk>  is not recommended. While<unk>  line catheters should be removed as soon as they are no longer necessary, scheduled removal and replacement, whether over a guidewire or with a new puncture site, has not been shown to be beneficial in preventing infections. *Medication impregnated dressing products can reduce the risk getting catheter-related blood stream infection. *There is inconclusive evidence whether longer interval of changing dressings for<unk><unk>  access devices is associated with more or less infections. *It is unclear whether cleaning the skin antiseptics or without skin cleansing can reduce the rate of catheter-related bloodstream infections. Occlusion One form of thrombosis is the formation of a fibrin sheath around the catheter, and is one of the most common causes of catheter obstruction. It is indirectly seen in these images before and after radiocontrast infusion, as the radiocontrast collects around the catheter.<unk>  catheters may occasionally become occluded by kinks in the catheter, backwash of blood into the catheter leading to thrombosis, or infusion of insoluble materials that form precipitates. However, thrombosis is the most common cause of<unk>  line occlusion, occurring in up to 25% of catheters .<unk> s are a risk factor for forming blood clots<unk>  thrombosis) including upper extremity deep vein thrombosis. It is thought this risk stems from activation of clotting substances in the blood by trauma to the vein during placement. The risk of blood clots is higher in a person with cancer, as cancer is also a risk factor for blood clots. As many as two thirds of cancer patients with<unk>  lines show evidence of catheter-associated thrombosis. However, most cases (more than 95%) of catheter-associated thrombosis go undetected. Most symptomatic cases are seen with placement of femoral vein catheters (3.4%) or peripherally inserted<unk>  catheters (3%). Anti-clotting drugs such as heparin and fondaparinux have been shown to decrease the incidence of blood clots, specifically deep vein thrombosis, in a person with cancer with<unk>  lines. Additionally, studies suggest that short term use of<unk> s in the subclavian vein is less likely to be associated with blood clots than<unk> s placed in the femoral vein in non-cancer patients. In the case of non-thrombotic occlusion (e.g. formation of precipitates), dilute acid can be used to restore patency to the catheter. A solution of 0.1N hydrochloric acid is commonly used. Infusates that contain a significant amount of lipids such as total parenteral nutrition (TPN) or propofol are also prone to occlusion over time. In this setting, patency can often be restored by infusing a small amount of 70% ethanol. Misplacement<unk>  misplacement is more common when the anatomy of the person is different or difficult due to injury or past surgery.<unk> s can be mistakenly placed in an artery during insertion (for example, the carotid artery or vertebral artery when placed in the neck or common femoral artery when placed in the groin). This error can be quickly identified by special tubing that can show the pressure of the catheter (arteries have a higher pressure than veins). In addition, sending blood samples for acidity, oxygen, and carbon dioxide content (pH, pO2, pCO2 respectively) can show the characteristics of an artery (higher pH/pO2, lower pCO2) or vein (lower pH/pO2, higher pCO2). During subclavian vein<unk>  line placement, the catheter can be accidentally pushed into the internal jugular vein on the
Central venous catheter
Peripheral venous catheter
Arterial line
Quinton catheter
Peripherally inserted central catheter
Vascular closure device
Hickman line
Vascular access