A Contemporary Assessment of Mechanical Complication Rates and Trainee Perceptions of Central Venous Catheter Insertion

Central venous catheter (CVC) placement is commonly performed in emergency and critical care settings for parenteral access, central monitoring, and hemodialysis. Although potentially lifesaving CVC insertion is associated with immediate risks including injury to nerves, vessels, and lungs.^1-3 These “insertion-related complications” are of particular interest for several reasons. First, the frequency of such complications varies widely, with published rates between 1.4% and 33.2%.^2-7 Reasons for such variation include differences in study definitions of complications (eg, pneumothorax and tip position),^2,5 setting of CVC placement (eg, intensive care unit [ICU] vs emergency room), timing of placement (eg, elective vs emergent), differences in technique, and type of operator (eg, experienced vs learner). Thus, the precise incidence of such events in modern-day training settings with use of ultrasound guidance remains uncertain. Second, mechanical complications might be preventable with adequate training and supervision. Indeed, studies using simulation-based mastery techniques have demonstrated a reduction in rates of complications following intensive training.⁸ Finally, understanding risk factors associated with insertion complications might inform preventative strategies and improve patient safety.^9-11

Few studies to date have examined trainees’ perceptions on CVC training, experience, supervision, and ability to recognize and prevent mechanical complications. While research investigating effects of simulation training has accumulated, most focus on successful completion of the procedure or individual procedural steps with little emphasis on operator perceptions.^12-14 In addition, while multiple studies have shown that unsuccessful line attempts are a risk factor for CVC complications,^3,4,7,15 there is very little known about trainee behavior and perceptions regarding unsuccessful line placement. CVC simulation trainings often assume successful completion of the procedure and do not address the crucial postprocedure steps that should be undertaken if a procedure is unsuccessful. For these reasons, we developed a survey to specifically examine trainee experience with CVC placement, supervision, postprocedural behavior, and attitudes regarding unsuccessful line placement.

Therefore, we designed a study with 2 specific goals: The first is to perform a contemporary analysis of CVC mechanical complication rate at an academic teaching institution and identify potential risk factors associated with these complications. Second, we sought to determine trainee perceptions regarding CVC complication experience, prevention, procedural supervision, and perceptions surrounding unsuccessful line placement.

Design and Setting

We conducted a single-center retrospective review of nontunneled acute CVC procedures between June 1, 2014, and May 1, 2015, at the University of Michigan Health System (UMHS). UMHS is a tertiary care referral center with over 900 inpatient beds, including 99 ICU beds.

All residents in internal medicine, surgery, anesthesia, and emergency medicine receive mandatory education in CVC placement that includes an online training module and simulation-based training with competency assessment. Use of real-time ultrasound guidance is considered the standard of care for CVC placement.

Data Collection

Inpatient procedure notes were electronically searched for terms indicating CVC placement. This was performed by using our hospital’s Data Office for Clinical and Translational Research using the Electronic Medical Record Search Engine tool. Please see the supplemental materials for the full list of search terms. We electronically extracted data, including date of procedure, gender, and most recent body mass index (BMI), within 1 year prior to note. Acute Physiology and Chronic Health Evaluation III (APACHE III) data are tracked for all patients on admission to ICU; this was collected when available. Charts were then manually reviewed to collect additional data, including international normalized ratio (INR), platelet count, lactate level on the day of CVC placement, anticoagulant use (actively prescribed coumadin, therapeutic enoxaparin, therapeutic unfractionated heparin, or direct oral anticoagulant), ventilator or noninvasive positive pressure ventilation (NIPPV) at time of CVC placement, and vasopressor requirement within 24 hours of CVC placement. The procedure note was reviewed to gather information about site of CVC placement, size and type of catheter, number of attempts, procedural success, training level of the operator, and attending presence. Small bore CVCs were defined as 7 French (Fr) or lower. Large bore CVCs were defined as >7 Fr; this includes dialysis catheters, Cordis catheters (Cordis, Fremont, CA), and cooling catheters. The times of the procedure note and postprocedure chest x-ray (CXR) were recorded, including whether the CVC was placed on a weekend (Friday 7 pm to Sunday at midnight) or weekday.