Quality Improvement Guidelines for Central Venous Access

Quality Improvement Guidelines for CentralVenous AccessCurtis A. Lewis, MD, Timothy E. Allen, MD, Dana R. Burke, MD, John F. Cardella, MD, Steven J. Citron, MD,Patricia E. Cole, MD, PhD, Alain T. Drooz, MD, Elizabeth A. Drucker, MD, JD, Ziv J. Haskal, MD,Louis G. Martin, MD, A. Van Moore, MD, Calvin D. Neithamer, MD, Steven B. Oglevie, MD,Kenneth S. Rholl, MD, Anne C. Roberts, MD, David Sacks, MD, Orestes Sanchez, MD, Anthony Venbrux, MD,Curtis W. Bakal, MD, MPH, for the Society of Interventional Radiology Standards of Practice CommitteeJ Vasc Interv Radiol 2003; 14:S231–S235CENTRAL venous access is an integralcomponent in the care of patients withmalignant, infectious, and chronic diseases.Image-guided placement of centralvenous access catheters has beenproven to be very safe and effective inproviding access to the central venouscirculation (1–21). Image-guided percutaneousplacement of venous cathetersand ports has become the methodof choice in many institutions becauseit has reduced morbidity and mortalityand has helped to reduce costs andlength of stay in the hospital (5,7,8,10–13,16–25).Participation by the radiologist inpatient follow-up is an integral part ofcentral venous access and will increasethe success rate of the procedure.Close follow-up, with monitoring andmanagement of the central venous accessdevice, is appropriate for the radiologist.These guidelines are written to beused in quality improvement programsto assess percutaneously placed centralvenous access devices. The most importantprocesses of care are (a) patient selection,(b) procedure performance, and(c) patient monitoring. The outcomemeasures or indicators for these processesare indications, success rates, andThis article first appeared in J Vasc Interv Radiol1997; 8:475–479.Address correspondence to the SIR, 10201 Lee Hwy,Suite 500, Fairfax, VA 22030.© SIR, 2003DOI: 10.1097/01.RVI.0000094590.83406.9ecomplication rates. Outcome measuresare assigned threshold levels.DEFINITIONSImage-guided percutaneous centralvenous access is defined as the placementof a catheter with its tip in thecaval atrial region utilizing the assistanceof real-time imaging. The mostcommonly used imaging techniquesduring placement include fluoroscopyand ultrasonography.Tunneled catheters are defined ascatheters that travel through a subcutaneoustract prior to exiting the bodythrough a small incision in the skin.Implanted ports are similar to tunneledcatheters. However, they do notexit the skin, but terminate with a deviceburied in the subcutaneous tissues.The catheter exit or implantedport site can be located in several differentlocations but is usually placedover the torso/neck or peripherally.However, other alternative accessroutes have been described (3,9,10,15,22,26).Successful placement is defined asfollows: introduction of a catheter intothe venous system with the tip in thedesired location and the catheter functionsfor its intended use (eg, can beused to deliver medications or for dialysis).Functional success is the mostimportant component of this definition.While practicing physicians shouldstrive to achieve perfect outcomes (eg,100% success; 0% complications), inpractice all physicians will fall short ofthis ideal to a variable extent. Therefore,indicator thresholds may be usedto assess the efficacy of ongoing qualityimprovement programs. For thepurpose of these guidelines, a thresholdis a specific level of an indicatorthat should prompt a review. “Procedurethresholds” or “overall thresholds”reference a group of indicatorsfor a procedure (eg, major complicationsfor the placement of central venousaccess devices). Individual complicationsmay also be associated withcomplication-specific thresholds. Whenmeasures such as indications or successrates fall below a (minimum)threshold, or when complication ratesexceed a (maximum) threshold, a reviewshould be performed to determinecauses and to implement changes, ifnecessary. Thresholds may vary fromthose listed here; for example, patientreferral patterns and selection factorsmay dictate a different threshold valuefor a particular indicator at a particularinstitution. Therefore, setting universalthresholds is very difficult andeach department is urged to alter thethresholds as needed to higher orlower values, to meet its own qualityimprovement program needs.Complications can be stratified onthe basis of outcome. Major complicationsresult in admission to a hospitalfor therapy (for outpatient procedures),an unplanned increase in thelevel of care, prolonged hospitalization,permanent adverse sequelae, ordeath.Minor complications result in no se-S231

S232 • QI Guidelines for Central Venous Access September 2003 JVIRTable 1Indications for Central Venous AccessTherapeutic IndicationsAdministration of chemotherapyAdministration of total parenteralnutritionAdministration of blood productsAdministration of intravenousmedicationsIntravenous fluid administrationPerformance of plasmapheresisPerformance of hemodialysisDiagnostic IndicationsTo establish or confirm a diagnosisTo establish a prognosisTo monitor response to treatmentFor repeated blood samplingTable 2Success RatesReported Rates(%)Threshold(%)Internal jugular approach (4,22,27–35) 96 95Subclavian vein approachCatheter (6,8,11,14,16,17,19,22,23,28,31–33,36–44) 95 90Infusion port (16,18,22,23,45) 95 90Peripherally inserted central catheters (PICC)96 90(1,7,20,22,23,25,46–51)Peripherally implanted ports96 90(2,5,10,12,13,16,21,23,24,48,52–57)Translumbar approach (9,15,26) 96 90Note.—Success rates and thresholds listed are for the adult population and could beexpected to be lower in a pediatric population.quelae; they may require nominal therapyor a short hospital stay for observation(generally overnight) (AppendixA). The complication rates and thresholdsbelow refer to major complications.INDICATIONS FOR CENTRALVENOUS ACCESSIndications for central venous accessare listed in Table 1. The thresholdfor these indications is 95%. Whenfewer than 95% of procedures are forthese indications, the department willreview the process of patient selection.The decision to place a central venousaccess device should be madeafter considering the risks and benefitsto each patient. Coagulopathy andsepsis may be relative contraindicationsto immediate implantation oflong-term central venous access devices.Appropriate effort should bemade to correct or improve a patient’scoagulopathy prior to placement of acentral venous catheter. Other factorsthat may also increase complicationsinclude venous stenosis, acute thrombosis,and local skin infection at theinsertion site. In patients in whomthese findings or abnormalities cannotbe corrected, the procedure may stillbe indicated if the risk/benefit ratio islower than the alternative methods ofdiagnosis or treatment.SUCCESS RATES OF CENTRALVENOUS ACCESSSuccess rates for central venous accessare listed in Table 2, along withrecommended threshold values.Table 3Complication Rates and Suggested Thresholds for Central Venous AccessSpecific Major Complicationsfor Image-guidedCentral Venous AccessCOMPLICATIONS OFCENTRAL VENOUS ACCESSComplications are defined as early(occurring within 30 days of placement)or late (occurring after 30 days).Early complications can be subdividedinto procedurally related, defined asthose that occur at the time or within24 hours of the intervention, and thoseoccurring beyond that period. Complicationsthat occur at the time of theprocedure usually consist of injury tothe surrounding vital structures ormalpositioning of the catheter tip. TheRate(%)SuggestedThreshold(%)Subclavian and jugular approachesPneumothorax 1–2 3Hemothorax 1 2Hematoma 1 2Perforation 0.5–1 2Air embolism 1 2Wound dehiscence 1 2Procedure-induced sepsis 1 2Thrombosis* 4 8Peripheral placement PICC and peripheral portsPneumothorax/hemothorax 0 0Hematoma 1 2Wound dehiscence 1 2Phlebitis* 4 8Arterial injury 0.5 1Thrombosis* 3 6Procedure-induced sepsis 1 2* The literature is difficult to define, and most complications are thought not to bemajor complications.incidence of early complications islower with image-guided techniqueswhen compared to blind or externallandmark techniques (7,27,31,34,38,43).Complications (major and minor)occur in approximately 7% of patientswhen image guidance is used (7,11,14,18,20,31,37,39). Published complicationrates and suggested thresholdsare listed in Table 3.Published rates for individual typesof complications are highly dependenton patient selection and are based onseries comprising several hundred pa-

Volume 14 Number 9 Part 2Lewis et al • S233tients, which is a volume larger thanmost individual practitioners arelikely to treat. It is also recognized thata single complication can cause a rateto cross above a complication-specificthreshold when the complication occursin a small volume of patients (eg,early in a quality improvement program).In this situation, the overallprocedure threshold is more appropriatefor use in a quality improvementprogram.The overall procedure threshold formajor complications resulting fromimage-guided central venous accessincluding the subclavian, jugular andperipheral approaches is 3%.References1. Abi-Nader JA. Peripherally insertedcentral venous catheters in critical carepatients. Heart Lung 1993; 22:428–434.2. Andrews JC, Walker-Andrews SC,Ensminger WD. Long-term centralvenous access with a peripherallyplaced subcutaneous infusion port: initialresults. Radiology 1990; 176:45–47.3. Andrews JC. Percutaneous placementof a Hickman catheter with use ofan intercostal vein for access. J VascInterv Radiol 1994; 5:859–861.4. Belani KG, Buckley JJ, Gordon JR, CastanedaW. Percutaneous cervical centralvenous line placement: a comparisonof the internal and external jugularroutes. Anesth Analg 1980; 59:40–44.5. Brant-Zawadzki M, Anthony M, MercerEC. Implantation of P.A.S.Portvenous access device in the forearmunder fluoroscopic guidance. Am JRoentgenol 1993; 160:1127–1129.6. Burnett AF, Lossef SV, Barth KH, et al.Insertion of Groshong central venouscatheters utilizing fluoroscopic techniques.Gynecol Oncol 1994; 52:69–73.7. Cardella JF, Fox PS, Lawler JB. Interventionalradiologic placement of peripherallyinserted central catheters. JVasc Interv Radiol 1993; 4:653–660.8. Cockburn JF, Eynon CA, Virji N, JacksonJE. Insertion of Hickman centralvenous catheters by using angiographictechniques in patients with hematologicdisorders. Am J Roentgenol1992; 159:121–124.9. Denny DF Jr, Greenwood LH, MorseSS, Lee GK, Baquero J. Inferior venacava: translumbar catheterization forcentral venous access. Radiology 1989;170:1013–1014.10. Denny DF Jr. The role of the radiologistin long-term central vein access.Radiology 1992; 185:637–638.11. Hull JE, Hunter CS, Luiken GA. TheGroshong catheter: initial experienceand early results of imaging-guidedplacement. Radiology 1992; 185:803–807.12. Kahn ML, Barboza RB, Kling GA,Heisel JE. Initial experience with percutaneousplacement of the P.A.S.Portimplantable venous access device. JVasc Interv Radiol 1992; 3:459–461.13. Lewis CA, Sheline ME, ZuckermanAM, Short JK, Stallworth MJ, MarcusDE. Experience and clinical follow-upin 273 radiologically placed peripheralcentral venous access ports.Radiology 1994; 193(P):245.14. Lund GB, Trerotola SO, Scheel PF Jr, etal. Outcome of tunneled hemodialysiscatheters placed by radiologist. Radiology1996; 198:467–472.15. 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Complications and side effectsassociated with large bore cathetersin the subclavian and internal jugularveins. Artif Organs 1994; 4:318–321.29. Damen J, Bolton D. A prospectiveanalysis of 1400 pulmonary arterycatheterizations in patients undergoingcardiac surgery. Acta AnaesthesiolScand 1986; 30:386–392.30. Goldfarb G, Lebrec D. Percutaneouscannulation of the internal jugular veinin patients with coagulopathies: an experiencebased on 1000 attempts. Anesthesiology1982; 56:321–323.31. Lameris JS, Post PJM, Zonderland HM,Kappers-Klunne MC, Schutte HE.Percutaneous placement of Hickmancatheters: comparison of sonographicallyguided and blind techniques.Am J Roentgenol 1990; 155:1097–1099.32. Skolnick ML. The role of sonographyin the placement and management ofjugular and subclavian central venouscatheters. Am J Roentgenol 1994; 163:291–295.33. Sznajder IJ, Zveibil FR, Bitterman H,Weiner P, Bursztein S. Central veincatheterization failure and complicationrates by three percutaneous approaches.Arch Intern Med 1986; 146:259–261.34. Troianas CA, Jobes DR, Ellison N. Ultrasound-guidedcannulation of the internaljugular vein: a prospective randomizedstudy. Anesth Analg 1991; 12:823–826.35. Tyden H. Cannulation of the internaljugular vein 500 cases. Scand Soc Anaesthesiologists1982; 26:485–488.36. Burri C, Ahnefeld FW. The cavalcatheter. Heidelberg, New York:Springer-Verlag, 1977.37. Fernando C, Juravsky L, Yedlicka J,Hunter D, Castaneda-Zuniga W, AmplatzK. Subclavian central venouscatheter insertion: angiointerventionaltechnique. Semin Intervent Radiol1991; 8:78–81.38. Gualtieri E, Deppe SA, Sipperly ME,Thompson DR. Subclavian venouscatheterization: greater success rate forless experienced operators using ultrasoundguidance. Crit Care Med 1995;23:692–697.39. Openshaw KL, Picus D, Darcy MD,Vesely TM, Picus J. 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S234 • QI Guidelines for Central Venous Access September 2003 JVIRpercutaneous central venous catheterization.2nd ed. London: Saunders, 1992.41. Jaques PF, Campbell WE, DumbletonS, Mauro MA. The first rib as a fluoroscopicmarker for subclavian vein access.J Vasc Interv Radiol 1995; 6:619–622.42. Gray RR. Radiologic placement of indwellingcentral venous lines for dialysis,TPN and chemotherapy. J VascInterv Radiol 1991; 6:133–144.43. Mansfield PF, Hohn DC, Fornage BD,Gregurich MA, Ota DM. Complicationsand failures of subclavian-veincatheterizations. N Engl J Med 1994;331:1735–1738.44. Moosman DA. The anatomy of infraclavicularsubclavian vein catheterizationand its complications. Surg GynecolObstet 1973; 136:71–74.45. Brothers TE, Von Moll LK, NiederhuberJE, Roberts JA, Ensminger WD.Experience with subcutaneous infusionports in three hundred patients. SurgGynecol Obstet 1988; 166:295–301.46. Cardella JF, Lukens ML, Fox PS. Fibrinsheath entrapment of peripherallyinserted central catheters. J Vasc IntervRadiol 1994; 5:439–442.47. Goodwin M, Carlson I. The peripherallyinserted central catheter. J IntravenousNursing 1993; 16:93–100.48. Hovsepian DM, Bonn J, Eschelman DJ.Techniques for peripheral insertion ofcentral venous catheters. J Vasc IntervRadiol 1993; 4:795–803.49. James L, Bledsoe L, Hadaway L. Aretrospective look at tip location andcomplications of peripherally insertedcentral catheter lines. J IntravenousNursing 1993; 16:104–109.50. Merrell SW, Peatross BG, GrossmanMD, Sullivan JJ, Harker G. Peripherallyinserted central venous catheterslow risk alternatives for ongoing venousaccess. West J Med 1994; 160:25–30.51. Andrews JC, Marx MV. The upperarm approach for placement of peripherallyinserted central catheters forprotracted venous access. Am J Roentgenol1992; 158:427–429.52. Bagnall-Reeb H. Initial use of a peripherallyinserted central venous accessport: a review of the literature.JVAN 1991; 1:10–14.53. Ensminger WD, Walker SC, Knol JA,Andrews JC. Initial clinical evaluationof a new implanted port accessedby catheter over needle systems. J InfusChemother 1993; 3:200–203.54. Kahn ML, Barboza RB. Percutaneousplacement of the P.A.S.Port venousaccess device: one year experience (abstr).Radiology 1992; 185(P):278.55. Laffer U, Bengtsson M, StarkhammarH. The P.A.S.Port-system: a new totallyimplanted device for long-termcentral venous access. Basel: Karger,1991; 58–64. Laffer U, Bachmann-MettlerI, Metzger U, eds. In: ImplantableDrug Delivery Systems.56. Schuman E, Ragsdale J. Peripheralports are a new option for central venousaccess. J Am Coll Surg 1995; 180:456–460.57. Starkhammar H, Bengtsson M, GainTB, et al. A new injection portal forbrachially inserted central venous catheter:a multicenter study. Med OncolTumor Pharmacother 1990; 7:281–285.58. Sitzmann JV, Townsend TR, Siler MC,Bartlett JG. Septic and technical complicationsof central venous catheterization.Ann Surg 1985; 202:766–770.59. Vazquez RM, Brodski EG. Primaryand secondary malposition of siliconecentral venous catheters. Acta AnaesthScand 1985; 81:22–25.60. Fink A, Kosefcoff J, Chassin M, BrookRH. Consensus methods: characteristicsand guidelines for use. Am J PublicHealth 1984; 74:979–983.61. Leape LL, Hilborne LH, Park RE, et al.The appropriateness of use of coronaryartery bypass graft surgery in NewYork State. JAMA 1993; 269:753–760.APPENDIX AClassification of Complications byOutcomeMinor ComplicationsA. No therapy, no consequence.B. Nominal therapy, no consequence;includes overnight admissionfor observation only.Major ComplicationsC. Require therapy, minor hospitalization(48 hours).D. Require major therapy, unplannedincrease in level of care, prolongedhospitalization (48 hours).E. Permanent adverse sequelae.F. Death.APPENDIX BMethodologyTechnical documents specifying theexact consensus and literature reviewmethodologies are available upon requestfrom the Society of InterventionalRadiology, 10201 Lee HighwaySuite 500, Fairfax, VA 22030.Reported complication-specificrates in some cases reflect the aggregateof major and minor complications.Thresholds are derived fromcritical evaluation of the literature,evaluation of empirical data fromstandards of practice committee memberpractices, and, when available, theHI-IQ ® system national database.Consensus on statements in thisdocument was obtained utilizing amodified Delphi technique (60,61).ADDENDUMDr. Curtis A. Lewis, Chairman ofthe Standards of Practice Committee,authored the first draft of this documentand served as topic leader duringthe subsequent revisions of thefirst draft. Dr. Curtis W. Bakal isCouncilor of the Standards of PracticeCommittee. All other authors arelisted alphabetically. Other membersof the Standards of Practice Committeeand SIR who participated in thedevelopment of this clinical practiceguideline are: Timothy Allen, MD,John Aruny, MD, Raymond Bertino,MD, Dana Burke, MD, John Cardella,MD, Paramjit Chopra, MD, StevenCitron, MD, Patricia Cole, MD, PhD,Philip Cook, MD, Martin Crain, MD,Donald Denny, MD, Alain Drooz, MD,Elizabeth Drucker, MD, JD, Neil Freeman,MD, Gregg Gaylord, MD, PatriciaThorpe, MD, Murray Gordon, MD,Ziv Haskal, MD, James Husted, MD,Patrick Malloy, MD, Louis Martin,MD, M. Victoria Marx, MD, TerenceMatalon, MD, Timothy McCowan,MD, Steven Meranze, MD, VanMoore, MD, Calvin Neithamer, MD,Albert Nemcek, Jr, MD, StevenOglevie, MD, Kenneth Rholl, MD,Anne Roberts, MD, David Sacks, MD,Orestes Sanchez, MD, James Spies,MD, Richard Towbin, MD, DanielWunder, MD, Anthony Venbrux, MD,and Robert Vogelzang, MD.

Volume 14 Number 9 Part 2Lewis et al • S235The clinical practice guidelines of the Society of Interventional Radiology attempt to define practice principles thatgenerally should assist in producing high-quality medical care. These guidelines are voluntary and are not rules. Aphysician may deviate from these guidelines, as necessitated by the individual patient and available resources.These practice guidelines should not be deemed inclusive of all proper methods of care or exclusive of othermethods of care that are reasonably directed toward the same result. Other sources of information may be used inconjunction with these principles to produce a process leading to high-quality medical care. The ultimate judgmentregarding the conduct of any specific procedure or course of management must be made by the physician, whoshould consider all circumstances relevant to the individual clinical situation. Adherence to the SIR QualityImprovement Program will not assure a successful outcome in every situation. It is prudent to document therationale for any deviation from the suggested practice guidelines in the department policies and procedure manualor in the patient’s medical record.