8. Dress with small, self-adhesive bandage or gauze pad

and inspect daily until healing occurs.

Complications of Central Venous

Lines (20)

1. Damage to other vessels and organs during insertion

a. Possible during both percutaneous and surgical

placement of central venous catheters

b. Complications include bleeding, pneumothorax,

pneumomediastinum, hemothorax, arterial puncture, and brachial plexus injury.

2. Phlebitis

a. Mechanical phlebitis may occur in the first 24 hours

after line placement as a normal response of the

body to the irritation of the catheter in the vein.

b. Management of mild phlebitis (mild erythema and/

or edema): Apply moist, warm compress, and elevate extremity.

c. Remove the catheter if symptoms do not improve, if

phlebitis is severe (streak formation, palpable venous

cord, and/or purulent drainage), or if there are signs

of a catheter-related infection.

3. Catheter migration/malposition (Fig. 32.14)

a. Can occur during insertion or at any point during

the dwell time of the catheter (possibly as a consequence of poor catheter fixation at the skin surface

and movement of the joints). The catheter can enter

a venous tributary during insertion or can reverse

direction, causing it to loop back.

b. Sites of misplacement include the cardiac chambers, internal jugular vein, contralateral subclavian vein, ascending lumbar vein (which communicates with the vertebral venous plexus),

superficial abdominal vein, renal vein, and others.

Consequences include pericardial effusion or

pleural effusion, cardiac arrhythmias, tissue

extravasation/infiltration, neurological complications such as seizures or paraplegia, thrombosis,

and death.

c. The decision to remove the catheter or attempt to

correct the position is based on the location of the

tip. Although PICCs are intended to be placed in

central veins (See Section E, page 195), occasionally, the tip is in a noncentral location (e.g., in the

subclavian vein). These noncentral PICCs may be

used, provided the fluids administered through them

are isotonic, but the care of the catheters must be as

stringent as for centrally placed catheters.

d. The catheter should be pulled back into an appropriate position if the tip is in the heart, as serious

consequences such as cardiac arrhythmia, perforation, or pericardial effusion can occur.

e. Catheters in the ascending lumbar vein or vertebral

venous plexus must be removed, since the infusion

of parenteral alimentation fluids in this area may

lead to severe CNS damage, manifesting as seizures,

paraplegia or death (Figs. 29.3, 32.14D) (20).

f. Spontaneous correction of malpositioned lines has

been demonstrated in some cases (21). If the tip of

the catheter is looped into the internal jugular or in

the contralateral brachiocephalic vein, the catheter

may be used temporarily (using isotonic fluids that

are suitable for peripheral venous cannulae) and reevaluated radiologically in 24 hours. If the catheter

Chapter 32 ■ Central Venous Catheterization 209

has not moved spontaneously into the desired location, it should be removed.