204 CENTRAL LINES Steele, Irvin • CENTRAL LINE MECHANICAL COMPLICATIONS

Central Line Mechanical Complication Ratein Emergency Medicine Patients

ROBERT STEELE, MD, CHARLENE BABCOCK IRVIN, MD

Abstract. Central line (CL) placement in the emergency department(ED) is a common practice. Previously published small-scale studieshave quoted mechanical complication rates in emergency medicine pa-tients of 10–15%. Objective: To determine the mechanical complica-tion rate of central venous catheterization in a large (65,000 visits/year) academic urban ED. Methods: This was a retrospective reviewof all ED-placed CLs over a three-year period from May 1995 to May1998. Data were collected as part of a monthly quality assurance proj-ect and analyzed using Fisher’s exact test (significance = p < 0.05).Central lines were defined as subclavian, internal jugular, femoral,and interosseous lines. Mechanical complication was defined as apneumothorax, hematoma, line misplacement, or hemothorax. Re-

sults: There were 22 complications of a total of 643 CLs placed [com-plication rate 3.4% (95% CI = 1.9% to 4.8%)]. The complication ratefor patients with a confirmatory chest x-ray receiving a subclavian orinternal jugular CL (excluding all patients who died prior to x-rayevaluation of CL) was 6.2% (22/355) (95% CI = 3.9% to 9.3%). Therewere 402 (63%) CLs placed during a code with a complication rate of2.2% (95% CI = 1.0% to 4.2%), 79% (317/402) medical and 21% (85/402) trauma codes. Thirty-seven percent (241) of the CLs were placedon an ‘‘elective urgent’’ basis. Residents placed the majority of CLs(567/643), with a complication rate of 3%. There was no statisticallysignificant difference in complication rates based on level of residenttraining. Conclusions: The CL mechanical complication rate in the EDat this institution is 3.4%. This is substantially lower than previouslyreported mechanical complication rates. Key words: central venous;complication; central vascular access; central line. ACADEMICEMERGENCY MEDICINE 2001; 8:204–207

Central line placement is a commonprocedure in emergency medicine(EM), yet little information exists re-garding the complication rate of cen-tral lines (CLs) placed in the emer-gency department (ED). Surgicalliterature quotes mechanical compli-cation rates at <1% preoperatively

From the Department of EmergencyMedicine (RS), St. John Hospital andMedical Center (CBI), Detroit MI; andWayne State University School of Medi-cine, Detroit, MI (CBI).Received March 21, 2000; revision re-ceived August 25, 2000; accepted Sep-tember 12, 2000. Presented as a posterat the SAEM annual meeting, Boston,MA, May 1999.Address for correspondence and reprints:Robert Steele, MD, Emergency Medicine,Covenant Hospital, 1447 North HarrisonRoad, Saginaw, MI 48602. E-mail:steelmd@123.net

and 2–5% in patients overall.1 Pre-viously published small-scale retro-spective studies have quoted me-chanical complication rates in EMpatients at 10–15%.2–4 A mechani-cal complication is considered animmediate complication from CLplacement such as pneumothorax,hematoma, or line misplacement. In-fection and thrombosis are consid-ered late complications related tomultiple variables and are not con-sidered mechanical complications.This study was initiated to deter-mine the current CL mechanicalcomplication rate in a large aca-demic ED.

METHODS

Study Design. This was a retro-spective observational study. The ob-jective was to identify the rate of

mechanical CL complications in pa-tients presenting to an academic ur-ban ED institution. This study wassubmitted for institutional reviewboard approval and considered ex-empt from informed consent, as itwas a review of routinely collectedquality assurance (QA) data. Patientconfidentiality was maintained.

Study Setting and Population.

A retrospective review of all CLsplaced in the ED over a three-yearperiod (May 1995 to May 1998) wasperformed. The data were collectedin an academic urban ED with65,000 patient visits a year. Thedata were collected as part of ongo-ing monthly QA project.

Study Protocol. A CL was de-fined as a 16- or 14-Fr cordis with asingle-, double-, or triple-lumencatheter. For the purpose of thisstudy, an intraosseous line was alsoconsidered a CL. The CL was placedinto the femoral, internal jugular, orsubclavian vein. Intraosseous lineswere placed in the tibia or femur.

It is routine policy in this insti-tution that the nurses in the ED andon inpatient units are required todocument and evaluate every CL.There is a uniform data sheet for CLevaluations in which the nurse doc-uments location, type of line, andany abnormalities related to the CL,including hematoma, pneumotho-rax, and misplacement, along withan ‘‘other’’ section where further in-formation regarding the CL can berecorded. The charts from all pa-tients who had a CL placed fromMay 1995 to May 1998 were re-viewed using a uniform data ab-straction sheet, and any documentedcomplication was recorded. Thesedata were entered into an Excelspreadsheet (Microsoft, Redmond,WA) to allow for statistical analysis.

A complication was defined as apneumothorax, hematoma, line mis-placement, or hemothorax. A hema-toma identified on chest x-ray uni-lateral to the CL was considered acomplication from the CL, even ifthe patient sustained major traumaon that side of the chest. A pneu-mothorax of any size was considereda complication. Chest x-rays werenot obtained after CL placement ifthe patient did not survive the re-suscitation. Line misplacement ne-cessitating removal and placement

ACADEMIC EMERGENCY MEDICINE • February 2001, Volume 8, Number 2 205

TABLE 1. Complication Rates for Central Lines (CLs)

Central Lines Number of CLs Complications

Codes 402 (63%) 9 (2.2%) CI = 1.9%, 4.8%Medical 317 5 (1.6%) CI = 0.5%, 3.9%Trauma 85 4 (4.7%) CI = 1.3%, 11.6%

Elective urgent 241 (37%) 10 (4.1%) CI = 2.0%, 7.5%

TOTAL 643 22 (3.4%) CI = 1.9%, 4.8%

TABLE 2. Locations for Central Lines

Lines Placed Number of Lines Complication Rate (CI)

SubclavianInternal jugularFemoralIntraosseous

329/643 (51%)155/643 (24%)147/643 (23%)12/643 (1.8%)

4.2%5.2%0.0%0.0%

(2.3%, 7.4%)(2.1%, 9.8%)(0.0%, 2.2%)(0.0%, 26%)

TABLE 3. Complications

Complication Complication Rate (CI)

PneumothoraxHematomaMisplacement

12/643 (1.9%)7/643 (1%)3/643 (<0.1%)

(0.3, 2.0)(1.0, 3.2)

(0.002, 0.01)

of a new CL was considered a com-plication. Failure to place a CL ne-cessitating a second attempt at an-other location was not considered acomplication. A consult related tothe CL not including infection andthrombosis was determined to be aCL complication. An arterial punc-ture by the 18-gauge ‘‘finder needle’’(used to locate the vein) not result-ing in a hematoma was not consid-ered a complication. If the arterywas cannulated or a CL was placedinto the artery, this was considereda complication. If the line required aminor adjustment such as beingpulled back 1–2 cm, this was notconsidered a complication. Infectionand thrombosis were not consideredmechanical complications.

The CLs were grouped into med-ical code, trauma code, or ‘‘electiveurgent.’’ A medical code was definedas any patient with unstable vitalsigns, with respiratory arrest, or un-dergoing cardiopulmonary resusci-tation. A trauma code was defined asper Advanced Trauma Life Support(ATLS) criteria.5 ‘‘Elective urgent’’lines were defined as those placedinto patients who were relativelystable but required central venousaccess in the ED. These patients ei-ther required large fluid volumes,central pressure monitoring, pres-sors, pacemaker placement, or vas-cular access that could not otherwisebe obtained.

Data Analysis. Charts were ret-rospectively reviewed for the follow-ing data: placement of a CL in theED, abnormal chest x-ray related tothe CL, consult related to CL, anddocumented CL abnormality, includ-ing CL misplacement, hemothorax,and pneumothorax. Each patientwho received a CL in the ED had hisor her ED course, disposition, andoutcome reviewed. The ED nurse’snotes regarding the CL were re-viewed.

The data were analyzed usingFisher’s exact test. Ninety-five per-cent confidence intervals (95% CIs)were measured when appropriate.Significance was defined as p < 0.05.

RESULTS

A total of 643 CLs were placed. Thecomplication rate was 3.4% (22/643)overall. Sixty-three percent (402/

643) of the CLs were placed in med-ical or trauma codes (Table 1). Theoverall complication rate for medicaland trauma codes was 2.2% (9/402).The distribution of cases and com-plications of line placement are pre-sented in Table 1.

Table 2 indicates the frequencyof CL placement at specific anatomicsites, and the associated complica-tion rate. The subclavian vein wasthe most frequently utilized site,[51% (329/643)], with a complicationrate of 4.2% (14/329). Patients witha subclavian CL who survived longenough to obtain a post-line-place-ment chest x-ray had a complicationrate of 4.5% (12/269). Internal jugu-lar lines resulted in a complicationrate of 5.2% (8/155). There were nocomplications noted with femoral(147/643) or intraosseous (12/643)lines. There was no statistically sig-nificant difference in complicationrates related to location of CL. Table3 illustrates types and the frequen-cies of specific complications. Threelines had to be changed because ofline misplacement. Two patientswith a line misplacement also hadanother complication (one pneumo-thorax and one hematoma). Forthese two patients, four complica-tions were recorded. In patients re-

ceiving chest x-rays after CL place-ment (n = 355), a pneumothorax wasmost frequently encountered compli-cation [3.4% (12/355)]. The hema-toma complication rate was 0.9%(7/643) (95% CI = 0.3% to 2.0%)(Table 3). The complication rate ofpatients with a confirmed post-CLchest x-ray who received an internaljugular or subclavian CL was 6.2%(22/355).

Residents under the supervisionof an attending placed 567 of 643lines, with a 2.8% complication rate(16/567; 95% CI = 1.7% to 4.8%). Theattending physicians placed theother 76 lines with a complicationrate of 5% (4/76; 95% CI = 1.4% to12.9%). There was no statisticallysignificant difference in complica-tions between resident-placed linesand attending-placed lines. Themean number of CLs placed per phy-sician was 7.3, with a range of 1–30lines/physician. The majority of CLswere placed by the EM residents(Table 4). The worst complicationfollowing resident CL placementwas a mediastinal hematoma neces-sitating surgical evacuation. This oc-curred during placement of a cordisand pacemaker. We could not ex-clude the cordis as the cause of themediastinal hematoma even though

206 CENTRAL LINES Steele, Irvin • CENTRAL LINE MECHANICAL COMPLICATIONS

TABLE 4. Complication Rate by Resident Specialty

SpecialtyNumber of Central

Lines Placed Complication Rate* (CI)

Emergency medicineInternal medicineSurgery

40310160

8/403 (2.0%)2/101 (2.0%)5/60 (8.3%)

(0.9%, 3.9%)(0.2%, 7.0%)(2.7%, 18%)

*No statistical difference was noted between groups.

the hematoma may have been sec-ondary to the pacemaker insertion.

DISCUSSION

Previously published small retro-spective studies evaluating CL com-plication rates in the ED havequoted a complication rate of 10–15%.2–4 These studies were per-formed as retrospective reviews,they were smaller-scale studies, andthey lacked the consistent documen-tation format of our study (the re-quired nursing CL evaluation form).In this retrospective review, thecomplication rate overall was 3.4%.There are several possible reasonsfor this difference. Old literaturemay not accurately reflect the truecomplication rate in the modern-dayED. Most of the previous literatureis at least ten years old, and the ma-jority does not include residency-trained EM specialists. Fifteenyears ago subspecialists placed mostof the CLs in the ED, and CLs wereused much less frequently. Now theyare more widely used and accepted.

Our lower complication rate maybe related to the higher acuity of dis-ease within our patient population.Trauma and medical codes repre-sented 63% of our patient population(Table 1). Mechanical complicationrates were lower during a code.These data, while intuitively sur-prising, are not new.6,7 There maybe several explanations for this. Achest x-ray was not performed if thepatient did not survive; thus, onlyclinically obvious pneumothoraceswould be identified in patients un-successfully resuscitated. If a pa-tient is profoundly hypotensive, thechance of a hematoma is much lesslikely. If the patient is mechanicallyventilated, it is easier to insert theneedle during expiration than inspi-ration, again reducing the chance ofa complication. Patients being resus-citated are frequently unconsciousand these patients are easier to

place into an accommodating posi-tion for the physician. In consciouspatients, there is a certain addedpressure because the patients areaware of the procedure, while thephysician’s performance anxiety inunconscious patients is probablyless. These may all be contributingfactors for our lowered complicationrate.

There was no statistical differ-ence in placements of a CL based onyear of residency training. Emer-gency medicine residents placed themajority of lines, and EM residentswere postgraduate year (PGY) 1–3.Internal medicine residents whoplaced lines were almost entirelysecond- or third-year residents. Sur-gery residents placing CLs wereusually PGY-1s, and had the highestcomplication rate of 8%. The attend-ing physician complication rate was5% (76/643); attending physiciansplaced lines after the resident hadtried and failed.

The location of a CL affects thecomplication rate. Subclavian lineswere more common at our institu-tion because of physician preference.They were also associated with afairly high complication rate. Thesubclavian vein is often accessedduring emergent codes because ithas the least variance in anatomy,allowing for rapid vascular access.8

Although this subgroup (with com-plications confirmed by post-CLchest x-ray) has the highest rate ofcomplications, this was still substan-tially less than previously reported.

Femoral lines traditionally havethe lowest complication rate of anyCL and in our study, there were nofemoral line mechanical complica-tions. This may be because femoralsites were selected by more experi-enced physician. Of the 44 CL at-tempts requiring a second location,59% of those second locations re-sulted in the placement of a femoralline. This meant that the femoralline was usually placed after the

first physician tried and failed. Afterthe initial attempt by a first-year in-tern, a more experienced resident orattending usually makes the secondattempt. Therefore, most of the fem-oral lines, which normally havefewer complications, were placed asa second attempt by more experi-enced physicians.

Although documentation is an is-sue in all retrospective studies, hav-ing three separate sources involvedin the evaluation in a CL helps toimprove the quality of the data pro-duced. The emergency physician(EP), the ED nurse, and the inpa-tient nurse are all responsible fordocumentation and evaluation of theCL. If either the nurse or physiciandocumented anything abnormal re-garding the CL, the case was re-viewed by the QA committee. Con-sults or radiographic findingssuggestive of a complication relatedto CL placement prompted a QAevaluation. The QA committeehelped to provide an objective anal-ysis of the data and helped to ensurethat very few items of significancewould be missed.

LIMITATIONS AND FUTUREQUESTIONS

This was a retrospective study. It isreliant on documentation of thenursing and physician staff. Smallhematomas may have been under-reported; however, their clinical sig-nificance is questionable. If a he-matoma was large enough to requireobservation, require consultation, orbe noted as a radiographic abnor-mality, it was most likely docu-mented and counted as a complica-tion, prompting review by the QAcommittee.

Infection and thrombosis werenot evaluated, because they are notconsidered a mechanical complica-tion. Infection and thrombosis arerelated to multiple variables, includ-ing the patient’s condition, nursingcare of the line, length of time theline has been in place, and physicianplacement of the line. Many of thesevariables are not under the controlof the EP. In our intensive care units(ICUs), a line emergently placed ischanged within 24 hours to avoidline-related sepsis; the delayed com-plication of infection would be un-likely. Clinically apparent line-re-

ACADEMIC EMERGENCY MEDICINE • February 2001, Volume 8, Number 2 207

lated thrombosis is a controversialissue. Ultrasound shows thrombosisrates as high as 15–25% in femorallines, yet the rate of pulmonary em-bolism or clinically detectable ve-nous thrombosis from a CL is quotedat less than 1%.7,9,10

This study was performed at anacademic institution. As a Level 1trauma center, more critical patientswho frequently need CLs may beevaluated here compared with asmaller community ED where CLsare less frequently inserted. It maynot be appropriate to extrapolate theCL mechanical complication rate atan academic Level 1 trauma centerto smaller institutions where CLsare less frequently placed.

CONCLUSIONS

The CL mechanical complication

rate at this academic urban ED is3.4%, lower than previously re-ported complication rates.

The authors thank Dane Piper, PhD, andSarah Platte for their help.

References

1. Purdue GF, Hunt JL. Placement andcomplications of monitoring catheters.Surg Crit Care. 1991; 71:723–30.2. Abraham E, Shapiro M, Sherman P.Central venous catheterization in theemergency setting. Crit Care Med. 1983;11:515–8.3. Cook D, Randolph A, Kernerman P, etal. Central venous catheter replacementstrategies: a systematic review of the lit-erature. Crit Care Med. 1997; 25:1417–24.4. Feliciano D, Mattox K, Graham J,Beall A, Jordan G. Major complications

of percutaneous subclavian vein cathe-ters. Am J Surg. 1979; 138:869–73.5. Advanced Trauma Life Support, fifthed. Dallas: American Heart Association,1993, p 317.6. Puri VK, Calson RW, Bander JJ, et al.Complications of vascular catheteriza-tion in the critically ill: a prospectivestudy. Crit Care Med. 1980; 8:495–500.7. Sznajder JI, Zveibel FR, Bitterman H,Weiner P, Burszstein S. Central veincatheterization: failure and complicationrates by three percutaneous approaches.Arch Intern Med. 1986; 146:259–61.8. Herbst CA. Indications, managementand complications of percutaneous sub-clavian catheters. Arch Surg. 1978; 113:1421–5.9. Warden GD, Wilmore DW, Pruitt BA.Central venous thrombosis: a hazard ofmedical progress [abstract]. J Trauma.1973; 13:620.10. Swanson RS, Uhlig PN, Gross PL,et al. Emergency intravenous accessthrough the femoral vein [abstract]. AnnEmerg Med. 1982; 11:244.

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