Goal: Evaluate the importance and reasons of non-infectious complications of non-tunneled central venous catheterization in our hemodialysis unit. Patients and methods: The study, a prospective type, was conducted in the department of nephrology and hemodialysis of Yalgado Ouedraogo University Hospital Center (YO-UHC) in Ouagadougou, Burkina Faso, from 15 February to 30 June 2015. Patients in whom a new central venous catheter (CVC) was inserted during the study period were included. Catheterization-related complications were noted. Results: During the study period, 156 CVCs (9 per week) were placed in femoral (56.4%), internal jugular (40.4%) or subclavian vein (3.2%). There were 114 patients (59.7% of men and 40.3% of women), average age 41.8 ± 17.1 years, low socio-economic level in 64% of cases. At least a non-infectious complication was observed in 67 cases representing 42.9%. They were: puncture failure (40%), arterial puncture (12.2%), puncture of the thoracic duct (1.3%), pneumothorax (1.3%), bleeding related to the catheter insertion (5.8%), hematoma (1.3%), opposite direction (0.6%), dysfunction of the CVC (10.3%), femoralthrombophlebitis (3.2%). Conclusion: Non-infectious complications of non-tunneled central venous catheterization in our hemodialysis unit were frequent and sometimes severe. Their common denominator was the absence of ultrasound guidance. Our study reaffirms the need for equipping with Doppler ultrasound in our hemodialysis units, even in developing countries, for better security of the patient during central venous catheterization.
The hemodialysis session requires access to the patient’s blood. This access is possible via a central venous catheter (CVC) of hemodialysis inserted into a vein of sufficient gauge, or by an arterialized vein resulting from an arteriovenous fistula (AVF) created surgically. The CVC has the advantage over the AVF to be immediately usable. The prevalence of its use in western countries varies from 7% to 39% [
We conducted a short cross-sectional study in the department of nephrology and hemodialysis of Yalgado Ouedraogo University Hospital Center (YO-UHC) in Ouagadougou, Burkina Faso. It covered the period from 15 February to 30 June 2015.
The hemodialysis unit was opened in 2000. Its initial capacity of nine hemodialysis stations has been extended to 29 since 2009, for about 250 patients at the time of the study. The modality used is conventional hemodialysis. Patients are admitted to the unit for chronic hemodialysis in end-stage renal disease, or acute hemodialysis. Despite the insufficient capacity of the unit, there is still no official text governing access for patients to chronic hemodialysis.
The unit benefits a state subsidy. To enter the chronic hemodialysis program, the patient must pay a lump sum of about US $840; CVC are given free. The acute hemodialysis costs about US $25. Drug costs and diagnostic tests are entirely the responsibility of the patient. The majority of patients are from the city of Ouagadougou.
The CVCs insertion was performed by the physicians of the department (three seniors and two new physi- cians) in a room dedicated to this activity, but not equipped with ultrasound. The common anatomical landmarks are used for insertion. A chest x-ray face is performed after the insertion of a CVC at the neck. Maintenance of the CVC is explained to patients. It is removed at the end of use or in the case of complication.
The CVCs used at the time of the study were short-lived, made of polyurethane and tuneless. Their length was 15 or 20 cm. The CVC measuring 15 cm was preferentially inserted into the internal jugular or right subclavian veins; those measuring 20 cm were inserted into the internal jugular, left subclavian or femoral veins. The tunneled CVC was not yet available neither used in the unity. The unit did not have ultrasound.
The study population consisted of patients receiving chronic hemodialysis in the department of nephrology and hemodialysis unit of YO-UHC. Patients in whom a new catheter was inserted during the study period were included. We have not included cases where the CVC was changed based on recommendation.
We considered as complications the following:
・ puncture failures;
・ aberrant direction of the CVC;
・ accidental punctures: arterial, of the thoracic duct (the puncture brings a milky liquid);
・ pneumothorax: air in the pleural space. The diagnosis is suggested by a chest pain and respiratory discomfort. The diagnosis is confirmed by a chest x-ray andthoracentesis;
・ thrombophlebitis on CVC: presence of thrombus on doppler study. Dysfunction of the CVC: no or insuffi- cient blood flow;
・ hemorrhage: unusual bleeding at the site of puncture;
・ hematoma: painful swelling of the skin next to the site of puncture.
Sociodemographic, clinical and paraclinical data (the workup prior to the insertion of the CVC involved only new patients) were collected. Patients were followed from the CVC insertion to its removal.
Data were collected from the clinical examination of patients and the clinical record. A survey form was used to collect these data. The data have been processed on PC using the software Epi Info version 7.1.3.3. For the comparison of qualitative variables, Chi square and exact Fischer tests were used. The student’s t test was used for comparison of quantitative variables. The level of statistical significance was set for a probability p ≤ 0.05.
The consent of the patients (or their representative if they are unconscious) was obtained before their inclu- sion. They have been informed of the objectives and constraints of the study, and necessary monitoring mea- sures. The study data were collected in the strict respect of anonymity and confidentiality. The YO-UHC lacked ethics committee at the time of the study.
During the study period, 156 CVCs were placed representing approximately nine per week. These CVC insertion sites were diverse (
114 patients were involved: 69 new patients (60.5%) for a first session of hemodialysis (acute or chronic) and 45 former patients already in chronic hemodialysis representing 39.5%. Among the 69 new patients, 20 patients representing 29% were in acute hemodialysis and 49 patients representing 71%in chronic hemodialysis. During the study period, 82 patients (71.9%) received a single CVC, 25 patients (21.9%) two CVCs, four patients (3.5%) three CVCs and three patients (2.7%) four CVCs.
The 114 patients included 68 men representing 59.7% and 46 women representing 40.3%. The sex ratio was 1.5. The average age of the patients was 41.8 ± 17.1 years (extreme = 5 and 85). It was 41.9 ± 17.1 years for men and 41.5 ± 17.3 years for women. There was no statistically significant difference for these two age groups (p = 0.9).
Seventy-three patients (64%) had a low socioeconomic level. The other patients had an average level (30 patients representing 26.3%) or high (11 representing 9.7%).
Personal history of patients is summarized in
The total number of CVCs received before the study by 45 former patients in chronic hemodialysis was 153 representing an average of 3.4 ± 2.3 per patient.
When placing the CVC, 25 patients representing 16% were febrile and 30 patients representing 19.2% had- dyspnea. In addition, we noted: edema of the lower limbs (62 patients representing 39.7%), global heart failure (17 cases representing 10.7%), right heart failure (4 cases representing 2.5%), comatose state (2 cases repre- senting 1.3%). The mean arterial pressures were 148.6 ± 24.6 mm Hg (extreme = 70 - 218) and 89.8 ± 17.0
Number | Percentage | |
---|---|---|
Femoral vein Right Left Total 1 | 59 29 88 | 37.8 18.6 56.4 |
Internal jugular vein Right Left Total 2 | 54 9 63 | 34.6 5.8 40.4 |
Subclavian Vein Right Left Total 3 | 4 1 5 | 2.6 0.6 3.2 |
Total | 156 | 100 |
Personal Medical History | Number | Percentage |
---|---|---|
Arterial Hypertension | 62 | 54.4 |
Thrombophlebitis on Central Venous Catheter* | 13 | 28.9 |
Diabetes | 9 | 7.9 |
Gout | 6 | 5.3 |
Human Immunodeficiency Virus Infection | 3 | 2.6 |
AL Lambda Amyloidosis | 1 | 0.9 |
*: The research was conducted in 45 chronic hemodialysis patients.
mm Hg (extreme = 40 and 125) respectively for the systolic and diastolic blood pressures.
The paraclinical workup prior to insertion of the CVC was done for 69 new patients. The average serum creatinine before hemodialysis was 2364.8 ± 1073.8 µmol/L (
At least a non-infectious complication was observed in 67 cases representing 42.9%.
The global rate of puncture failure was 40%. The average number of punctures in the CVC insertion vein was 1.8 ± 1.4 per patient (extreme = 1 and 8). It was 1.6 ± 1.1 (extreme = 1 and 6) for men and 2 ± 1.7 (extreme = 1 and 8) for women. The difference between the gender was not statistically significant (p = 0.1). The average number of punctures of the vein did not vary significantly according to the CVC insertion site (
One hundred-thirty-nine CVCs representing 89.1% were inserted without change of site. In the 17 remaining cases, the change of insertion site was motivated by:
・ no progression of the guide: five CVCs representing 29.4%;
・ iterative arterial puncture: seven CVCs representing 41.2%;
・ difficulty in tracking the vein: five CVCs representing 29.4%.
An arterial puncture was observed during the insertion of 19 CVCs representing 12.2 percent of the 156 CVCs. The affected artery was the femoral (11 cases representing 12.5% of the 88 femoral CVCs) or the right carotid artery (8 cases representing 12.7% of the 63 internal jugular CVCs).
The thoracic duct was punctured during insertion of two CVCs in the right internal jugular vein representing 1.3% of the 156 CVCs. A pneumothorax was observed during insertion of two CVCs in the right internal jugular vein representing 1.3% of the 156 CVCs and 3.2% of the 63 jugular CVCs.
A hemorrhage through the insertion hole of the CVC was observed after insertion of nine CVCs representing 5.8% of 156 CVCs. It concerned the femoral vein in 8 cases representing 9.1% of 88 CVCs inserted into the femoral vein and the jugular vein in one case representing 1.6% of 63 CVCs inserted into the internal jugular vein. A hematoma was observed when inserting two CVCs in the internal jugular vein, representing 3.2% of jugular CVCs.
One CVC representing 0.6% has taken the wrong direction into the right internal jugular vein while attempting to insert it into the right subclavian vein. This path has been favored by the presence of a large thrombus (as seen on the subsequent Doppler) into the right subclavian vein just downstream of the right subclavian-jugular venous confluence (
n (%) | m ± SD | Extreme | |
---|---|---|---|
Serum Creatinine (µmol/L) | 69 (100) | 2364.8 ± 1073.8 | 444 - 5868 |
Azotemia (mmol/L) | 69 (100) | 38.1 ± 16.1 | 10.4 - 99.8 |
CRP (mg/L) | 13 (18.8) | 89.9 ± 143.7 | 0.2 - 479 |
Hemoglobin (g/dL) | 69 (100) | 7.3 ± 1.5 | 3.7 - 11.7 |
Leukocytes (éléments/mm3) | 69 (100) | 8612.8 ± 6735.5 | 1200 - 39100 |
Platelets (éléments/mm3) | 69 (100) | 238126.1 ± 147420.1 | 20000 - 927000 |
CRP: C Reactiv Protein; m: mean; n: number of patients who completed the biological examination; SD: standard deviation.
Insertion Site of the Catheter | m ± SD | Extreme |
---|---|---|
Femoral Vein | 1.9 ± 1.6 | 1 et 8 |
Internal Jugular vein | 1.6 ± 1.1 | 1 et 5 |
Subclavian vein | 2.6 ± 1.5 | 1 et 5 |
m ± SD: mean ± standard deviation; p = 0.3.
The dysfunction of the CVC was observed in 16 cases representing 10.3%. It involved 13 femoral CVCs re- presenting 14.8% of femoral CVCs, three jugular CVCs representing 4.8% of internal jugular CVCs. The dysfunction was precocious in three cases and caused by an intraluminal thrombosis (one case), a wrong direction (one case); and undetermined in the third case. In 13 cases, the dysfunction was late. It concerned the CVCs inserted in femoral vein in 11 cases. It was due to an intraluminal thrombosis of the CVC (seven cases), a bending of the CVC (one case) and a thrombophlebitis on CVC (five cases).
There were five thrombophlebitis on CVC representing 3.2% of 156 CVCs. The CVCs in question were all in- serted into a femoral vein. Four women and one man were involved. The average duration of use of these CVCs
was 26.8 ± 24.1 days (extreme = 9 and 67) vs 26 ± 28.4 days (extreme = 0 - 122) for the femoral CVCs without thrombophlebitis.
Our study took place in a context of limited resources. As such, the means were not always available to enable good practices according to international recommendations on catheterization for hemodialysis. Nevertheless, our study has the merit of showing the reality of our hemodialysis unit; providing results that are reliable and could serve us for the improvement of our hemodialysis patients’ care.
Our study population was young; the average age was 41.8 ± 17.1 years, as in most of the developing countries [
The majority of our patients had a low socioeconomic level (64%). It fits in the context of general poverty in Burkina Faso, ranked 181 among 187 countries with a low human development index (0.388) [
The activity of CVC insertion was very important in our hemodialysis unit. In fact, about nine CVCs were inserted per week. The 45 chronic hemodialysis patients received an average three CVCs by patient. This is explained by the very frequent use of temporary CVCs due to a long delay for making AVFs or lack of possibilities to repair them. This long delay was related to the lack of surgeon availability and financial means for a significant proportion of patients.
The CDC (Center of Diseases Control) and KDOQI [
Regarding acute hemodialysis, the recommendations of learned societies have been met. Thus, the femoral vein was used first (87.5%). No CVC has been inserted into the subclavian vein. The reasons given for the cases of chronic hemodialysis patients reveal the poor care conditionsin our country: hemodialysis session every four days, lack of compliance of some patients to the salt and water restriction, bad control of pressure sometimes due to a therapeutic rupture related to lack of financial means.
The change of the site of insertion was observed with 10.9% of CVCs. The main reasons were the non-pro- gression of the CVC guide (41.2%), iterative arterial punctures (29.4%) and the difficulty of locating the insertion vein (29.5%). These reasons are mainly related to the lack of use of ultrasound guidance. Thus, one could for example avoid unnecessary punctures in the cases of stenosis and thrombosis that could have been revealed by a previous Doppler ultrasound. The lack of operator change in case of iterative puncture failures should not be overlooked. During our study, the change of operator for the same patient was only after multiple puncture failures or puncture failure after changing site. However, the risk of accidental arterial puncture is associated with the increased number of percutaneous puncture [
In our context, the high incidence of complications mentioned in
Internal Jugular (%) | Subclavian (%) | Femoral (%) | |
---|---|---|---|
Arterial Puncture McGee* Iovino [ | 6.3 - 9.4 1 12.7 | 3.1 - 4.9 2.7 0 | 9 - 15 - 12.5 |
Pneumothorax McGee* Iovino [ | <0.1 - 0.2 0 3.2 | 1.5 - 3.1 3.1 0 | NA NA NA |
Hematoma McGee* Iovino [ | <0.1 - 2.2 - 3.2 | 1.5 - 3.1 - 0 | 3.8 - 4.4 - 0 |
*: Data of several authors reported by McGee et al. [
sound guidance, in agreement with the current international recommendations, is considered as the technique of reference for the insertion of CVCs [
A case of CVC in the wrong direction in the right internal jugular vein was observed. The incident occurred in a patient who had previously received several CVCs (two in the right subclavian vein and three in the right internal jugular vein). The Doppler has highlighted a large thrombus just downstream of the jugular-right subclavian confluence. Few similar cases were reported. Merrer et al. [
In our study, CVC dysfunctions were observed in 16 cases. They involved the femoral site in 13 cases re- presenting 81.3%, but 14.8% of femoral CVCs. A prospective randomized study compared the femoral and internal jugular sites in terms of dysfunction of the CVC. It was found that the femoral and jugular sites were equivalent in terms of dysfunction of CVCs, subject to the use of a CVC adapted to the specificities of the femoral route (length 24 cm). However, the left internal jugular exposes to a higher risk of dysfunction compared to the femoral and right internal jugular approach [
The use of a CVC very frequently leads to the formation of a fibrous sheath in the vein where the CVC is placed. The thromboses arising the reform are very often asymptomatic. For these reasons, they are undervalued. During the study of Timsit and al on 208 CVCs, the Doppler of the catheterized sites has highlighted a thrombosis in 42% of cases but it was occlusive in only 3% of cases [
The incidence rate of thrombosis is variable according to the CVC insertion site. The jugular and femoral sites are more thrombogenic than the subclavian sites [
Non-infectious complications of non-tunneled central venous catheterization were frequent in our series. Some are potentially serious because that may, directly or not, be life-threatening. The main reason for these complications was the absence of ultrasound guidance due to insufficient equipment in our hemodialysis unit. Some aspects not less important as the deficiency in qualified human resources have contributed to this high frequency. Thus, our study reaffirms the need for an ultrasound-Doppler in hemodialysis units, even in developing countries, for a better patient safety and better legal coverage of the doctor performing the catheterization.
The authors have no conflicts of interest to declare.
The authors thank Dr. Manan Hien for translating the text into English.
Gérard Coulibaly,Gildas Ilboudo,Adama Roger Karambiri,François P. Kissou,Adama Lengani, (2016) Non-Infectious Complications of Non-Tunneled Central Venous Catheterization for Hemodialysis: Incidence and Reasons in Ouagadougou (Burkina Faso). Open Journal of Nephrology,06,1-9. doi: 10.4236/ojneph.2016.61001