•During internal jugular vein and femoral vein puncture, always keep one hand over the artery to prevent arterial puncture.

•Never lose control of the guidewire, and hold it in one hand.

•When there is increased risk of bleeding, internal jugular vein route is preferable (with ultrasound guidance).

II.Infectious complications

1.Insertion site infection

The following methods are required to prevent infectious complications:

1. Use the line only when necessary and remove it as soon as it is not required. 2. Use the subclavian vein and avoid femoral or internal jugular vein

cannulation.

3. Use a CVC with the minimum number of ports or lumens essential.

4. Hand hygiene and maximal sterile barrier precautions are needed at all times. 5. Use sterile gauze or sterile, transparent, semipermeable dressing to cover

the catheter site.

6. If the patient is diaphoretic or if the site is bleeding or oozing, use a gauze dressing until this is resolved.

7. Replace dressings used on short-term CVC sites every 2 days for gauze dressings and every 7 days for transparent dressings.

8. Use a chlorhexidine-impregnated sponge dressing if the infection rate is not decreasing despite adherence to basic prevention measures.

9. Use a 2% chlorhexidine wash for patients’ daily skin cleansing, not the insertion site.

10. Evaluate the catheter insertion site daily for signs of infection.

11.Use a sutureless securement device.

12.Useachlorhexidine/silversulfadiazineorminocycline/rifampin-impregnated CVC in patients whose catheter is expected to remain in place for more than 5 days or if the high infection rate is expected.

13.Use povidone-iodine antiseptic ointment or bacitracin/polymyxin B ointment at the hemodialysis catheter exit site after catheter insertion and at the end of each dialysis session.

14. Do not use guidewire exchanges to replace a catheter suspected of being source of infection.

III. Misinterpretation of data

Suggested Reading

1.O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control. 2011;39(4 Suppl 1):S1–34.

The latest version of the CDC guidelines for the prevention of intravascular catheter-related infections discusses in detail and provides recommendations on all aspects of catheter care and CRBSI reduction.

2.Biffi R, Orsi F, Pozzi S, Pace U, et al. Best choice of central venous insertion site for the prevention of catheter-related complications in adult patients who need cancer therapy: a randomized trial. Ann Oncol. 2009;20(5):935–40.

Central venous insertion modality and sites had no impact on either early or late complication rate, but US-guided subclavian insertion showed the lowest proportion of failures.

3.McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. 2003;348(12):1123–33.

NEJM current concepts series—a lucid description of the insertion maintenance and complications of central venous catheters.

4.Hind D, Calvert N, McWilliams R, et al. Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ. 2003;327(7411):361.

A real-time two-dimensional ultrasound guidance for cannulating the internal jugular vein in adults was associated with a significantly lower failure rate both overall and on the first attempt.

5.Ruesch S, Walder B, Tramèr MR. Complications of central venous catheters: internal jugular versus subclavian access—a systematic review. Crit Care Med. 2000;30(2):454–60.

This study shows significantly more arterial punctures with jugular catheters compared with subclavian. There are significantly less malpositions with the jugular access. They further show that the incidence of bloodstream infection is less with subclavian.

Internal jugular vein cannulation using dynamic guidance of ultrasound in the transverse view