Complication Rates of Central Venous Catheters: A Systematic Review and Meta-Analysis

Abstract

Importance: Central venous catheters (CVCs) are commonly used but are associated with complications. Quantifying complication rates is essential for guiding CVC utilization decisions.

Objective: To summarize current rates of CVC-associated complications.

Data sources: MEDLINE, Embase, CINAHL, and CENTRAL databases were searched for observational studies and randomized clinical trials published between 2015 to 2023.

Study selection: This study included English-language observational studies and randomized clinical trials of adult patients that reported complication rates of short-term centrally inserted CVCs and data for 1 or more outcomes of interest. Studies that evaluated long-term intravascular devices, focused on dialysis catheters not typically used for medication administration, or studied catheters placed by radiologists were excluded.

Data extraction and synthesis: Two reviewers independently extracted data and assessed risk of bias. Bayesian random-effects meta-analysis was applied to summarize event rates. Rates of placement complications (events/1000 catheters with 95% credible interval [CrI]) and use complications (events/1000 catheter-days with 95% CrI) were estimated.

Main outcomes and measures: Ten prespecified complications associated with CVC placement (placement failure, arterial puncture, arterial cannulation, pneumothorax, bleeding events requiring action, nerve injury, arteriovenous fistula, cardiac tamponade, arrhythmia, and delay of ≥1 hour in vasopressor administration) and 5 prespecified complications associated with CVC use (malfunction, infection, deep vein thrombosis [DVT], thrombophlebitis, and venous stenosis) were assessed. The composite of 4 serious complications (arterial cannulation, pneumothorax, infection, or DVT) after CVC exposure for 3 days was also assessed.

Results: Of 11 722 screened studies, 130 were included in the analyses. Seven of 15 prespecified complications were meta-analyzed. Placement failure occurred at 20.4 (95% CrI, 10.9-34.4) events per 1000 catheters placed. Other rates of CVC placement complications (per 1000 catheters) were arterial canulation (2.8; 95% CrI, 0.1-10), arterial puncture (16.2; 95% CrI, 11.5-22), and pneumothorax (4.4; 95% CrI, 2.7-6.5). Rates of CVC use complications (per 1000 catheter-days) were malfunction (5.5; 95% CrI, 0.6-38), infection (4.8; 95% CrI, 3.4-6.6), and DVT (2.7; 95% CrI, 1.0-6.2). It was estimated that 30.2 (95% CrI, 21.8-43.0) in 1000 patients with a CVC for 3 days would develop 1 or more serious complication (arterial cannulation, pneumothorax, infection, or DVT). Use of ultrasonography was associated with lower rates of arterial puncture (risk ratio [RR], 0.20; 95% CrI, 0.09-0.44; 13.5 events vs 68.8 events/1000 catheters) and pneumothorax (RR, 0.25; 95% CrI, 0.08-0.80; 2.4 events vs 9.9 events/1000 catheters).

Conclusions and relevance: Approximately 3% of CVC placements were associated with major complications. Use of ultrasonography guidance may reduce specific risks including arterial puncture and pneumothorax.

Figure 1.. PRISMA Diagram

^aOther catheter types such as urinary catheters, peripheral intravenous catheters, midline catheters, peripherally inserted central catheters, and dialysis catheters were excluded from this study. ^bOther study types such as case reports, case series, study protocols for future research, guidelines, systematic reviews, and surveys were excluded from this study.

Figure 2.. Summary of Central Venous Catheter-Associated Complications Based on Bayesian Random-Effects Meta-Analysis Models

95% CrI indicates 95% credible interval; NA, not applicable.

Figure 3.. Central Venous Catheter-Associated Complication Rates by Catheter Insertion Site

Placement failure, arterial puncture, pneumothorax, and infection were the only 4 outcomes with sufficient data for comparison across catheter types. The subgroup others encompasses unknown, unclear, or mixed central venous catheter types. For placement failure, the upper bound of the 95% credible interval (CrI) for femoral catheters extends beyond the limits of the graph, and it is not displayed for simplicity. Number of groups refers to the number of patient groups with different insertion sites among studies. For studies that had more than 1 study group (eg, internal jugular vs femoral), each study group was treated separately in the analysis.

Figure 4.. Estimates From Meta-Regression Models for the Association of Use of Ultrasonography With the Rate of Complications

In the context of meta-regression models, each study may contribute 2 distinct estimates, for instance, when 1 group received ultrasound treatment while another group did not. Use of ultrasonography was included as a categorical variable with the following values: 0 for “no,” 1 for “partial,” 2 for “yes,” and 3 for “unclear.” 95% CrI indicates 95% credible interval.