title: Central venous catheters: legal issues.
abstract: In dialysis patients, both central venous catheter (CVC) insertion and CVC use during the dialysis procedure pose important legal issues, because of potentially severe, even fatal, complications. The first issue is the decision of the kind of vascular access that should be proposed to patients: an arteriovenous (AV) fistula, a graft, or a CVC. The second issue, when choosing the CVC option, is the choice of CVC: nontunneled versus tunneled. Leaving a temporary nontunneled CVC for a prolonged time increases the risk of complications and could raise a liability issue. Even when choosing a long-term tunneled CVC, nephrologists should systematically explain its potential harms, presenting them as "unsafe for long-term use" unless there is a clear contraindication to an AV native or prosthetic access. Another critical issue is the preparation of a complete, informative, and easy-to-understand consent form. The CVC insertion procedure has many aspects of legal interest, including the choice of CVC, the use of ECG monitoring, the use of ultrasound guidance for cannulation, and the use of fluoroscopy for checking the position of the metal guidewire during the procedure as well as the CVC tip before the end of the procedure. Use of insertion devices and techniques that can prevent complications should obviously be encouraged. Complications of CVC use are mainly thrombosis and infection. These are theoretically expected as pure complications (and not as malpractice effects), but legal issues might relate to inappropriate catheter care (in both the inpatient and outpatient settings) rather than to the event per se. Thus, in the individual case it is indeed very difficult to establish malpractice and liability with a catheter-related infection or thrombosis. In conclusion, we cannot avoid complications completely when using CVCs, but reducing them to a minimum and adopting safe approaches to their insertion and use will reduce legal liability.
authors.affiliation: Nephrology and Dialysis Unit, Hospital San Carlo Borromeo, Milan, Italy. maurizio.gallieni@fastwebnet.it
authors.forename: Maurizio
authors.initials: M
authors.lastname: Gallieni
authors.forename: Valentina
authors.initials: V
authors.lastname: Martina
authors.forename: Maria Antonietta
authors.initials: MA
authors.lastname: Rizzo
authors.forename: Luciana
authors.initials: L
authors.lastname: Gravellone
authors.forename: Francesca
authors.initials: F
authors.lastname: Mobilia
authors.forename: Antonino
authors.initials: A
authors.lastname: Giordano
authors.forename: Daniele
authors.initials: D
authors.lastname: Cusi
authors.forename: Umberto
authors.initials: U
authors.lastname: Genovese
mesh_terms: D055499:Catheter-Related Infections / Q000209:etiology* / Q000517:prevention & control; D002405:Catheterization, Central Venous / Q000009:adverse effects* / Q000295:instrumentation; D002408:Catheters, Indwelling / Q000009:adverse effects*; D032882:Comprehension; D003428:Cross Infection / Q000209:etiology* / Q000517:prevention & control; D004867:Equipment Design; D004868:Equipment Failure; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007258:Informed Consent / Q000331:legislation & jurisprudence; D016365:Liability, Legal; D008318:Malpractice / Q000331:legislation & jurisprudence; D010353:Patient Education as Topic / Q000331:legislation & jurisprudence; D061214:Patient Safety / Q000331:legislation & jurisprudence*; D018579:Patient Selection; D006435:Renal Dialysis / Q000009:adverse effects*; D018570:Risk Assessment; D012307:Risk Factors; D056824:Upper Extremity Deep Vein Thrombosis / Q000209:etiology* / Q000517:prevention & control