title: Incidence of Mechanical Complications of Central Venous Catheterization Using Landmark Technique: Do Not Try More Than 3 Times.
abstract: OBJECTIVE
  Central venous catheterization is a standard procedure in intensive care therapy. In developing countries, this intervention is frequently performed by physicians in training and without the availability of ultrasound guidance. Purpose of this study was to determine the incidence and potential risk factors for mechanical complications during central venous catheterization in an intensive care setting performed by a mixed group of practitioners without the use of adjunct ultrasound.
  
  
  METHODS
  Prospective observational cohort study in a university teaching hospital. Three hundred critically ill patients requiring their first central venous catheter insertion were enrolled. All patients were observed for 24 hours for mechanical complications (pneumothorax, hemothorax, arterial puncture, incorrect tip position, cardiac dysrhythmia, and/or subcutaneous hematoma). Potential associations with mechanical complications were adjusted using multivariable analysis. Main outcome was the cumulative incidence of mechanical complications.
  
  
  RESULTS
  The incidence of mechanical complications was 17% (n = 51). After covariate adjustment, the number of punctures was significantly related to mechanical complications. Compared with 1 puncture, 3 or more attempts were significantly associated with mechanical complications (odds ratio 3.62 [95% confidence interval 1.34-9.8]; P = .011). Experience of the operator was not associated with mechanical complications.
  
  
  CONCLUSIONS
  The incidence of mechanical complications is affected by the number of punctures performed. After adjustment, the risk increases substantially with more than 3 attempts. Limiting the number of attempts, appropriate supervision and the use of ultrasound guidance when available are recommended for the further reduction in mechanical complications of central venous catheterization.
authors.affiliation: Department of Anaesthesiology, Erasmus University Medical Centre Rotterdam, Rotterdam, the Netherlands Department of Biostatistics, Erasmus University Medical Centre Rotterdam, Rotterdam, the Netherlands Departamento de Anestesiología, Universidad del Cauca, Popayán, Cauca, Colombia jacalvache@gmail.com.
authors.forename: Jose-Andres
authors.initials: JA
authors.lastname: Calvache
authors.affiliation: Clínica La Estancia, Intensive Care Unit, Popayán, Cauca, Colombia.
authors.forename: Maria-Virginia
authors.initials: MV
authors.lastname: Rodríguez
authors.affiliation: Departamento de Anestesiología, Universidad del Cauca, Popayán, Cauca, Colombia Clínica La Estancia, Intensive Care Unit, Popayán, Cauca, Colombia.
authors.forename: Adolfo
authors.initials: A
authors.lastname: Trochez
authors.affiliation: Department of Anaesthesiology, Erasmus University Medical Centre Rotterdam, Rotterdam, the Netherlands.
authors.forename: Markus
authors.initials: M
authors.lastname: Klimek
authors.affiliation: Department of Anaesthesiology, Erasmus University Medical Centre Rotterdam, Rotterdam, the Netherlands.
authors.forename: Robert-Jan
authors.initials: RJ
authors.lastname: Stolker
authors.affiliation: Department of Biostatistics, Erasmus University Medical Centre Rotterdam, Rotterdam, the Netherlands.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Lesaffre
mesh_terms: D002405:Catheterization, Central Venous / Q000009:adverse effects* / Q000379:methods*; D003422:Critical Care; D016638:Critical Illness / Q000628:therapy*; D005260:Female; D006801:Humans; D015994:Incidence; D007601:Jugular Veins / Q000000981:diagnostic imaging / Q000293:injuries; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D011677:Punctures; D018084:Ultrasonography, Interventional
keywords: catheterization; central venous; central venous catheter; mechanical complications