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Clinical Observations |
1 Department of Radiology, Cincinnati Children's Hospital Medical Center, MLC
5031, 3333 Burnet Ave., Cincinnati, OH 45229-3039.
2 University of Cincinnati College of Medicine, Cincinnati, OH.
Received March 19, 2007;
accepted after revision June 30, 2007.
Address correspondence to L. F. Donnelly
(lane.donnelly{at}cchmc.org).
Abstract
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CONCLUSION. Administration of IV contrast material by means of hand injection led to damage of four central venous catheters during a 6-year period at our institution (0.3% of central venous catheters hand injected during that time). In addition to the growing evidence of the safety of power injection of IV contrast material in central venous catheters, the potential danger of hand injection of central venous catheters should be considered when policies are made concerning the delivery of IV contrast material via central venous catheters.
Keywords: children • CT • IV contrast material • power injection administration • safety
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One question that has not received much attention is whether hand injection of central venous catheters, the alternative to power injection, is safe. We have experienced a number of incidents in which there has been damage to central venous catheters related to hand injection of IV contrast material. Our purpose is to review our experience with the safety of hand injection of central venous catheters.
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In all subjects, ioversol 320 (Optiray 320, Mallinckrodt) at room temperature was used. The amount of contrast material used was 2 mL/kg of body weight up to 100 mL. The size of syringes used for contrast material injection ranged from 5 to 20 mL and was based on the size of the child and total volume of contrast material to be injected. Syringes are always greater than 5 mL in size. Lines are always tested with a saline flush before injection of contrast material. During the period of the study, our institutional policy was to place a peripheral IV catheter and use power injectors for the delivery of IV contrast material for patients without central venous access and to hand inject all central venous catheters.
At our institution, central venous lines are injected with contrast material by either a radiology nurse or CT technologist, either of whom is certified for contrast material injection of central venous lines. Certification involves reviewing an online module and educational handout that describe step-by-step how to scrub a central line, inject contrast material, test lines, flush lines, draw laboratory samples, and recognize and manage complications related to the lines. The central venous line trainee then watches the process live, performs the technique in simulation while under supervision of a certified nurse on a central venous line model, and then performs central venous line care under supervision on three patients. After the trainee has shown proper technique on the patients and passed a test, the supervising nurse signs off on the trainee's competency.
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All injections had been performed by certified central venous line personnel. In all cases, the contrast material was being injected in preparation for CT of the abdomen and pelvis or CT of the chest, abdomen, and pelvis. In no cases was it in preparation for neuroimaging studies.
Subjects and relative parameters are summarized in Table 1. In all cases, the catheters could be repaired and did not need to be replaced. Repairs were performed using a repair kit specific to the brand of catheter being repaired. The catheter was cut just distal to the damaged portion. A sleeve with new proximal end of the catheter was placed over the original distal portion of the catheter and glued in place. In no cases was other harm caused to the patient outside of the need for catheter repair.
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Contrast enhancement via power injectors has been shown to have a positive effect on the quality of CT scans [5, 6]. However, at many imaging centers there is a reluctance to use power injection of contrast material via central venous catheters because of the risk of catheter rupture and other associated problems such as catheter fragmentation, embolization, and loss of usable venous access [2, 3, 7, 8].
Despite these reservations about safety, an increasing number of publications have shown that pressure-limited power injection of central venous lines can be safely accomplished in both children and adults [2, 3, 7–9]. A recent report in the AJR showed that by using pressure-limited power injection, central lines could be successfully used in children with no complications related to power injection [2].
Independent of the debate of whether the practice of power injection of central venous catheters is safe, there has been little attention to whether the alternative practice, hand injection of central venous catheters, is safe. This report identifies four examples in which central venous catheters of various types were damaged by the pressure generated during hand injection of IV contrast material. These four incidents at a single children's hospital in a 6-year period raise the question of how frequently such events occur and whether nationally the number of damaged catheters related to hand injection is greater or less than the damage related to power injection of central venous catheters.
The hand injection of liquids, particularly when using smaller syringes, can generate large amounts of pressure. Another disadvantage of hand injection compared with power injection is that the pressure generated is not only potentially high, but the pressure and rate of injection are unknown. In one study, hand injection generated higher peak pressures at equivalent flow rates than did power injection [10]. Hand injection of contrast material can result in inconsistent and sometimes high pressure [10].
It may be coincidence that all four occurrences in this series were related to body applications and none occurred related to neurologic applications. The emphasis on the need for faster delivery of contrast material because of the importance of timing of scanning related to contrast material injection in body imaging relative to routine neurologic imaging could be a contributing factor.
One limitation of this study is that the data were collected retrospectively and were gathered from an incident reporting system. Identification of incidents involving damage to a central venous catheter by hand injection of IV contrast material relied on both active reporting of catheter damage and realization that the damage was related to IV contrast material administration. Also, catheters may have been damaged in their internal portion, and in cases where this did not lead to catheter fragmentation and complication, the damage may have not been identified. We also think that damaged catheters that were recognized in radiology or soon thereafter would accurately be captured by the incident reporting system. However, catheter damage not recognized until later might not be attributed to the CT study. Therefore, the frequency of damage to central venous catheters from hand injection may actually be higher than reported here.
A second limitation is that mechanical complications of central venous catheters can occur with routine use [11, 12]. A rate of 0.3% damage to central venous catheters during hand injection of contrast material could be argued to be within the expected risk of complications related to routine use of central venous catheters. However, we think it is important to note that central venous catheters can be damaged during hand injection of contrast material. Another limitation of the study is that the amount of pressure generated by hand injection was not known. However, the unknown amount of pressure generated by hand injection is one of the points of this article. A final limitation was that we could not accurately determine the age of the catheters from our review of available medical records in all cases.
In conclusion, we report four incidents of damage to central venous catheters related to hand injection of IV contrast material in preparation for CT over a 6-year period. The frequency of damage to central venous catheters related to hand injection was 0.3%. These incidents raise the question of the relative safety of hand injection of IV contrast material via central venous catheters. In addition to the growing evidence of the safety of power injection of IV contrast material of central venous catheters, the potential danger of hand injection of central venous catheters should be considered when policies are made concerning the delivery of IV contrast material via central venous catheters.
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