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.

Non-Infectious Complications of Non-Tunneled Central Venous Catheterization for Hemodialysis: Incidence and Reasons in Ouagadougou (Burkina Faso)

“…The ultrasound, by guiding the puncture into the vein and detecting anatomical variations, improves the success rate and comfort, and decreases the insertion time, the number of punctures, the number of complications and the cost [19] [20]. This could also help reduce the risk of being sued to which any operator may be exposed [21]. A case of CVC in the wrong direction in the right internal jugular vein was observed.…”

Practical guide for safe central venous catheterization and management 2017

“…When catheterization is performed for long-lasting therapeutic purposes, the patient's psychological condition and other factors must be considered, unlike catheterization with surgical anesthesia. In either, the procedure should be explained to the patient and his/her family, and informed consent should be obtained beforehand [2,3]. When central venous catheterization needs to be performed in an emergency case, it is preferable to explain the procedure beforehand even just to the family.…”

“…The objective of the pre-scan is not only to confirm the location of arteries and veins (veins are easily flattened by pressure from the ultrasound probe, whereas arteries resist pressure and will cause the probe to throb with the pulse) [18]. Objectives of the pre-scan include (1) assessing whether a vein is suitable for puncture (presence or absence of the target vein, presence or absence of venous thrombosis), (2) assessing risk at the time of puncture (tortuous or deviated veins, positional relationship to arteries, relationship to surrounding tissue), (3) post-procedural risk assessment (vein diameter: catheterization can reduce blood flow in small veins, which can cause thrombus formation or stenosis of the vein) ( Fig. 3).…”

Ultrasound-Guided Vascular Access during Cardiopulmonary Resuscitation

“…With this position of the ultrasound probe, the needle is usually inserted vertically (vertical out-of-plane technique) above the middle part of the ultrasound probe in a position 1-1.5 cm cranial from the upper margin of the clavicle. This allows the operator to simultaneously visualize the IJV and all surrounding structures and ensures a caudal vein access [20]. With this type of technique, the operator has a very limited view of the needle (Figure 10).…”