INTRODUCTION

Central venous catheters are used to administer intravenous drug therapies, fluids, blood sampling, and hemodialysis [1]. More than 15% of patients have catheter complications [2]. Catheter insertion may result in thrombolytic (2-26%) [3, 4] and infectious (5-26%) [5-7] complications. Temporary hemodialysis catheters often possess delayed and premature complications [8, 9]. The most common of complication is infection with an incidence 0.46 to 30 per 1000 catheter days [10]. In addition, mechanical complications such as pneumothorax, hemothorax, and thrombosis may occur [11]. Catheter use may also result in air embolism and cardiac arrhythmias that are not common [12]. About 5 million central venous catheters are used annually in the United States [13, 14]. Central vein catheters are inserted through the cutaneous in large veins such as jugular, subclavian, and femoral [15]. The choice of location for insertion of central venous catheter in 

patients depends on the degree of failure and its complications [16]. Surgeons choose a method based on the disadvantages and advantages of each of these methods.

Therefore, the aim of this study was to identify catheter complications in patients with Shaldone dialysis catheter and the choice of the best method for preventing the occurrence of these complications in patients.

Method

This epidemiological study is descriptive and based on hospital data of dialysis patients, who referred to ICU poisoning department of Ahvaz Razi Hospital between March 2013 and February 2015. The study population consisted of all patients, who were admitted in the ICU poisoning for dialysis and used Shaldon's catheter. Information including age, sex, cause of admission, duration of admission, duration of catheterization, the type of complication, and the use of Shaldon's catheter were extracted from patients' files and special forms.

Data Analysis

After collecting information about the patients, the findings were analyzed using SPSS-20. Descriptive statistics (abundance, graphs) were used to represent percentages. The mean for quantitative variables was used and the frequency and percentage for qualitative variables were used. Also, to compare the ratio of the incidence of complications of intubation, the comparison of ratios was used.

RESULTS

In this study, 80 patients using catheters for dialysis in Razi hospital in Ahavaz city were enrolled. The minimum and maximum ages were 13 and 87, respectively. There were 49 males and 31 females. The patients included 30 cases of pesticides poisoning, 23 cases with drug poisoning, 8 cases of alcohol poisoning, 3 cases snake bite, 9 cases scorpion bite, and 7 cases with sepsis. The average of time of using catheter in patients was 5.5 days. The minimum and maximum of time was 1 and 26 days, respectively. 16 patients used catheter in 3 days that was a high percent (20%). Catheter placement was performed in 42 patients in the jugular vein, 37 in the femoral vein, and one in the subclavian vein (Table 2). Table 3 shows the frequency of complications in patients admitted to ICU poisoning section of Ahvaz Razi Hospital. Among the 80 patients, who had Shaldone's catheter, 59 were uncomplicated and 21 were complicated. The most common complication was catheter site infection (8.8%). There were 5% of patients with pneumothorax, 5% with bleeding, 2.5% with thrombosis, 1.3% hemothorax, 1.3% hematoma, 1.3 % pneumothorax plus hemothorax, and 1.3% catheter site infection along with thrombosis.

DISCUSSION

The aim of this study was to evaluate the complications of Shaldon's catheter occurring in hemodialysis patients in Ahvaz Razi Hospital. The results showed that among 80 patients, 59 patients were uncomplicated and 21 patients (26.2%) had complications. A study by Beigi and colleagues on dialysis patients showed that among 114 patients, 30 patients had central vein catheter related complications which matched our results [17]. They also showed that the percentage of complications in males and females was 28.5 and 29, respectively and indicated that the incidence of complications in males and females was equal [17]. Borges et al reported that catheter-related complications have occurred in men more than women (31% in men and 17% in women) and most of the catheters used in men were femoral vein. In addition, they reported that there was no direct relationship between the age of hospitalized patients and catheter-related complications, except for bleeding [18]. The results of the present study showed that the most common catheter-related complication is infection of the catheter site (10%) and this incidence rate in the study by Beigi was 15.3 percent. In 2007, Di Lorio demonstrated that 10% of the patients had an infection due to the placement of the catheter [19]. In 2006, a survey of 68 children in the hemodialysis department of Sheikh Mashhad's specialist hospital showed that the most frequently complication related to central vein catheters was infection of catheter site (48.1%). Since the health care in adults is better than children, this high rate of infection in children can be is justified. In the current study, the duration 

of catheterization had a significant relationship with the incidence of infection, so that one hundred the percentage of infections occurred after the sixth day of catheterization. In a similar manner, Gil et al showed that catheter site infection increased by 1.5% to 10% with a catheterization period of more than 6 days. In this study, 75% of the total infection occurs when using the femoral approach [20]. In 2009 and 1998, respectively, Knuttinen and Goetz reported that the onset of infection is most common when using a femoral catheter [21, 22]. Furthermore, Parienti found that when using femoral catheter, the prevalence of catheter tip infection is significantly higher than jugular catheter and subclavian [23]. Because femoral area is susceptible to bacterial infection, it can be justified that more infections occur in this area. In this study, the authors investigated 80 patients and found that the rate of pneumothorax and hemothorax occurrence was 8.7 percent. Because these complications only occurred when using jugular and subclavian approaches (43 cases), the actual percentage is 16.1 percent (7 of 43 cases) which is more than previous studies. In a study on dialysis patients, Abdoulhosseini et al showed that the mean incidence of pneumothorax and hemothorax was 6 % and 5%, respectively[24]. While Shahmoradi reported only one case of pneumothorax in relation to catheterization complications [5]. Develter also maintained that catheterization-induced pneumonia was less than 1% [25]. The reason for this difference can be attributed to the lack of facilities for the insertion of ultrasound catheters and lack of skill and follow up on the catheter insertion. It is necessary to use a radiograph of the tip of the catheter to connect the upper inferior vein to the right atrium, ensuring proper placement of the catheter during and end of the work, and also the absence of pneumothorax and hemothorax. Obviously, the placement of an ultrasound catheter minimizes the chance of developing these complications. In the present study, the incidence rate of bleeding was 5% of the patients and 21% of the total complications, which was more than the results of the study of Bambauer (2.4%). A remarkable point in relation to patients admitted to the ICU section of poisoning was the occurrence of coagulation and blood disorders due to various types of bites, which justifies the bleeding incidence of 5% in this study.

Additionally, in this study, the incidence of bleeding increased significantly with age (P<0.05) and all bleeding occurred in age more than 26 years. The incidence rate of thrombosis was 12.65% of the all complications. Likewise, Leung et al showed that the incidence of deep venous thrombosis and superficial thrombosis was 1.8 and 9.2%, respectively [26]. With respect to the study by Scholz, an important factor in the formation of thrombosis is damage to the wall of the vein [27]. Handling and intravenous trauma, especially when inserting a catheter, and in addition, a larger catheter diameter is one of the causes of more thrombosis. It can be contended that the incidence of thrombosis, in this study, is due to the lack of experience of the personnel, multiple attempts at catheterization, as well as the lack of facilities for the insertion of an ultrasound catheter. The incidence of hematoma, in this study, was 1.3% of patients 

(4.34% of all complications). Istrate and Mansfield reported that the incidence rate of hematoma following catheter placement was 3.5% and 0.6%, respectively [28]. Bambauer showed that repeated attempts to fit a catheter eventually lead to an extensive vascular hematoma [29]. It seems that having experience and expertise in reducing the incidence of hematoma has a crucial role. In general, in this study, 52.17% of the total complications were related to femoral catheter and 47.82% of complications were related to jugular and subclavian catheters. Of the 25.5% complications associated with the jugular catheter and subclavian, the highest contribution was made by pneumothorax and hemothorax (16%). The results showed that the incidence rate of complications was 67.5% in femoral catheter and 32.5% in jugular and subclavian catheters.

CONCLUSION

This study showed that a significant number of patients treated in the ICU section of the poisoning at the Razi Hospital of Ahvaz only benefited from the benefits of catheters and did not directly affect any of the complications of the catheter and its placement.  This study shows that the rate of complications is lower than previous studies, and it can be concluded that the benefits of using catheters are more than their damage. However, the incidence rate of pneumothorax and hemothorax as two complications was much higher than usual. Hence, the femoral catheter appears to be a safer way. However, according to previous studies, if the experienced patients practice catheterization, the internal jugular catheter is a more appropriate and feasible approach than femoral. It is recommended to conduct catheterization by experienced individuals with the introduction of a catheter and under the guise of ultrasound to minimize the occurrence of some complications.

LIMITATIONS

Although the retrospective design of the study limited the data that could be collected and thorough follow-up of patients, we believe that the number of possible missed cases was low.

ACKNOWLEDGMENTS

The authors would like to acknowledge the ICU poisoning department of Ahvaz Razi Hospital for their cooperation and patience in providing registries needed for collecting retrospective data.

Funding and Support: None.

Conflict of Interest: None to be declared