Central venous catheters (CVC) provide reliable venous access for various medical needs. With ultrasound positioning, central venous catheterization has become safer, more convenient, and faster[8, 9]. For significant and prolonged surgery, the anesthesiologist will often consider inserting a central venous catheter for the patient as appropriate to ensure stable venous access during the operation. In addition to fluid therapy and central venous pressure monitoring, it can also provide a stable channel for postoperative parenteral nutrition.
In response to an emergency during the operation, clinical anesthesiologists will appropriately relax the indications for central venous catheterization, which will lead to medical waste. In China, especially in some large medical units, anesthesiologists have a routine to indwell CVC on rectal cancer surgery patients.
However, small and short-term surgeries do not always require CVC. In low-risk surgeries and short anesthesia time, unnecessary CVC applications are increasing[6]. Compared with traditional open surgery, laparoscopic radical resection of rectal cancer has the advantages of less trauma, less bleeding, and shorter operation time and has been widely accepted[4]. The overutilization of central venous catheters can be found in this study.
The anesthesiologist might have overestimated the duration of the operation or the risk of the case. For most patients, intraoperative blood transfusion and application of vasoactive drugs are not required. In this study,Out of 150 patients with CVC, only 21(14%) received fluid transfusion volume over 3000ml, and the blood loss of patients with CVC was only 600ml at most. CVC not only increases the risk of related complications but also wastes medical resources. Even if heavy bleeding during the operation or rapid fluid therapy is required, emergency inserting CVC is feasible.
The multi-lumen catheter has commonly used because of its advantages in treating patients who require a large amount of drug infusion. Bloodstream infections are the main complication of CVC. However, whether multi-lumen catheters increase the risk of infections is still controversial[10]. A meta-analysis suggests that multi-lumen catheters may be associated with a slightly higher risk of infections[11]. The application of antimicrobial-impregnated CVC[12] dramatically reduces the incidence of bloodstream infections. Thanks to the application of antimicrobial-impregnated CVC, none of the 150 patients with CVC had related complications. Although the risk of infection does not necessarily increase, using a multi-lumen catheter when a single-lumen catheter can meet the patient's infusion needs will undoubtedly increase vascular damage and medical costs.
Therefore, a sufficient assessment of the patient's operation time and blood loss before surgery can reduce unnecessary use of CVC as much as possible and reduce the patient's trauma and medical expenses.
Some surgeons believe that inserting CVC in advance can provide reliable venous access for parenteral nutrition while reducing peripheral vascular puncture and infusion. With advances in technical catheters, non-invasive hemodynamic monitoring and improved venipuncture techniques have also reduced the need for perioperative central venipuncture[13]. For patients with no peripheral blood vessel puncture obstacles and undergo short-term parenteral nutrition, peripheral parenteral nutrition can fully meet the needs[14].
Whether patients undergoing laparoscopic radical resection of rectal cancer should be routine parenteral nutrition is currently inconclusive,[15, 16] early enteral nutrition is more conducive to patients' recovery. Enhanced Recovery After Surgery (ERAS )[17] has been proven to reduce morbidity rates, improve recovery and shorten the length of stay in elective colorectal surgery. Resumption of oral nutrition on the first day after surgery after colorectal cancer surgery may be associated with improved 5-year cancer-specific survival[18]. The surgeon will insert peripherally inserted central catheters (PICCs) or infusion port for patients who need chemotherapy after surgery. Then the CVC inserted during the operation is a bit redundant.
Medical waste is increasingly recognized as the cause of patient harm and high costs. "Unnecessary services" is the most significant cause of waste in healthcare in the United States. In 2010, the Institute of Medicine called attention to this problem[19]. A United States survey on over-treatment found that the most common cause of over-treatment is "fear of malpractice" (84.7%)[20], 71% of respondents said they were more likely to perform unnecessary procedures when they profit from them.
This study had several limitations. First, this study was conducted in a single-center, resulting in the patients' selection bias. Second, the study was retrospective, and observational character relied on the quality and availability of data in the patient medical records. We cannot know whether the patient has difficulty in peripheral intravenous infusion before CVC catheter insertion, nor can we know the actual application of CVC catheter after surgery. None of the included patients had CVC catheter-related complications after surgery. However, it was impossible to see the patient's CVC insertion's specific process, including the number of punctures and whether mechanical complications occurred. It is necessary to develop guidelines for intraoperative inserting CVC through future prospective randomized controlled studies.