1Department of Anesthesia, Uwajima Social Insurance Hospital and 2Department of Anesthesiology and Resuscitology, Ehime University School of Medicine, Ehime, Japan*Corresponding author
Accepted for publication: May 4, 2001
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Abstract |
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Br J Anaesth 2001; 87: 51011
Keywords: equipment, central venous catheter; complications, hemidiaphragmatic elevation; complications, phrenic nerve palsy
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Introduction |
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Case report |
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On the third day of admission, central venous catheterization was attempted to improve the nutritional and fluid balance of the patient before surgery. A 16-G catheter was passed into the left subclavian vein through an infra-clavicular approach at the first attempt. Blood returned freely through the catheter. The chest x-ray film confirmed the proper placement of the catheter, but it also showed an elevation of the right side hemidiaphragm (Fig. 1). The patient was not dyspnoeic and the arterial blood gas data were normal.
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On the 18th day of admission, resection of the sigmoid colon with formation of a colostomy was performed under general anaesthesia. In spite of the persistent elevation of the right hemidiaphragm, the patients postoperative recovery was uneventful. On the fourth postoperative day, the tip of the catheter was withdrawn by 3 cm because the flow rate of infusion fluid through the catheter was sluggish and the chest X-ray film showed the catheter tip to be impinged more perpendicularly on the wall of the superior vena cava than in the previous films. The infusion speed improved and the chest x-ray film 3 days after the withdrawal revealed complete resolution of the right phrenic nerve palsy (Fig. 1). On the 17th postoperative day the patient was discharged from hospital with no recurrence of the phrenic nerve palsy.
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Discussion |
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In our case we punctured the left subclavian vein by the infraclavicular approach where there is no possibility of damaging the right phrenic nerve with the needle, local anaesthetic infiltration and/or haematoma formation at the puncture site. One possible cause for the right phrenic nerve damage was the compression of the nerve through the vein wall by the tip of the catheter. When a central venous catheter is introduced through the left subclavian vein, the tip of the catheter hits the wall of the superior vena cava more perpendicularly than when it is introduced from the right side. Central venous catheter-related vascular erosion or perforation is more common when the catheter is introduced from the left subclavian vein.6 7 Therefore, we concluded that the cause of the phrenic nerve palsy was the tip of relatively rigid polyurethane catheter impinging upon the thin venous wall and compressing the phrenic nerve running alongside the superior vena cava.
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References |
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